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F101 - Health (Detailed) > Glossary > Flashcards

Glossary Flashcards

1
Q

Accelerated critical illness benefit

A
  • Benefit
  • Sum Assured on first of death or diagnosis of critical illness
  • Termination of policy if acceleration fully triggered (most cases)
  • if portion accelerated, balance on death
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2
Q

Activities of Daily Living (ADLs)

A
  • Set of functional tests

- Measure incapacity/disability

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3
Q

Activities of Daily Working (ADWs)

A
  • Alternative set of functional tests
  • Measure incapacity/disability
  • Focus=workplace
  • E.g. Ability to follow instructions
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4
Q

Acute illness

A
  • Illness/condition
  • Non-degenerative
  • Cure is reasonable prospect
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5
Q

Affinity group

A
  • Group of people
  • Something definitive in common
  • E.g. Membership or employee of particular organisation - but not common employment
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6
Q

Age at entry pricing

A
  • Pricing practice
  • Premiums not subject to age related increases from standard pricing (provided renewed)
  • Entry price allows for increasing probability of claim
  • Right retained to allow for medical inflation (or excess medical inflation)
  • Annual renewal basis
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7
Q

AIDS Exclusion (RSA)

A
  • Post-2005, no AIDS exclusions on new business

* 2007, best practice guideline (voluntary) to waive exclusions on post-2007 claims

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8
Q

Aliasing

A
  • Linear dependency among observed covariates
  • i.e. covar = linear combo of others
  • Equivalent: linear dependency among design matrix’s columns
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9
Q

Anti-selection

A

-Tendency for people who believe their risk to be higher than premium allows for to take out cover
OR
for sick/sub-standard people to renew policies or exercise options
-(benefits>premium)
-E.g.

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10
Q

Assessment period

A

-Time when insurer will assess condition before decision on accepting a claim
-Under CI or Disability cover - time testing “permanent” condition
Normally <12months given evidence provided

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11
Q

Asset share

A
  • Retrospective accumulation
  • Past premiums, less expenses, less cost of cover at actual rate of return on assets
  • Single or group basis
  • Aka “earned asset share”/”retrospective earned asset share”
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12
Q

Association for Savings and Investment South Africa (ASISA) (RSA)

A 
*Industry body in SA representing
 \+Asset managers 
 \+CIS Management companies
 \+Linked investment service providers
 \+Multi-managers
 \+Life insurance companies
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13
Q

ASU Insurance

A

-ST Insurance covering:
+Accident
+Sickness and…
+Unemployment

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14
Q

Bancassurance

A

-Companies
-Offer financial services encompassing both
+banking
and
+insurance operations
-Big objective: cross selling between operations

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15
Q

Benefit limitation

A

-Caps on annual amounts for specific treatments

=To contain claim costs

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16
Q

Brokers/Independent Financial Advisers (IFAs)

A
  • Intermediary
  • Between seller and buyer of particular insurance contract
  • Not tied to either party
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17
Q

Bulk rate/Unit rate

A
  • Premium rate
  • Uniformly per head
  • Per membership type
  • Age + gender independent
  • Large schemes
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18
Q

Burning cost

A

-Estimated cost of claims
-For forthcoming insurance period
-Based on past numbers
-Adjustments:
+Book changes
+Cover changes
+Medical inflation

-Can be used to describe historic cost of claims only

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19
Q

Capitation

A
  • Pricing practice
  • Premium = likely claims on individual basis, adjusted for expenses and profit
  • Risk passed onto the provider
    (risk: funds < treatment costs)
  • Premiums paid in advance instead of on claim
  • Proportion of insurance premium for separated set of medical benefits paid to provider, based on number of people served
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20
Q

Cash plan/Health cash plan

A
  • Health product
  • Pre-specified cash sum on occurrence of certain medical events
  • E.g. Hospitalisation
  • Typically benefits low relative to true costs
  • More cash in hand than indemnity
  • Normally coinsurance + Annual limit
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21
Q

