Health Flashcards
NEW BORN CHILD COVERAGE
All individuals and group health plans which provid coverage to family members of insured must provide coverage for the insureds new born at the moment of birth. If a premium is required to continue the newborn it must be paid within the first 31 days. Coverage includes injury and sickness including medical care for diagnosed congenital defects and birth abnormalities.
Handicapped Dependent
Are not subject to an age limitation and are covered until the become self supportive. Proof of incapacity must be provided to the insurer within 31days of attainment of the limiting age.
Claims form provision
Specifies the formal request to an insurance company asking for payments based on the terms of the insurance policy. Must supply a claim form within 15 days after receiving a notice of claims.
Relation of earnings to income
Disability payments shall not exceed the average monthly earnings of the insured at the time Disability begins or for two years prior to Disability.
Notice of claims
A policy provision that describes the policy owners obligation to provide notification of a claim to the insurer within a reasonable period of time. Usually 20 days after the occurrence or a commencement of the loss. Or as soon after as is reasonably possible. For disability claims an insurer may request from the insured a notice of claims every 6 months
Grace Period
Is a period after the due date of a premium during which the policy remains in force without penalty. The beneficiary will receive the face amount of the policy minus any required premiums. 7 days for weekly policies 10 days for policies with premium payable monthly 31 days for other policies
Reinstatement
If the insurer takes no action on the application for 45 days the policy is reinstated automatically. Losses resulting in sickness are covered only if sickness occurs at least 10 days after the reinstatement date.
Delayed Disability Provision
Is a disability income policy provision that allows a certain amount of time after an accident for a disability to result and the insured remains eligible for benefits.
Creditable coverage
Is a previous coverage under another insurance plan when there has not been a break in coverage of 63 days. Waiting period is reduced or eliminated all together when he/she has creditable coverage.
Simultaneous Death Act
States that if the insurerd and the primary beneficiary die at approximately the same time for a common accident with no clear evidence as to who died first. The uniform simultaneous death act law will assume that the primary died first this allows the death benefit proceeds to be paid to the contingent beneficiary.
Payment of claims
State that health insurance benefits must be payable to the insured. Pay directly to hospital or provider of medical. Pays to named beneficiary. May not exceed $1000 dollars.
Noncancellable policies
States the policy cannot be canceled nor can its premium rates be increased under any circumstances. Disability policy are the most common noncancellable.
Limited risk policies
Provides coverage for specific such as injuries received as a result of travel accidents or medical expenses stemming from a specific disease.
Service providers
Offer benefits to subscribers in return for payment of premiums. Benefits are in the form of services provided by hospitals and physicians in the plan.
Per Stirpes
By bloodline means that in the event that a beneficiary dies before the insured. Benefits from the policy will be paid to that beneficiary heirs.
Business overhead expenses insurance
Is a form of disability income coverage designed to pay expenses such as rent should the insured business owner become disabled. Includes things such as mortgage payments utilities telephones leased equipment.
Per capita
Evenly distributes benefits among all named living beneficiaries.
Basic medical expense insurance
Is a health insurance policy that provides first dollar benefits for specified health care such as hospitalization surgery or physician service.
Health reimbursement arrangements
Are employer funded and employer established tax advantage health benefit plans that reimburse employees and individual health insurance premiums.
Physical Exam and Autopsy provisions
Standard health insurance policy provision allowing the insurer to examine the insured when a claim is pending. In the event of death perform an autopsy where not prohibited by law allows company to physical examination of the insured at responsible intervals during the claim pending. Unless it’s forbidden by state law.
Conversation Privilege
Allows a policy owner before an original policy expires to elect to have a new policy issued that will continue the insurance coverage.
Core benefits
All Medicare supplement plans cover coinsurance on hospital cost up to an additional 365days after Medicare part a hospital benefits run out.
Guaranteed renewable policies
Specify that the policy must be renewed however the insurer still has the option to increase the premiums.
Guaranteed Insurability rider
Is an arrangement usually provided by riders where by additional insurance may be purchased at various times without evidence of insurability.
