Contract Provisions, Definitions, and Benefits

Question 1

Contract

Answer 1

A legal agreement between the Employer (also known as the Policyholder or Group) and the insurance company which outlines what coverage will be extended to eligible employees and under what conditions. Can be one or all of the following: Application/Subscription Agreement, Certificate, or Policy.

Question 2

Participating Unit

Answer 2

Participating Unit means any sole proprietorship, partnership, corporation, limited liability company, limited liability partnership, firm, school district, individual school, or other instrumentality of a state or political subdivision thereof, that has been approved by AUL and added by amendment to the Group Policy.

Question 3

Policyholder (PH)

Answer 3

The entity with whom OneAmerica has entered into an insurance contract.

Question 4

Policyholder Name

(Group Name)

Answer 4

This is the name of a specific customer.

Question 5

Policyholder Number

(Group number)

Answer 5

This is the number used to identify a customer.

Question 6

Employer (ER)

Answer 6

The entity or organization for which the Person performs services and which has the right to control what will be done, and how it will be done. An Employer has the right to control the details of how the services are performed by the Person. The Person must not be considered an independent contractor or agent unless classified by the IRS as a statutory employee of the Employer. The Employer is the entity or organization for which the Person performs his occupation, and is required to withhold and pay income, social security, and Medicare taxes on wages.

Question 7

Insured

Answer 7

A person covered under a group insurance contract.

This is not necessarily always group contract, but for AUL, it is.

Question 8

Prudent Person

Answer 8

An individual who uses good judgment or common sense in handling practical matters.

Question 9

Employee (EE)

Answer 9

A person employed by a company/person who puts in a claim for benefits.

Question 10

Initial Employee

Answer 10

An employee hired before the Policyholder or coverage effective date.

Question 11

Effective Date

Answer 11

The date that a coverage is in-force or employee is covered under the group contract.

Question 12

Waiting Period (WP)

Answer 12

The amount of time a person must be actively at work prior to becoming eligible for coverage.

Question 13

Initial Enrollment Period

Answer 13

Time period when initial employee’s enrolled for coverage and during which new employees have to enroll for coverage without Evidence of Insurability.

Question 14

Scheduled Enrollment Period

Answer 14

A period of time each year when employees can change their coverage or apply for coverage if they are late enrollees.

Question 15

Late Enrollee

Answer 15

An employee who did not elect coverage during the initial enrollment period.

Question 16

Evidence of Insurability (EOI)

Answer 16

A statement or proof of an Employee’s medical history upon which eligibility for insurance will be determined by AUL. EOI may be required for late enrollees, increase of elected benefit or other reasons as defined by the Policy. Coverage will be approved or declined by medical underwriting. See AWD for letter confirming effective date of coverage.

Question 17

Statement of Insurability (SOI)

Answer 17

A form that must be completed when Evidence of Insurability (EOI) is required. EOI and SOI are sometimes used interchangeably to describe this form. The form contains questions about a person’s current and previous medical history and health.

Question 18

Family Status Change

Answer 18

A change in your situation (e.g. such as marriage, child birth, etc.) that can make you eligible for a Special Enrollment Period, allowing you to enroll in insurance outside the yearly Open Enrollment Period.

Question 19

Certificate

Answer 19

A document containing contractual information outlining the benefits elected by the Policyholder.

Question 20

Certificate Number

Answer 20

The number assigned to the Certificate

Question 21

Class

Answer 21

A well-defined segment of the covered group that has been separated according to specific criteria.

Question 22

Closed Class or Plan

Answer 22

A class that has employees enrolled, but no future enrollment into that class. A closed class is typically to accommodate a particular situation, i.e., grandfathered employees, employees from a takeover that may have a different benefit, etc.

Question 23

Elected Benefit

Answer 23

The benefit amount is not based on salary. It’s either a true flat amount (one for everyone) or an incremental amount.

Question 24

Coverage Month

(Policy Month)

Answer 24

The period of time beginning on the Person’s Individual Effective Date, and continuing from the first day and ending on the last day of each succeeding Policy Month.

Question 25

Schedule of Benefits

Answer 25

This is a summary of benefits that appears after the table of contents of each certificate and Policy. A Policy contains all Schedule of benefits page for all classes for a particular coverage.

Question 26

Amendment

Answer 26

A legal document changing the provisions of the Policy that is signed jointly by the insurance company and an authorized representative of the policyholder.

Question 27

Rider

Answer 27

An optional coverage of feature that can be added to coverage (generally at an additional cost).

Typically, Riders can be located in the policy’s Schedule of Benefits (see definition). Examples: COBRA, Supplemental Disability Benefit, Social Security Incentive, Survivor Benefit, etc.

Question 28

Conversion

Answer 28

A provision in the insurance Policy that allows individuals who through termination are no longer eligible for coverage under the group Policy, to convert to an individual plan of insurance without providing evidence of insurability.

Question 29

Portability

Answer 29

A provision under some policies which allows employees to take the coverage with them upon termination of employment.

Question 30

Guaranteed Issue (GI)

Answer 30

The maximum amount of coverage allowed without Evidence of Insurability (EOI).

Question 31

Guaranteed Increase in Benefit (GIB)

Answer 31

The amount of coverage that does not require Evidence of Insurability (EOI). This amount is shown on the Schedule of Benefits page. Of note, although no EOI required, with increased election, the GIB, may be subject to pre-existing review. Each Policy will outline parameters regarding this.

Question 32

Special Conditions Limitations

Answer 32

A policy provision that applies when chosen by the Participating Unit on the Subscription Agreement. Benefits for Disability due to Special Conditions, whether or not benefits were sought because of the condition, will not be payable beyond a number of months as defined by the Policy and is also stated on the Subscription Agreement. Benefits payments for Disabilities due to Special Conditions are cumulative for the lifetime of the contract.

Question 33

Waiver of Premium (WOP)

Answer 33

A provision that allows the insured to not pay premiums under certain circumstances set forth in the Policy.

Question 34

Advance Survivor Benefit

Answer 34

Provision in some policies that generally allows a Person to receive an Advanced Survivor Benefit prior to the Person’s death if he has been diagnosed with a Terminal Illness, while covered under the Group Policy, in lieu of any other Survivor Benefit under the Group Policy upon the Person’s death.

Question 35

Elimination Period (EP)

Answer 35

A defined term under the Policy. Generally it is a period of time that a person must be totally disabled or partially disabled under the terms of the Policy, and for which benefits are not paid.

Question 36

Survivor Benefit

Answer 36

A benefit offered in OA Disability group coverages that, upon death of the claimant, and under certain conditions a benefit amount may be payable to an eligible survivor.

Question 37

Dependent Child

Answer 37

A child born to the Employee, adopted by Employee, a stepchild living with Employee, whom the Employee has legal guardianship, or whom the Employee must provide insurance in accordance with court order.

Question 38

Social Security Normal Retirement Age (SSNRA)

Answer 38

The age at which a person is eligible for retirement under the Federal Social Security Act. This is sometimes called Social Security Full Retirement Age (SSFRA).

Question 39

Social Security Application Assistance

Answer 39

AUL determines that a Person is a likely candidate for Social Security Disability Insurance (SSDI), AUL may assist the Person with the application process for these benefits through the use of a Vendor specializing in Social Security benefits. Upon written request, a representative from AUL’s Group Claims Department may supply pertinent information to the Person about:
1. eligibility for SSDI benefits;
2. how to begin the application process;
3. how to submit an appeal;
4. guidelines established by the Social Security Administration for submitting appeals; and
5. names of organizations offering assistance.