Categorical variables

A
  • Explanatory variables
  • For modelling
  • Each level distinct + often no natural ordering
  • E.g. Gender
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22
Q

Chronic illnesses

A
  • Illnesses/conditions
  • Degenerative and/or incurable
  • Treatment purpose = Palliative
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23
Q

Claim escalation rates

A
  • Rate at which LTCI claims increase
  • During course of payment
  • Compound annually (unless stated otherwise)
*(RSA): 
Two categories
1. CPI
2. Fixed %
-May be subject to min or max
-Gen linked to index + increase pre- and during payment
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24
Q

Claim notification period

A

-Claims Management Requirement for insurer to be notified of claims at early stage
-Purpose:
+To improve claims handling procedures by…
++ensuring valid claims are ready to be paid at the end of the deferred period
++enabling early intervention from a claims management perspective
-Categories:
+Set time after incapacity begins
+Set time before end of deferred period

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25
Q

Claims history

A
  • Combination of claims paid (total amounts actually paid) and claims incurred (amounts paid + outstanding reserves = claims commenced in a particular year).
  • NB for reporting
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26
Q

Claims pre-authorisation

A

-Claims Management Requirement (/recommendation) for insurer approval on certain treatments/surgeries before costs incurred
-Purpose:
++manage care provision
++reduce post-event claim denials

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27
Q

Coinsurance

A
  • PMI policy condition

- Policyholder required to pay for at least part of medical expenses incurred (gen %)

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28
Q

Community rating

A
  • Pricing practice
  • Charging all/most policyholders the same premium rate
  • Irrespective of rating factors

-Sometimes refers to Pricing practice where tabular rates applied irrespective of claims history

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29
Q

Comprehensive cover

A

-Level of cover
-Full reimbursement of…
++all medical costs incurred in hospitals within appropriate bands
++other stipulated treatments
-High limits sometimes apply (p.a. or per risk section

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30
Q

Consumer Price Index (CPI) (RSA)

A
  • Index published by StatsSA

- Measures changes in prices for a basket of goods and services

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31
Q

Continuation option

A
  • Benefit
  • Insured can choose to continue cover without further health evidence (when it normally would have ceased)
  • Terms = healthy person’s at age of exit
  • E.g. leaving group scheme or term individual scheme
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32
Q

Continued Personal Medical Exclusions (CPME)

A
  • Type of No Worse Terms acceptance

- New PMI undertakes cover for same medical conditions as existed under previous insurance policy (only)

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33
Q

Co-payment

A
  • Charge to policyholder
  • For certain healthcare services under terms of the policy
  • Typically fixed ZAR amounts
  • E.g. for doctor visits, prescriptions, hospital admissions
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34
Q

Cost plus

A
  • Type of Reinsurance
  • Covers excess of pre-agreed claim fund (insured against extreme experience)
  • Purpose: to limit possible downside
  • Similar to stop loss agreement
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35
Q

Council for Medical Schemes (RSA)

A
  • Regulator of medical schemes

- Falls under Minister of Health

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36
Q

Credibility

A
  • Factor representing proportion of final risk premium derived from past experience (vs book rates)
  • Relates to experience rating
  • Depends on size of scheme
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37
Q

Creditor insurance

A

-Form of cover
-Protection on loan or mortgage
-Full payment out on…
++Death (sometimes only)
++TPD (Total and Permanent Disability)
++Critical Illness
-Temporary repayments possible under…
++Temporary disability
++Retrenchment

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38
Q

Critical illness

A

-Type of insurance contract
-Provides benefit on diagnosis of “critical illness” (or specified illness)
-Two forms:
++Accelerated
++Stand-alone
-E.g. of decrements:
++Cancer
++Heart attack
++Transplant
++Stroke
++Multiple sclerosis
-Requirement for decrement
++Perceived as serious by public (life/lifestyle threatening)
++Perceived to occur frequently