Non-renewable policies
Are for predetermined terms of a year or less. Short term health insurance is a form of this
Cost of living adjustment rider
Is a rider avaliable with some policies that provide for automatic increase in benefits.
Cancellable policies
Allows the insurer the option to terminate the policy at anytime. This type of renewability is prohibited in most states.
Hospital indemnity policies
Are forms of health insurance providing a stipulated daily weekly or monthly indemnity during hospital confinement. Payable on an unallocated basis without regard to hospital expense.
Hospital expense Policies
Covers hospital room and board miscellaneous hospital expenses use of operating room and supplies. These expenses are covered while the insured is confined In hospital. No deductible, limits on room and board are set at a specified dollar amount per day up to the maximum number of days.
Optionally Renewable Policies
Gives the insurer the option to terminate the policy on a date specified in the contract. Also have the option to increase the anniversary date.
Social security rider
Provides for a payment of additional income when the insured is eligible for social insurance but those benefits have not begun have been denied or have begun in an amount less than the benefit amount.
Entire contract
States that the insurance policy itself and riders and endorsement, amendments and the application comprise the entire contract. Contract between all parties. Insurance producers cannot make any changes to a policy. Found in the beginning of every insurance policy issued. Authorized officers are allowed to make changes to the contract.
Twisting
Is inducing or attempting to induce any insured person through misrepresentation to lapes forfeit or surrender insurance.
1970 Fair credit reporting act
Is the authority that requires a fair and accurate reporting of info about consumers including applications for insurance. Insurers must inform applicants about any investigations that are being made upon completion of the application.
Commercial insurance
Are companies owned by private citizens or groups that offer more insurance lines. Are not government owned.
Disability income
Are valued contracts the amount of benefit that the insurance company will pay is based apon the applicant net earned income.
65% for higher incomes
85% for lower incomes
Consideration clause
States that a policy owners must pay a premium in exchange for the insurers promise to pay benefits.
Boycott,Coercion and intimidation
Is to be involved in any activity of boycott, coercion, or intimidation that is intended to restrict fair trade or create a monopoly.
Benefit period
Is the maximum length of time during which a benefit is paid the longer the benefit period the higher the premium.
Franchise Health plans
Provides health insurance coverage to members of an association or professional society. Individual policies are issued to individual members. Association or society serve as a sponsor for the plan
Premium rates are usually discounted for franchise plans.
Recurrent disability provision
Is a disability income policy provision that specifies the period of time during which the reoccurence of a disability is considered a continuation of a prior disability.
Change of occupation provisions
Allows the insurer to reduce the maximum benefit payable under the policy . If the insured switches to a more hazardous occupation or to reduce the premium rate charged to a less hazardous.
Waiting period
Is a period of time 12 months beginning with your effective date during which your health insurance plan does not provide benefits for pre existing conditions.
Revocable beneficiary
Is a beneficiary that the policy owner may change at anytime without notifying or getting promisson from the beneficiary.
Enrollment period
Is the limited period of time during which all members may sign for a group plan. Once a year for a set number of days.
Renewability provision
The right of the insurer to cancel the policy at different points during the life of the policy. These policy cannot be canceled by the insurer unless the policy owner fails to make a required premium payment.
1985 Cobra act
Is a federal legislation which extends group health coverage to terminated employees families. For up to 18 months any company which has at least 20 full time employees over the past calender year must comply.
Nondisabling Injuries
Are injuries that may have resulted from an accident but are not necessarily disabling.
Medicare part D
Program that offers a prescription drug benefit to help Medicare beneficiary pay for drugs they need. It’s optional. Only available to anyone who is entitled to Medicare part A and B
Credit policies
Are designed to help the insured to pay off loans in the event they are disabled due to an accident or sickness or in the event they die. Can’t exceed amount of loan
Provides monthly benefit payments equal to the monthly payments due. Pays a lump sum to the creditor to pay off the loan.
Replacement health insurance
A notice must be signed by producer and applicant
Copy of notice left with applicant
A replacement policy must also allow the policy owner to return the policy for a full premium refund if not satisfied with it for any reason within 30 days of purchase.
