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.