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39
Q

Day case admissions

A
  • Treatment practice
  • Straightforward operations in hospital surgical units on the day of admission
  • Occupy bed during day, discharged same day (no overnight stay)
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40
Q

Deferred period

A
  • Period of incapacity before any benefit is paid

- Feature in CI and LTCI

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41
Q

Definition of incapacity

A 
-Includes:
\++Cognitive impairment 
\++Inability to perform one or more ADLs
(context LTCI)
-Structure of LTCI benefit generally attributes higher benefit to higher level of incapacity
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42
Q

Diagnostic treatment

A
  • Medical treatment
  • Purpose: identifying medical problem
  • E.g. X-rays, laboratory tests, pathology
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43
Q

Direct marketing

A
  • Marketing (advertising/selling) of products where customer is invited to apply for product directly with insurer
  • No intermediary or third party sales person
  • E.g. Mail, newspapers, periodicals, telephone, email, internet
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44
Q

Direct sales force

A
  • Salespeople employed by the insurer
  • Only sell their products
  • Products sold directly
  • May operate on self-employed basis
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45
Q

Earned premium

A

-Proportion of premiums written and received that relates directly to the expired period of cover

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46
Q

Elective surgery

A

-Surgery deemed to be non-emergency

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47
Q

Excess/Deductible

A
  • The first fixed amount of a claim, for which the insured is responsible to pay, before the insurer will contribute to the claim’s cost
  • May apply on an individual claim basis, on a policy year aggregate basis, on a per-life basis, or on a per-policy basis
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48
Q

Exclusions

A

-Perils that are excluded from cover provided by a policy
-Big E.g.
++War, terrorism, acts of violence, civil unrest
++Self-inflicted injury, attempted suicide
++Drugs
++Alcohol
++Hazardous pastimes or sports
++Aerial activity (besides as fare-paying passenger)
++Criminal acts
++Failure to seek or follow medical advice
++Treatment relating to standard pregnancy (PMI)

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49
Q

Experience rating

A
  • Pricing practice
  • Partial or full credibility given to past claims history in assessing premium payable at renewal
  • 100% credible if premium only assessed from history (otherwise partially credible)
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50
Q

Explanatory variables

A
  • Inputs into model
  • Expected to influence
  • Rating factors in pricing context
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51
Q

Facultative

A
  • Reinsurance with no obligations on insurer or reinsurer to offer or accept risk
  • =”Optional”
  • Insurer chooses when and where to take it up, and reinsurer decides whether or not to accept
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52
Q

Financial Advisory and Intermediary Services Act (FAIS) (RSA)

A

-Governs intermediary conduct in SA

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53
Q

Financial Services Board (FSB)

A
  • Regulator of long-term and short-term insurers in SA

- Falls under National Treasury

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54
Q

Fixed Price Surgery (per-case fee)

A
  • Payment arrangement between PMI insurer and hospital or chain
  • All surgical procedures of particular type charged at particular cost per case rate
  • Regardless of individual complexity
  • Includes all care (may include complications that follow)
  • Aka “case rates”/”procedure pricing
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55
Q

Free cover

A
  • Benefit level
  • Below which member is not subject to individual underwriting
  • Group risk arrangement context
  • Function of number of members or aggregate of benefits provided
  • “Free cover limits”=”Non-selection limits”
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56
Q

General Practitioner (GP)

A
  • Doctor who provides primary medical care to the individual
  • First port of call for all health concerns
  • Often holds all individual health records
57
Q

GP Referral

A
  • Common medical protocol

- Patient referred for secondary medical care after initial consultation with GP

58
Q

Generalised Linear Model (GLM)

A
  • Model
  • Flexible generalization of the ordinary least squares regression
  • Allows for linear model to be related to response variable via link function and for variance to be function of predicted value
59
Q

Group business

A
  • Insurance type
  • Number of individuals covered under single policy
  • Members of the group linked I some way (e.g. credit card, employer)
  • Often sponsor facilitates payment and administration
  • May be compulsory or voluntary
60
Q