Cancelation by the insured
If an insured changes occupation to a less hazardous one than stated in the policy the insured can upon written request either cancel policy and receive a refund of the unearned premium. Reduce premiums accordingly.
Continuation of coverage
An employee whose group coverage ends because of employment is terminated is entitled to continued coverage for up to 18 months after termination. Coverage will be continued on a monthly renewable basis until earliest of the following date.
Time of payment of claims
Provides for immediate payment of claims after the insurer receives notification and proof of loss.
Proof of loss
After a loss occurs or after the company becomes liable for periodic payments have 90 days to submit proof of loss.
Common disaster provision
Ensures a policy owner if both the insured and the primary beneficiary die within a short period of time. The death benefits will be paid to the contingent beneficiary l. Also states the primary beneficiary must out live the insured a specified period of time in order to receive proceeds.
Coordination of benefits
Is designed to prevent duplication of group insurance benefits. Limits benefits from multiple group health insurance policies.
Group health insurance
Is an insurance that provides coverage for a group of persons usually employees of a company under one master contract.
Labor unions
Trade/professional association.
Medical savings account
Created to help employees of a small employer as well as self employed individuals to pay for the medical care expenses
Tax free account set up by banks
Available for employers with no more than 50 employees.
Conformity with state statues
States that any provisions of this policy that is in conflict with state statutes in the state where the insured lives at the time of the policy is issued is automatically amended to conform with the minimum statutory requirements.
Non-occupational coverage
Is coverage provided by a disability income policy that does not provide benefits for losses occurred as the result of the insured employment.
Definition of a small employer
One that employs 2-50 employees.
Policy renewal
An insurer must deliver to the insured a written notice of its intentions not to renew the policy at least 30 days before the premiums due date.
Notice if lapse
An insurance company must provide a notice to the insured 15 days before a policy will be canceled or lapse due to non payment.
Free look
A policy owner has 10 days after policy delivery to return health insurance policy and receive a full refund on premiums.
Elimination period
Found in most policy range from 30 - 180 days
Medical expenses Insurance
Pays benefits for nonsurgical doctor fees commonly rendered in a hospital sometimes pays for home and office calls.
Medicare supplements
A health insurance that provides coverage to fill the gaps in Medicare coverage. Free look period on Medicare supplements is 30 days begins 3 months before 65th birthday and last for 7 months. Insurer may exclude pre existing coverage conditions for up to 6 months.
Medicare select
Is a type of Medicare supplement plan sold in some states that can be any of the standardized medigap plans which requires policy holders to receive service from within defined network of hospitals and some cases doctors in order to be eligible for benefits.
Patient protection and affordable care act
Was designed to increase health insurance quality and affordability, lower the uninsured rate.
Unpaid premiums provision
States if there is an unpaid premium at the time of a claim becomes payable the amount of the premium is to be deducted from the sum payable to the insured or beneficiary. Is a provision that provides unpaid premiums to be taken from claims payments.
Blanket health policies
Are issued to cover group who may be exposed to the same risk but the composition of the group are constantly changing.
Issue in air lines or bus companies to cover passengers.
Major medical expense
Is a health insurance policy that provides broad coverage and high benefits for hospitalization surgery and physicians. Characterized by deductibles and coinsurance cost sharing.
Producer responsibilities
Producers must provide applicants and prospects with approved buyers guide and policy summary no later than when the policy is delivered.
Insurable Interest
Must be subject to loss upon death disability or illness of the insured. A married person has insurable interest in their spouse.
South Dakota life & health guarantee association
Provides claims payments of admitted insolvent financially impaired insurers
Life and health guarantee association
Is funded by insurance companies through assessments. 30 days notice must be given prior to the collection of each assessment.
Unfair claims practice
Misrepresenting to insured pertinent facts
Failing to adopt and implement reasonable standardsFor prompt investigation and processing of claims.
Failing to affirm or deny coverage of claims within reasonable time after proof of loss
Denying an insureds claims without indicating the basis of denial under the policy life and health guarantee association.
