A

Accelerated benefits: Benefits available in some life insurance policies before death, usually triggered by long-term, catastrophic or terminal illness. Also known as living benefits.

Accumulation period: The time during which a person pays money into an annuity contract and builds up a fund to provide a deferred annuity.

Actuary: A mathematician working for a health insurance company responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.

Adjustable life insurance: A type of insurance that allows the policyholder to change the plan of insurance, raise or lower the death benefit of the policy, increase or decrease the premium and lengthen or shorten the protection period.

Admitting privileges: The right granted to a doctor to admit patients to a particular hospital.

Adverse selection: Under a health insurance plan, if only the sick people who need to take advantage of the covered benefits join the plan, the high number of resulting claims could cause the costs paid by the plan to soar and threaten it with financial collapse, a phenomenon known as “adverse selection.”

Advocacy: Any activity done to help a person or group to get something the person or group needs or wants.

Agent: Licensed salespersons who represent one or more health insurance companies and present their products to consumers.

Allocated benefits: Maximum amount for specific services as itemized in an insurance contract.

Ambulatory care: Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation.

Annuities: Annuities are contracts sold by life insurance companies (the seller must be a licensed insurance entity in your state). In their simplest form, you pay a sum of money (either a lump sum or a series of payments) and the insurance company makes periodic payments to you, beginning on the date in your contract and continuing for the rest of your life. The earnings on your annuity payments are not taxable during the accumulation phase of your agreement; the annuity payments are taxable as income when you receive them. You may place your payments in professionally managed funds, similar to mutual funds, and control how these payments are invested during the life of your contract. Annuities may entail extensive taxation and estate issues, and annuity buyers should make sure they’re aware of such issues.

Application: A statement of information made by someone applying for any type of insurance. The information gathered helps the insurance company assess whether the risk presented by the applicant is acceptable to underwriters.

Association: A group. Often, associations can offer individual insurance plans specially designed for their members. Associations often get special underwriting consideration on member’s policies.

B

Beneficiary: The person or financial instrument (for example, a trust fund), named in the policy as the recipient of insurance money in the event of the policyholder’s death.

Benefit: Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.

Blanket medical expense: A provision that entitles the insured person to collect up to a maximum for all hospital and medical expenses, without limitations on specific types of medical expenses.

Bond insurance: Insurance issued by a private insurance company for either an entire issue or specific maturities that guarantees to pay principal and interest when due. This will provide a credit rating of triple-A and thus a lower borrowing cost for the issuer.

Brand-name drug: Prescription drugs marketed with a specific brand name by the company that manufactures it, which is usually the company that develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.

Broker: Licensed insurance salesperson who obtains quotes and plans from multiple sources for clients.

Business insurance: A policy that provides coverage to a business. It is often purchased to indemnify a business for the loss of services if a key employee (such as a partner) becomes disabled.

Business life insurance: Life insurance purchased by a business enterprise on the life of a member of the firm. It is often bought by partnerships to protect the surviving partners against loss caused by the death of a partner, or by a corporation to reimburse it for loss caused by the death of a key employee. (Also known as key person insurance.)

C

Capitation: Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

Carrier: The insurance company or HMO offering a health plan.

Case Management: Case management is a system embraced by employers and insurance companies to ensure that individuals receive appropriate, reasonable health care services for ongoing medical claims.

Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what is covered, what is not, and dollar limits.

Claim: A request by an individual (or his or her provider) to an individual’s insurance company for the insurance company to pay for services obtained from a health care professional.

Co-Insurance: Co-insurance refers to money that an individual is required to pay for services after a deductible has been paid. Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent. This should not be confused with a co-payment or deductible.

Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 “co-payment” for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.

COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your employer-sponsored coverage is otherwise terminated. For more information, visit the Department of Labor website, www.dol.gov.

Comprehensive medical expense insurance: Insurance that provides coverage, in one policy, for basic hospital expense and major medical expense.

Conventional health plan: Plan that provides all benefits and issues certificates containing the insurance company’s guarantees.

Convertible term insurance: Term insurance that offers the policyholder the option of exchanging it for a permanent plan of insurance without evidence of insurability.

Coordination of benefits (COB): Method of integrating benefits payable under more than one health insurance plan so that the insured persons benefits from all sources do not exceed 100 percent of allowable medical expenses or eliminate incentives to contain costs.