Guaranteed premium rates

A

-Situation where benefit-premium relationship is set from the outset for the duration of the policy

61
Q

Health Maintenance/Management Organisation (HMO)

A
  • Form of Health Organisation (akin to insurance)
  • Combines range of coverages on group basis
  • Group of medical professionals offer care for monthly subscription
  • Only visits within (and cleared by) the HMO network will be covered
  • Primary doctor within HMO deals with all referrals
  • Common in USA
62
Q

Immediate needs annuity

A

-Immediate annuity purchased by impaired life requiring long-term care
-Protection against uncertain survival duration through…
++Regular
++Guaranteed
++Lifetime
…payments made to insured in exchange for upfront premium

63
Q

Income protection insurance

A

-Insurance product
-Provides cover against incapacity (protection against temporary loss of income)
-Benefit:
++Income (usually monthly)
++Paid during disability
++Up to pre-defined age (e.g. 65) or retirement if earlier
-Subject to benefit limits (based on specified income replacement ratio)
-Formerly known as Permanent Health Insurance (PHI)

64
Q

Increase options

A

-Two types of increases securable without formal underwriting:

++Increases incorporated into original contract (automatic). Premiums may…

  • **be level throughout lifetime of policy
  • **increase in line with the benefit
  • **increase by some other pattern

++increases are costed as they arise. Premium increase may be…
**fixed monetary sum
**be in line with fixed percentage
***be in line with some form of earnings or prices index
(Opportunity for fixed increase is presented periodically to insured. New policy costed normally based on current age and outstanding term)

-Generally on CI and IP plans

65
Q

Incurred But Not Reported (IBNR)

A
  • Describes claims where event has happened but insurer is not yet notified of the event
  • Insurer is required to hold reserves against such events (for results and accounts)
66
Q

Indemnity

A
  • Principle that after a loss, the insured will be restored to same financial position as before the loss
  • E.g. PMI (generally)
  • Cash limits sometimes applicable = not full indemnity
67
Q

Individual business

A
  • Insurance covering individual under single policy document

- Can cover immediate family members on joint life basis

68
Q

In-patient

A

-Person who is admitted to hospital and occupies a bed overnight

69
Q

Insurance intermediaries

A
  • Third parties who are independent of any particular financial services company
  • Select and recommend products they consider to be the most appropriate for the customer, using various criteria
  • Aka brokers/financial advisors
70
Q

Interaction term

A
  • Parameter used to capture the effect of a combination of factors on a response variable
  • Used when the effect of one factor varies depending on the value of another
71
Q

International Classification of Diseases (ICDs)

A
  • Classification of Diseases and surgical operations
  • Through coding and wording
  • Purpose: maintain international standard
  • E.g. ICD-9 and ICD-10
72
Q

Investigative surgery

A
  • Surgery with purpose of advancing the diagnosis (nature and extent of complaint)
  • Generally covered under PMI products. May not be under MME products
73
Q

Irreversible

A
  • Describes conditions thsy cannot be cured by medical treatment or surgical procedures at the time of the claim
  • Generally used to define CI conditions
    (e. g. Blindness, deafness, loss of speech, paralysis of limbs)
74
Q

Keyperson cover

A

-Insurance product taken out by employer to cover key employees
-Two categories of product designs:
++Compensation for loss of profits
++Cover for employee’s salary (to facilitate temporary recruitment of replacement)
-Perils:
++Sickness
++Incapacity
++Death

75
Q

Long-term care insurance

A

-Provides financial security against tidk of needing care as an elderly person (in home or at nursing home)

-Two types:
++Indemnity (pays for all costs of care for remainder of life)
++Cash lump sum or annuity

-Peril:
++Satisfy disability conditions (generally in terms of ADLs)