Critical illness policy
Insurer is contracted to typically make a lump sum cash payment if the policy owner is diagnosed with one of the specific illnesses on a predetermined list of an insurance policy.
Home health care
Is skilled or unskilled care provided Ian an individual home usually on a part time basis.
Probationary period
Specific number of days after an insurance policy issue date during which coverage is not afford to sickness dose not apply to accidents.10-30days from policy issued date.
Custodial care
Is a level of care given to meet daily needs such as dressing, bathing, getting out of bed. Though it does not require medical training it must be administered under a physicians orders.
Adult daycare
Type of care made for people who require assistance with various activities of daily living while primary caregivers are absent. Offered in care centers
Respite care
Is a type of health and medical care designed to provide a short rest period for a care giver characterized by its temporary status.
Continuing care
Designed to provide benefits for elderly individuals who live in a continuing care retirement community.
Pre-existing conditions replacement policy
When replacing an individual health policy in South Dakota the required replacement notice to applicant must include notice that pre- existing conditions may not be covered.
Pre-existing conditions group coverage
Are health issues that existed were treated or diagnosed within 6 months prior to employment an enrolle for health benefit plan may be excluded up to 12 months. 18 months for late enrollees.
Legal action
There is a waiting period of 60 days to file a lawsuit after a claim for loss has been filed after 3 years has passed from when the claim was submitted.
Long term care insurance
Refers to a broad range of medical and personal service for individuals who need assistance with daily activities for an extended period of time.
Disability income insurance
Insurers the beneficiary earned income against risk that disability creates.
Key person disability insurance
Is the protection of a business against financial loss cause by the death or disablement of a vital member of the company. Pays monthly benefits to the business to cover for additional help benefits tax free because the premium paid is not tax deductible.
Time limit on certain defense
States that a policy is incontestable after it has been in force a certain period of time usually two years. Unlike life policies a fraudulent statement on a health insurance application is grounds for contest at anytime unless the policy is guaranteed renewable.
HMO
Is another type of organization offering comprehensive prepaid health care service to subscribing members. Are distinguished by the fact that they are not only finance health care services but they also organize and deliver health services
Conditionally Renewable
And individuals health policy is renewable unless the insured failed to pay premiums. Fraudulently or intentionally misrepresented material facts. Became eligible for Medicare coverage. May discontinue offering a particular type of insurance if they notify each insurer and beneficiary at least 90 days before the date of continuation. Offer to each insured other opportunity to buy other health plans It has available in market.
PPO
Is a collection of health providers such as physicians hospitals and clinics who offer services to certain groups at a prearranged discount prices. In return the group refers it’s members to the preferred providers.
Federally administered medicare program
Took effect in 1966 purposed to provide hospital and medical expense insurance protection to those age 65 and older also provides protection to an individual who suffers from kidney disease or receiving social security disability benefits.
HIPPA
Provthe ability to transfer and continue health insurance coverage for millions of Americans workers and their families when they change or lose their jobs. Providers federal protection for an individuals health information.
Premium rates
All premium rates charged for individual health insurance policies must be filed with the director who has 30 days to disapprove of any rates. Premium rates must be reasonable in relation to benefits available.
Group health certificate
In South Dakota a group health certificate of insurance must contain a summary of policy features and benefits.
Proof of loss
A mandatory health insurance provision stating the insured must provide a complete claim form to the insurer within days of the date of loss
Special risk policy
Covers unusual hazards normally not covered under ordinary accident and health insurance. Actress who insurers her legs for 1 million dollars.
Corridor Deductible
Comes into play when a major medical policy is supplementing basic coverage that contains no deductible not applied till the basic coverage has exhausted.
Legal action
At least give 2 months before taking them to court any lawsuit the insurer by policy holders must commense within 3 years from the date of proof of loss.
Irrevocable Beneficiary
May not be changed without the written consent of the beneficiary. Policy owner may not exercise certain rights without the consent of the beneficiary.
Reinstatement
A lapsed policy may be reinstated within 3 years if evidence or insurability is provided along with all back premiums being paid with interest.
