accident and health Flashcards
provides periodic income weekly or at least monthly. income not taxable on individual policy
Disability income
pays 66 2/3 of gross pay
disability income
BOE policy
pays overhead, rent utilities
buyout partner who becomes disables
Business disability buyout, for permanent disability
principal sum
refers to the accidental death or death benefit
capital sum
refers to the dismeberment
limited benefits provided for daily hospital charges at a flat rate per day. pays first dollar (no deductible) days are limited
basic hospital insurance
pays physician visits in hospital, flat dollar amount per day
basic medical insurance
provides benefits for a surgeon in or out of hospital. flat amount for each operation.
basic surgical insurance
pays high dollar amounts after the insured pays the deductible.
Major medical
allows the insured to carry over expenses paid in 4th quarter of prior year to reduce current year deductible when no claims were paid to the insured
carry over provision
% participation (80 20) insured and insurer share the cost after deductible
Coinsurance
Limits the insureds liability to a certain dollar amount
out of pocket limit or stop loss provision
Amount insured pays on major medical
deductible plus 20 percent of bill
when the insured owns both basic and major medical
comprehensive, basic pays first then corridor deductible then major pays third
imposed controls on use of health care services, fees charged for those services, providers of healthcare services
managed care
health maintenance organization HMO
provides prepaid doctor and hospital care, stresses preventative medicine with exams and diagnostic procedures
Requires employers with 25 or more employees ro offer HMO/PPO if there is a health plan or hmo in area
HMO act of 1973
allows the insured the freedom of choice in selecting a health care professional non preferred provider
PPO
This insurance always has a deductible
Major medical
covers routine medical exams and diagnostic prodedures
HMO/PPO
stresses preventive medicine
HMO/PPO
pays first dollar coverage
Basic medical
Small dollar amount that must be paid by this member with treatment
HMO/PPO
coinsurance % participation
Major medical
provides limited coverage
Basic
gatekeeper PCP required
HMO/PPO
managed care
HMO/PPO
Pays directly to hospital and doctors
service organizations BC/BS
pays directly to the insured
reimbursement insurer
insured has choice of going in or out of network
point of service plan
deduct money placed in a fund to pay medical expenses that were not reimbursed
MSA
this account can be used to pay for expenses that are not covered by group health plans
Flexible spending account and HRA
Must have 30 day free look
medicare supplement policies
Must cover preexisting conditions after 6 months
medicare supplement policies
Allows the insured to convert from group to individual without proving insurability (31 days)
group conversions
provides better benefits at less cost
group
all employers with 20 or more employees must provide continuation of group health insurance to all former employees and dependents
COBRA
time allowed to choose cobra
60 days
must provide coverage for at least 12 consecutive months
LTC
must cover preexisting after 6 months
LTC
must be at least guaranteed renewable
LTC
includes entire contract, riders, endorsements and changes
entire contract
time limit on certain defenses
2 years, except fraud
additional time after due date
grace period 31 days
getting back into force a lapsed policy
reinstatement
if insurer fails to respond to the reinstatement form after _____ days, automatic reinstatement
45
waiting period on reinstatement
10 days
time required to file notice of claim
20 days
must be sent to insured within 15 days
claim forms
formal or sworn statement about loss
proof of loss
time of payment of claims
immediately
have ____ days to file suit against insurer after proof of loss
60
this provision limits the time period that the insurer ay deny a claim based on prexisting conditions or misrepresentations
time limit for certain defenses
provision that deals with the agent making revisions on the policy
entire contract - changes
provision that states who will receive death benefits
payment of claims
restricts the time for insured to file suit
legal actions
provision allows the insurer at its expense to examine the insured when a claim is pending
physical exam and autopsy
requires the insurer to mail forms within 15 days
claim forms
companys promise to pay
insuring clause
period of time after purchase before benefits are paid
probationary period (happens once)
totally disabled from a covered accident or illness for _____ insurer waives premium
3 to 6 months
refers to a condition that returns before the insured has been back to work for 6 months following total disability
recurrent
insurer may cancel at any time
cancelable
insurer may cancel on anniversary date
optionally renewable
insurer may cancel based upon the conditions specified in policy
conditionally renewable
insurer may not cancel but can raise premium on class basis
guaranteed renewable
insurer may not cancel or raise
non cancelable
when do you receive your first disability check
6 months
provides periodic payments when unable to work
disability insurance
time before benefits are payable after a covered accident or illness occurs is usually found in disability policies
elimination period
provides funds to pay operating expenses of a business
business overhead insurance
pays a monthly benefit to a business to cover additional help and pay an essential person while disabled
key employee
pays the insured for loss of earnings after returning to work in the insured is unable to earn as much as before the total disability
residual disability
refers to a disability where the insured is expected to recover
temporary
inability to perform one or more but not all of the duties of the occupation (educated and trained for)
partial disability
insurer would not require the insured to submit to periodic exams by their physician to prove continued disability
presumptive
related disability relapse before being back to work for 6 months would be called
recurrent
unable to work for rest of life
permanent
inability to perform any of the duties required in occupation
total disability
buyout of an owners interest if permanent disability occurs
key employee disability
insurer wold not require the payment of premiums while totally disabled
waiver of premium