76
Q

Loss ratio

A

-Ratio of claims incurred to the relevant premiums
-Claims have allowance for ultimate settlement amounts
-Sometimes claims include expenses
(called Combined Ratio/Operating Ratio)

77
Q

Low cost options (budget policies)

A

-Cheaper policies with restricted cover
-Generally PMI
…Types of restrictions:
++Excesses
++Contingency on public service waiting periods
++In-patient cover only

-Sometimes CI
…Types of restrictions:
++Restricted list of diseases covered

-Sometimes IP
…Types of restrictions:
++Limited benefit period

78
Q

Major medical expenses (MME)

A

UK:
-Variant of PMI cover
-Pays fixed amount from schedule (relating to severity)
-Perils:
++Non-investigative and non-cosmetic surgery

USA:

  • Comprehensive PMI type
  • Reimbursement of costs of primary, secondary and tertiary care, as defined in the policy
79
Q

Managed care

A

-Process whereby insurer intervenes in the provision of medical care
-Purpose:
++Optimising quality of treatment
++Controlling costs
-Through:
++Preferred provider utilisation
++Claims preauthorisation

80
Q

Means test

A

-Examination into the financial state of a person to determine their eligibility for public assistance

81
Q

Medical History Disregarded (MHD)

A
  • Underwriting approach
  • Policy written without regard to individual’s past medical history (no exclusions for pre-existing medical conditions)
  • Common in group PMI
  • May be offered to individual transferring out of group
82
Q

Medical inflation

A

-The annual increase in the average cost of medical treatment per insured life
-Can reflect increases due to…
++Increase in treatment costs
++Increase in average incidence

83
Q

Medical savings account

A

-Fund contributed to by PMI policyholder
-May be used for:
++Copayments
++Amounts above maximum benefit levels
++Treatments not covered by PMI cover
-Contributions are often tax deductible

84
Q

Microinsurance

A
  • Insurance products that are characterised by low premiums and low coverage limits
  • Based on pooling or community approach
  • Typically targeted at low wealth segments
  • Provides social benefit
  • Well developed in India and parts of Africa (but still growing market)
85
Q

Moratorium

A
  • Alternative to formal underwriting at outset
  • Instead of initial formal underwriting, insurer will not cover medical conditions that existed during a re-specified period, and verify this basis at the point of claim
  • Period is typically 2 to 5 years
  • Pre-existing conditions will be covered if no treatment, symptoms or advice have taken place for the specified uninterrupted period
  • All other conditions covered immediately
86
Q

National Health Insurance (NHI)

A

-Universal system offering healthcare to:
++ those who contribute
++ those who cannot afford to do so
-Usually a split between purchaser and provider
…Purchaser may either be single entity (e.g. State) or multiple entities (insurers)

87
Q

National Health Service (NHS) (UK)

A
  • UK’s public health service
  • Originally formed to provide free medical care to all throughout life
  • Funded by general taxation
  • Increasingly, payments required at point of claim (such as copayments for prescriptions, dental case, glasses, etc.)
88
Q

No claims discount (NCD)

A
  • System of increasing discount to some reference premium applied for each year that no claims are made
  • Subject to limit
  • For each claim made, level of discount reduces (can even result in higher premium than reference premium)
  • Own-experience proxy (better risk segmentation)
89
Q

No Worse Terms (NWT)

A
  • When insurer offers cover at least as comprehensive as policyholder’s current policy (with no additional underwriting conditions)
  • The renewal or “switch” is accepted on no worse terms
  • Under PMI or group business
90
Q

Non-medical limits

A
  • Maximum long-term policy benefits for which one can propose, without needing an automatic medical examination or PMAR
  • Not a guarantee that the proposer will not be asked to attend a medical examination
  • Right is always reserve to call for additional medical evidence (if felt necessary in light of any info they already have)
91
Q

Non-proportional reinsurance

A
  • Reinsurance protection that covers amounts above pre-defined limits (rather than splitting proportionally)
  • Under PMI: often applied to portfolio of risks as a whole than individual risks
  • E.g. Stop loss, Catastrophe excess of loss
92
Q

