Glossary Terms E - M Flashcards
Eligibility Period
The period of time in which an employee may enroll in a group healthcare plan without having to provide evidence of insurability.
Elimination period
The waiting period that is imposed on the insured from the onset of disability until benefit payments begin.
Emergency
An injury or disease which occurs suddenly and requires treatment within 24 hours.
Endodontics
Area of dentistry that deals with diagnosis, prevention, and treatment of the dental pulp with natural teeth at the root canal.
Enrollment period
The amount of time an employee has to sign up for a contributory group health plan.
Estoppel
A legal impediment to denying the fact or restoring a right that has been previously waived.
excess charge
The difference between the Medicare approved amount for a service or supply and the actual charge.
Expiration
Date specified in the policy as the date of termination.
Explanation of benefits (EOB)
A statement that outlines what services were rendered, how much the insured paid, and how much the insured was billed
Explanation of Medicare benefits
A statement sent a Medicare patient indicating how the Medicare claim will be settled.
Exposure
The unit of measure used to determine rates charged for insurance coverage.
Express authority
The authority granted to an agent by means of the agent’s written contract.
Extended care facility
Facility which is licensed by the state to provide 24 hour nursing care.
Extension of benefits
A provision that allows coverage to continue beyond the policies expiration date for employees were not actively at work due to disability or who have dependents hospitalized on that date. This coverage continues only until the employee returns to work or the dependent leaves the hospital.
Fair credit reporting act
A federal law that established procedures that consumer reporting agencies must follow in order to ensure that records are confidential, accurate, relevant and properly used.
Fiduciary
An agent/broker who handles insurer’s funds in a trust capacity.
Flexible spending account (FSA)
A salary reduction cafeteria plan that uses employee funds to provide various types of healthcare benefits.
Foreign insurer
And insurance company that is incorporated in another state.
Fraternal benefit societies
Life or health insurance companies formed to provide insurance for members of an affiliated lodge, religious organization, or fraternal organization with a representative form of government.
Fraud
Intentional misrepresentation or deceit with the intent to induce a person to part with something of value.
Free look
A period of time, usually required by law, during which a policy owner may inspect a newly issued individual life or health insurance policy for a stated number of days and surrender it in exchange for a full refund of premium if not satisfied for any reason.
Gatekeeper model
A model of HMO and PPO organizations that uses the insured’s primary care physician (the gatekeeper) as the initial contact for the patient for medical care and for referrals.
Grace period
Period of time after the premium due date in which premiums may still be paid, and the policy and its riders remain in force.
Group disability insurance
A type of insurance that covers a group of individuals against the loss of pay due to accident or sickness.
Group health insurance
Health coverage provided to members of a group.
Hazard
A circumstance that increases the likelihood of a loss.
Hazard, moral
The effects of a person’s reputation, character, living habits, etc. on his/her insurability.
Hazard, morale
The effect a person’s indifference concerning loss has on the risk to be insured.
Hazard, physical
A type of hazard that arises from the physical characteristics of an individual, such as a physical disability due to either current circumstance or a condition present at birth.
Health insurance
Protection against loss due to sickness or bodily injury.
Health maintenance organization (HMO)
A prepaid medical service plan in which specified medical service providers contract with the HMO to provide services. The focus of the HMO is preventative medicine.
Health savings accounts (HSA’s)
Plans designed to help individual save for qualified health expenses.
Health reimbursement account (HRA’s)
Plans that allow employers to set aside funds for reimbursing employees for qualified medical expenses.
Home health agency
An entity certified by the insured’s health plan that provides healthcare services under contract.
Home healthcare
A type of care in which part-time nursing or home health aide services, speech therapy, physical or occupational therapy services are given in the home of the insured.
Home health services
A covered expense under part A of Medicare in which a licensed home health agency provides home health care to an insured.
Hospice
Facility for the terminally ill that provides supportive care such as pain relief and symptom management to the patient and his or her family. Hospice care is covered under part a of Medicare.
