Flashcards
Reinsurance occurs when the insurance company buys insurance on the risks it insures, done to reduce the insurance company’s risk.
Representations are the truth to the best of your knowledge. Life and health insurance applications ask the applicant to make representations.
Funds held by the insurance company to help fulfill future claims.
A disability that affects the ability of a person to work full-time. Residual disability must be preceded by the insured’s total disability. Residual disability is more accurate than partial.
Retention of risk is the net amount of any risk that an insurance company does not reinsure but keeps for its own account.
Retrospective review examines coverage after treatment. The review includes evaluating requests for medical treatment and determining, on a case-by-case basis, whether that treatment is necessary.
A rider is an amendment to an insurance policy. Some riders cost extra and make a policy better, for example, an accidental death benefit rider. Impairment riders are free and take away coverage.
Risk is the chance of loss. Pure risk is insurable. Pure risk involves no chance of gain.
The basic premise of insurance, a large number contribute to cover the losses of a few.
A type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals may be used, it’s also generally the area where an enrollee can get routine (non-emergency) services. The plan may end the coverage if the enrollee moves out of the plan’s service area.
The short-term disability income policy provides benefits, often a portion of lost income, for a temporary time defined in the policy. The likelihood is that the insured can return to work or restore the lost income.
Services from licensed nurses in a person’s own home or a nursing home. Skilled care services are from technicians and therapists in a person’s own home or in a nursing home.
Skilled nursing care and rehabilitation services are provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
Social Security provides financial protection, supporting Americans throughout all of life’s journeys. While working, a person pays taxes into the Social Security system. When they retire or become disabled, the person, their spouse, and the dependent children may get monthly benefits that are based on the reported earnings. Survivors may be able to collect Social Security benefits if a person dies. Social security includes various benefits including retirement, disability, survivor, and family benefits, as well as Medicare. Sometimes you will see Social Security referred to as OASDHI (old age, survivor, disability, and health insurance).
The amount an enrollee gets from Social Security Disability, Retirement (including Railroad retirement), or Survivor’s Benefits each month.
Social Security benefits based on a decedent’s record that are paid to their widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22; children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22; and parents if the decedent provided at least one-half of their support. An ex-spouse could also be eligible for a widow/widower’s benefit on the decedent’s record. A special one-time lump sum death payment of $255 may be made to your spouse or minor children.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
A type of dental plan that’s not included as part of a health plan.
An insurance company owned by its stockholders. Stock insurers issue nonparticipating policies. Dividends, when paid, are paid to the stockholders, not the policyholders.
An easy-to-read summary that helps a person to make apples-to-apples comparisons of costs and coverage between health plans. Options can be compared based on price, benefits, and other features that may be important. The “Summary of Benefits and Coverage” (SBC) is made available when a person shops for coverage on their own or through their job, renews or changes coverage, or requests an SBC from the health insurance company.
A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.
Unauthorized insurers are those who are nonadmitted, meaning they have not been approved or authorized to sell insurance in the state.
The person who reviews the insurance application and decides if the applicant is acceptable and at what premium rate.
Most states have adopted similar laws related to unfair claims settlement practices. These practices apply to both the insured and the insurer.
Unfair discrimination happens when similar risks are treated differently and premiums are based not on relative risk but on factors like race. State laws will address unfair discrimination related to insurance. For example, in some states, car insurance premiums cannot be based on gender. In those states to base car insurance premiums on gender would be a form of unfair discrimination.
Most states have adopted similar laws related to unfair trade practices. These include unfair discrimination, misrepresentations related to the benefits, advantages, conditions, or terms of an insurance policy, misrepresentations related to dividends, and misleading statements related to the financial health of the insurer, amongst many others.
Insurance contracts are an example of a unilateral contract. This means they are one-sided. So long as the life insurance premium is paid, the insurance company promises to pay the beneficiary the death benefit if a certain event occurs (the insured dies). With a unilateral contract only the insurer makes a legally enforceable promise to pay covered claims.
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
The review process used by insurance companies to reduce healthcare costs by avoiding unnecessary care. Utilization management includes three basic categories: prospective review, concurrent review, and retrospective review.
A health benefit that at least partially covers vision care, like eye exams and glasses. All plans in the Health Insurance Marketplace® include vision coverage for children. Only some plans include vision coverage for adults. A stand-alone vision plan can be purchased by an individual to reduce vision care expenses.
The waiting period, or elimination period, is the amount of time that a person is unable to work before the coverage kicks in. The waiting period begins when the person meets the policy’s definition of totally disabled. The longer the waiting period, the lower the premium.
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
A voluntary giving up of a legal, given right.
If the underwriter approves an incomplete application the insurer is waiving their rights to contest a claim related to whatever was left blank (doctrine of waiver and estoppel).
A warranty is a guarantee of truth. Applicants cannot be asked to warranty their health.
An insurance plan that employers are required to have to cover employees who get sick or injured on the job.