Open enrolment

A

-Process where insurer is obliged to accept all proposers for insurance at standard rates

93
Q

Original terms

A

-Method of reinsurance
-Reinsurer has virtually identical contract to insurance company in respect of reinsured portion of the risk
-Reinsurer receives the same gross premiums for its share as insurance company EXCEPT policy fee is normally retained in full
-Reinsurer is responsible for:
++proportionate share of the sum insured under claim event
++proportionate share of the surrender value under surrender event

94
Q

Out-of-pocket costs

A

-Amounts of medical treatment not covered by PMI or State healthcare
-Paid by person seeking treatment
-Can be result of:
++Co-payments
++Deductibles
++Benefit limits
++Exclusions

95
Q

Out-patient

A
  • Person who attends hospital for treatment or consultation, but does NOT occupy a bed
  • Aka “ambulatory treatment”
96
Q

Permanent

A
  • Describes health condition that’s expected to last throughout the insured person’s life, irrespective of when cover ends or person retires
  • Used in relation to claim for TPD benefit under CI contract
97
Q

Personal accident insurance

A
  • Type of insurance
  • Provides specified fixed benefit amounts in event that the insured suffers the loss of a limb, or another specified injury
98
Q

Personal capability assessment (PCA)

A
  • Alternative way of assessing disability
  • Largely independent of age and occupation of person being assessed
  • Involves assessment to complete everyday tasks of living
  • E.g. climbing stairs, bending, lifting, carrying
99
Q

Policy limit

A
  • Maximum amount that can be paid out under a policy
  • Sometimes expressed over defined period of time (e.g. annual limit)
  • Some indemnity policies limit benefits payable under particular sections of the policy –> partial indemnity
100
Q

Pre-Existing Conditions (PEC) Exclusion

A
  • Exclusion terms where cover not provided in respect of the policy’s standard covered conditions where the insured life has already suffered from the condition
  • Commonly includes conditions where other previously suffered conditions result in a materially higher risk of that condition occurring
  • Used in PMI and CI
101
Q

Preferred Provider Organisation (PPO)

A

-Medical establishments, outside of which a PMI policy may:
++not provide cover to
++limit the scale of its reimbursement
-Policies with such restrictions will typically have cheaper premium
-Insurer will have special arrangements with the organizations (often financial)

102
Q

Prescribed Minimum Benefits (PMBs) (RSA)

A

-Minimum package of benefits re-introduced in the Medical Schemes Act of 1998
-Consist of…
++PMB-DTP (270 Diagnoses and Treatment Pairs, introduced in Jan 2000)
++PMB-EMC (Emergency Medical Conditions, introduced in Jan 2003, usually included in PMB-DTP)
++PMB-CDL (diagnosis, treatment and medication according to therapeutic algorithms for 25 defined chronic conditions introduced in Jan 2004)

103
Q

Primary Care

A
  • Advice and treatment provided by a general practitioner

- Generally a nurse practitioner in public sector

104
Q

Private Medical Attendant’s Report (PMAR)

A
  • Report sough by insurer
  • To provide further insight into an individual’s state of health
  • At the proposal or claim stage
105
Q

Private Medical insurance (PMI)

A
  • Insurance product
  • In return for premiums, insurer promises to pay certain sums of money, on occurrence of certain medical events
  • Generally classified as a short-term insurance
  • Events are frequently surgical in nature (esp. in UK)
  • Benefits are usually indemnifying
106
Q

Profit sharing

A

-Practice where insurer rewards a group for better-than-expected-experience through a share in the profit arising
-Group scheme business
-Share may be expressed as:
++Cash refund
++Discount against the future premium

107
Q

Reported But Not Settled (RBNS)

A
  • Claims that the insurer has been notified of, but where the sum insured due has yet to be agreed and paid
  • Insurer is required to hold reserves against these claims (results and accounts)
108
Q