Contributory plan: Group plan under which the insured shares in the cost of the plan with the policyholder.

Credit life insurance: Term life insurance issued through a lender or lending agency to cover payment of a loan, installment purchase or other obligation, in case of death.

Credit for Prior Coverage: This may or may not apply when you switch insurance plans. A pre-existing condition waiting period met under under another insurance plan may satisfy the the waiting period required by the new plan, provided there is not an interruption in the coverage between the two plans that exceeds state guidelines.

D

Deductible: The amount an individual must pay for health care expenses before insurance covers the costs. Most insurance plans are based on a calendar year deductible. Deductibles are waived for doctor office visits and prescription drugs on many PPO (Preferred Provider Organization) plans.

Deferred annuity: Annuity payments that will begin at some future date.

Delinquency: Failure to comply with the terms and conditions of a mortgage, usually by not making payments on time. A delinquency rate is the sum of delinquencies at a point in time divided by the total of outstanding mortgages at that time.

Denial Of Claim: Refusal by an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured. Current law provides that children up to age 26 may remain on a parents plan of insurance in most cases.

Deposit term insurance: A form of term insurance, not really involving a “deposit,” in which the first-year premium is larger than subsequent premiums. Typically, a partial endowment is paid at the end of the term period. In many cases the partial endowment can be applied toward the purchase of a new term policy or, perhaps, a whole life policy.

Disability benefit: A feature added to some life insurance policies providing for waiver of premium, and sometimes payment of monthly income, if the policyholder becomes disabled.

Disability income insurance: Insurance that provides periodic payments when an insured person is unable to work as a result of illness or injury.

E

Effective date: The date your insurance coverage actually begins. You are not covered until the policy’s effective date regardless of the application date or payment date.

Eligibility date: Date when a member of an insured group is eligible to apply for insurance.

Eligible employees: Employees who meet the eligibility requirements for insurance set forth in a group policy by meeting the waiting period and required number of hours worked per week.

Eligibility period: Time following the eligibility date (usually 31 days) during which a member of a group may apply for insurance without evidence of insurability.

Employee Assistance Programs (EAPs): Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to directly pay for services provided through an employee assistance program.

Employer-Sponsored Health Insurance: Nearly 60% of Americans obtain their health insurance through an employer-sponsored plan, often called group health insurance. Most employer sponsored plans are required to pay a significant portion of the employee’s insurance premium. Some employers cover the dependent’s portion of the premium as well. Group health plans are also guaranteed issue, meaning that a carrier must cover all eligible applicants and dependents whose employment qualifies them for coverage. Many employer-sponsored plans include a range of plan options from HMO and PPO plans to additional coverage such as dental, life, short-term and long-term disability.

E&O: Errors and omissions insurance covers insurance agents in the event an error or omission results in a civil claim being brought against them. Errors and omissions coverage pays defense costs if an agent is negligence in providing a product or service to a client. It can also cover (at least partially) the agent’s costs if he or she is found liable for damages. It does not cover criminal acts such as fraud.

Exclusions: Medical services that are not covered by an individual’s insurance policy.

Experience: Relationship, usually expressed as a percent or ratio, of claims to premiums for a stated period.

Explanation of Benefits: The insurance company’s written explanation to a claim, showing what they paid and what the client must pay.

Extended term insurance: A form of insurance available as a non-forfeiture option. It provides the original amount of insurance for a limited period of time.

G

Generic Drug: A “twin” to a “brand name drug” with the same active ingredients. Once the brand name company’s patent has expired, other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.

Grace period: The period of time between when your premium is due until your policy is canceled. For life and health insurance policies that is typically 31 days. Auto and Home policies do not always have the same provisions

Group annuity: A pension plan providing annuities at retirement to a group of people under a master contract. It is usually issued to an employer for the benefit of employees. The individual members of the group hold certificates as evidence of their annuities.

Group Health Insurance: Coverage through an employer or other entity that covers all individuals in the group.

Group life insurance: Life insurance that usually does not require medical examinations, on a group of people under a master policy. It is typically issued to an employer for the benefit of employees, or to members of an association, for example, a professional membership group. The individual members of the group hold certificates as evidence of their insurance.

H

Health Care Decision Counseling: Services, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of medical tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual’s unique set of circumstances.

