Chapter 11 - Health Insurance Basics Flashcards
Insuring Clause
statement in the policy that states the promise the insurer makes to the insured
Free Look Provision
Insurer must give the insured time to review the contract upon receiving at policy delivery
10 days
If the insured chooses to return the policy, the insurer provides a full refund
Probationary (waiting) Period
Period of time the insured must wait before coverage is available for sickness
Begins at the effective dare
Only one time
Elimination Period
Period of time the insured must wait before coverage is available for sickness or accidents
Begins with the benefit period
Could occur multiple times
Deductible
Amount of risk the insured retains full responsibility for
Used to control over utilization
Larger the deductible, lower the premium
- calendar year/policy year
- family/per person
Coinsurance - the insured and insurer share this cost of a medical bill
- bill must exceed the deductible
- insurer and insured split based off percentage
Stop loss/Out of pocket expenses:
- once reached, insurer begins to pay 100% of covered services
Term
Policy renewal provision
Cannot be renewed
Designed to be temporary coverage
Cancelable
May be cancelled at any time
Illegal now
Optionally Renewable
Insurer has the option to renew the policy or not, at the renewal date
Illegal now
Conditionally Renewable
Renewable, except under certain conditions listed in the contract
Illegal now
Guaranteed Renewable
Cannot be cancelled or non renewed
Premiums can be increased on a class basis only
Renewability may be limited by age (usually 65)
Noncancellable
Cannot be cancelled or non renewed
Premiums are locked in and cannot be changed
Renewability may be limited by age (usually 65)
Preexisting Conditions
A health condition that existed prior to the purchase of the policy
May or may not be covered by the policy
Exclusions
Things not covered
Subrogation
Passes the right of recovery to the insurer