Residence (location)

A

-Clause limiting the location/countries in which a policyholder may be resident to, to make a valid claim
(ensures effective claims management)
-Esp. in group cover, but may be seen in individual

109
Q

Residential facilities

A
  • Long-term care facilities that provide supervision and assistance in ADLs with medical and nursing services when required
  • E.g. Assisted living facilities, homes for the elderly
110
Q

Response variable

A
  • Outputs from a model (what a model tries to predict)
  • Likely to be affected by the explanatory variables
  • E.g. in pricing, response variable = premium
111
Q

Reviewable premium

A
  • Form of premium
  • Allows insurer to alter premiums if aspect of the premium basis for the portfolio as a whole (e.g. prospective claims) is different from what was originally expected
  • Offered in CI
  • Most companies with reviewable rates, undertake reviews every 5 years (though experience monitoring done more regularly)
112
Q

Rider benefits

A
  • Extra benefits that can be added to a basic policy
  • Either at commencement of cover, or at defined policy anniversaries
  • Benefits underwritten at outset and normally affect premium rates (and possible underwriting requirements)
  • Some riders offered at no additional charge (for marketing reasons)
  • E.g. in CI: rehabilitation benefits or hospital cash
113
Q

Risk equalisation

A

-System in some markets whereby profits/losses on specified policies/risks are pooled and reapportioned among participating insurers, so that each shares in the average market experience

114
Q

Risk premium

A
  • Method of reinsurance
  • Used when long-term insurer wishes to reinsure only the risk element (mortality/morbidity) of a policy
  • Insurer and reinsurer agree on a set of risk premium factors to be applied to the benefit reinsured (e.g. age, gender, smoker status -> depending on legislation)
  • Under health contracts, these risk premium rates are often used as the basis of the insurer’s office premium rates
115
Q

Secondary care

A

-Advice and treatment as provided by hospitals, consultants and other specialists, usually after referral by the patient’s GP

116
Q

Service Level Agreement (SLA)

A

-Contract between service provider and procurer of services
-Sets out the services’:
++nature
++quality
++scope
++penalties (under service failure)
-E.g. contract between insurer and Third Party Administrator

117
Q

Smoker/Non-smoker rates

A

-For long term contracts, most companies offer different rates based on smoker status
-Purpose:
++Reflects different morbidity/mortality of smokers vs non-smokers
-Generally doesn’t apply to pricing of larger group schemes (more experience-rated)
-Definition of smoker status may vary between insurers

118
Q

Social Health Insurance (SHI)

A
  • System that only provides health cover to those who can afford to contribute
  • Those who can afford to contribute are compelled to do so
  • Services are provided by private sector
  • Public sector provides for those who can’t afford to contribute
119
Q

Solvency II (UK)

A
  • Set of regulatory requirements implemented on 1 Jan 2016
  • Aim of EU solvency rules:
    1. Ensuring that insurance undertakings are financially sound and can withstand adverse events
    2. Protecting policyholders and the stability of the financial system as a whole (as a result of 1.)
120
Q

South African Insurance Association (SAIA) (RSA)

A

-Industry body of short-term insurers

121
Q

Stand-alone critical illness plans

A

-Policies that only provide cover against critical illnesses
-Do not provide/accelerate any benefit in the event of death
(stand-alone rider adds pure CI benefit to product)
-Policy terminates following payment of CI benefit
-Occasionally, such policies may offer nominal sum in the even of death (if before CI was suffered)

122
Q

Statistics South Africa (StatsSA) (RSA)

A
  • Government agency
  • Responsible for compiling and analyzing South Africa’s economic, social and demographic statistics
  • E.g. CPI, trade figures, labour market data, periodic census of the population, health statistics
123
Q

Stop loss

A
  • Reinsurance contract
  • Insurer’s claims exposure will be restricted at some multiple of premium
  • Arrangement stipulates loss ratio above which reinsurer becomes responsible for all/the majority of further claims
  • Similar to cost plus
124
Q