Hospital confinement rider
An optional disability income rider that waves the elimination period when an insured is hospitalized as an inpatient.
Income replacement contracts
Policies which replace a certain percentage of the insured’s pure loss of income due to a covered accident or sickness.
Implied authority
Authority that is not expressed or written into the contract, but which the agent is assumed to have in order to transact the business of insurance for the principal.
Identify
To restore the insured to the same condition as prior to loss with no intent of loss or gain.
Insolvent organization
A member organization which is unable to pay its contractual obligation‘s and is placed under a final order of liquidation or rehabilitation by the court of competent jurisdiction.
Insurability
The acceptability of an applicant who meets an insurance companies underwriting requirements for insurance.
Insurance
A contract whereby one party (insurer) agrees to indemnify or guarantee another party (insured)against a loss by a specific future contingency or peril in return for payment of a premium.
Insured
The person or organization that is protected by insurance; the party to be indemnified.
Insuring clause
A general statement that identifies the basic agreement between the insurance company and the insured, usually located on the first page of the policy.
Intentional injury
An act that is intended to cause injury. Self-inflicted injuries are not covered under accident insurance; intentional injuries inflicted on the injured by another are covered.
Intermediaries
Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services.
Intermediate care
A level of care that is one step down from skilled nursing care; provided under the supervision of physicians or registered nurses.
Investigative consumer report
Report similar to consumer report, but one that also provides information on the consumers character, reputation and habits.
Lapse
Termination of a policy because the premium has not been paid by the end of the grace period.
Law of large numbers
A principal stating that the larger the number of similar exposure units considered, the more closely the loss is reported equal the underlying probability of loss.
limited policies
Health insurance policies that cover only specific accidents or diseases.
Limiting charge
The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment of the Medicare approved amount.
Lloyd’s associations
Organizations that provide support facilities for underwriters or groups of individuals that accept insurance risk.
Long-term care (LTC)
Health and social services provided under the supervision of physicians and medical health professionals for persons with chronic diseases or disabilities. Care is usually provided in a Long-Term Care Facility which is a state licensed facility that provide services.
Long-Term Disability Insurance
A type of individual or group insurance that provides coverage for illness until the insured reaches age 65 and for life in the case of an accident.
Loss
The reduction, decrease, or disappearance of value of the person or property insured in a policy, by a peril insured against.
Loss of income insurance
Insurance that pays benefits for inability to work because of disability resulting from accidental bodily injury or sickness.
Major medical insurance
A type of health insurance that usually carries a large deductible and pays covered expenses up to a high limit whether the insured is in or out of the hospital.
Medicaid
A medical benefits program jointly administered by the individual states and the federal government.
Medical expense insurance
A type of insurance that pays benefits for medical, surgical, and hospital costs.
Medical information bureau (MIB)
An information database that stores the health histories of individuals who have applied for insurance in the past. Most insurance companies subscribe to this database for underwriting purposes.
Medical savings account
An employer–funded account linked to a high deductible medical insurance plan.
Medicare
The United States federal government plan for paying certain hospital and medical expenses for persons who qualify.
Medicare supplement insurance
A type of individual or group insurance that fills the gaps in the protection provided by Medicare, but that cannot duplicate any Medicare benefits.
Medigap
Medicare supplement plans issued by private insurance companies that are designed to fill some of the gaps in Medicare.
Misrepresentation
A false statement or lie that can render the contract void.
Morbidity rate
The ratio of the incidence of sickness to the number of well persons in a given group of people over a given period of time.
Morbidity table
A table showing the incidence of sickness at specified ages.
Multiple–employer trust (MET)
A group of small employers who do not qualify for group insurance individually, formed to establish a group health plan or self-funded plan.
Multiple employer welfare Association (MEWA)
Any entity of at least two employers, other than a duly admitted insurer, that establishes an employee benefit plan for the purpose of offering or providing accident and sickness or death benefits to the employees.
Mutual companies
Insurance organizations that have no capital stock, but are owned by the policyholders.