Surplus reinsurance

A
  • Reinsurance arrangement

- Long-term insurer will cede all sums that exceed its retention on each individual life, to the reinsurer

125
Q

Switch

A
  • Process whereby an existing policyholder (individual or group) changes insurer on renewal
  • Possibly without further underwriting, or with reduced underwriting (e.g. declaration of good health)
126
Q

Telemarketing

A
  • Marketing of products via the telephone
  • Usually enquiries are generated by direct marketing with customer calling-in
  • Aim = complete application procedures over telephone
  • Policy will then be dispatched together with a direct debit instruction completion, and a copy of the completed application for signature by applicant (confirming answers given to underwriting questions)
127
Q

Terminal illness

A
  • Medical condition

- Expected to result in person’s death within short period

128
Q

Tertiary care

A
  • Medical care
  • Only provided in specialist centres (for specialist investigation and treatment)
  • Usually on referral from secondary medical care personnel
  • E.g. neurosurgery, burns care
129
Q

Third Part Administrator (TPA)

A
  • Administrator
  • Providing claims processing and/or other services
  • To self-funded group health programs or PMI insurers
130
Q

Tied agents

A
  • Salespeople
  • Act more independently than direct salesforce (more operational freedom + can employ their own salespeople)
  • Sell only the products of one insurance company (“tied”)
  • Aka appointed representatives
131
Q

Total and Permanent Disability

A
  • Disability cover
  • Often included within CI product
  • Permanency of disability distinguishes it from income protection cover (definition of “permanent” NB)
  • “Total” means failure of ability to perform a major or substantial part of the job/function
132
Q

Treating Customers Fairly (TCF) (RSA)

A

-Best practice guideline from ASISA (2011)
-For engaging with consumers at all stages (product design, marketing, advice, complaints, pre- and post-sale, claims management, etc.)
-6 key outcomes:
++Having the right business culture (governance: responsibility sits with board and senior management)
++Market needs approach (not product push approach)
++Communicating information in a way that is clear, fair, balanced and not misleading
++Giving appropriate advice
++Ensuring products meet the needs of the largest market, contain clear, understandable info and are sold through the appropriate distribution channels
++Ensuring ease of product switching, claiming and making complaints

133
Q

Treatment protocol (RSA)

A

-Set of guidelines setting out the optimal sequencing of diagnostic testing and treatment for specific conditions

134
Q

Treaty

A
  • Formal agreement between insurer and reinsurer
  • Sets out terms of reinsurance arrangement
  • Imposes obligation on reinsurer to automatically accept business ceded within the scope of the treaty
  • Also usually imposes similar obligation on the insurer to pass business onto reinsurer that falls within the scope and other terms of the treaty
135
Q

Voluntary group

A
  • Describes collection of policyholders for whom membership of a PMI scheme is voluntary
  • May include affinity groups or employment groups
136
Q

Waiting period

A
  • Feature adopted by insurer
  • Specified period after policy inception during which benefits will not be paid
  • May also be applied to any additional benefit taken up after inception (from the amendment date)
  • Aka “no-claim period”
137
Q

Waiver of premiums

A

-Practice whereby premium for CI policy is covered in addition to the main benefit provided by the policy in the event of disability

138
Q

World Health Organisation (WHO)

A

-Autonomous health organization
-Set up in 1948
-Aim:
++Assisting the population in the attainment of the highest possible level of health
-Actions:
++Proposes…
**Conventions
**Agreements
**Regulations
++Makes recommendations about…
**Nomenclature of diseases
**Causes of death
**Public health practices
++Develops, establishes and promotes:
***International standards (concerning foods and biological/pharmaceutical/similar substances)

139
Q

Written premiums

A
  • Regular premium business:
  • *Annualised amount of premiums for all policies commencing or renewing in a given period
  • Single premium business:
  • *Wholly written

F101 - Health (Detailed) (34 decks)

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