Health Cooperatives: Health Cooperatives are groups of people structured as non-profits and owned by their members. They could offer health care through a network of health care providers or contract out for medical services.

Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with the HMO. Depending on the type of the HMO, services may be provided in a central facility, or in a physician’s own office. Typically members pay a copay at the time of service but no deductible.

HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is “The Health Insurance Portability and Accountability Act of 1996.”

Hospice: Care provided to terminally ill patients and their families that emphasizes emotional needs and coping with pain and death rather than a cure.

Hospital indemnity insurance: Health insurance that provides a stipulated daily, weekly, or monthly payment to an insured person for each period of hospital confinement, without regard to the actual confinement expense.

I

Immediate annuity: An annuity that begins its payment stream to the policyholder after a single premium is paid. The number of payments may vary but the most common types pay for the annuitant’s entire life or their lifetime or a certain number of years, such as 10, 15 or 20 paid to the beneficiaries.

In-network: Providers or health care facilities which are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

Indemnity Health Plan: Indemnity health insurance plans are also called “fee-for-service.” These are the types of plans that primarily existed before the rise of HMOs and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals with no network restrictions.

Independent Practice Associations: IPAs are similar to HMOs, except that individuals receive care in a physician’s own office, rather than in an HMO facility.
Individual Health Insurance: Health insurance coverage issued on an individual, not group, basis. The issuing company may be able to decline your application, waiver medical conditions, charge a higher premium or a combination of the above. Starting in 2014 companies will no longer have those options.

Individual retirement account (IRA): An account set up by an individual that in some cases allows contributions to be deducted from income and permits earnings on contributions to accumulate tax-deferred until retirement, regardless of whether the contributions are deductible. Under the 1986 tax law, only those who do not participate in a pension plan at work or who do participate and meet certain income guidelines can make tax-deductible contributions to an IRA. Contributions to an IRA can be made on a non-deductible basis such as with a Roth IRA where the withdrawals are not taxable.

Insurable risk: The conditions that make a risk insurable are (1) the peril insured against must produce a definite loss not under the control of the insured, (2) there must be a large number of homogeneous exposures subject to the same perils, (3) the loss must be calculable and the cost of insuring it must be economically feasible, (4) the peril must be unlikely to affect all insured’s simultaneously, and (5) the loss produced by a risk must be definite and have a potential to be financially serious.

L

Lapsed policy: A policy terminated at the end of the grace period because of non-payment of premiums.

Level premium insurance: Insurance for which the cost is distributed evenly over the premium payment period. The premium remains the same from year to year and is more than the actual cost of protection in the earlier years of the policy and less than the actual cost in the later years. The excess paid in the early years builds up a reserve to cover the higher cost in the later years.

Liability insurance: Liability involves the cause of damage to someone’s property and the bodily injury someone incurs as a result of the negligence of another party. Liability insurance provides coverage for either individuals or businesses.

Life annuity: A contract that provides an income for life.

Lifetime Maximum Benefit (or Maximum Lifetime Benefit): the maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.

Limitations: a limit on the amount of benefits paid out for a particular covered expense, as disclosed in the Certificate of Insurance.

Limited payment life insurance: Whole life or Universal life insurance on which premiums are payable for a specified number of years or until death, if death occurs before the end of the specified period.

Long-Term Care Policy: Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include care in a skilled nursing facility, nursing home care, home health care services, and custodial care in formal and informal settings. Long term care policies typically cover all levels of care, skilled, intermediate and custodial care. Medicare covers a limited period of skilled care.

Long-term Disability Insurance (LTD): Pays an insured a percentage of their monthly income if they become disabled and unable to perform the duties of their occupation. LTD Insurance is normally from a few years up to age 65.

LOS: LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.

M

MSA: Medical savings account (MSA) set up as a tax-deferred trust or savings account, similar to an IRA, in which you set aside money for your routine, out-of-pocket health care expenses and build up savings for your future medical costs.

Major medical expense insurance: Insurance that provides benefits for most types of medical expenses up to a high maximum benefit. Such contracts often contain limits and usually are subject to deductibles and co-insurance. Starting 2014 major medical insurance can no longer have lifetime benefit limits.

Managed Care: A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease.

Maximum Dollar Limit: The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime. Lifetime limits will end in 2014.

Medicaid: Simply put, Medicaid is health insurance for the poor. It was created in 1965 as a joint federal/state public assistance program for those too poor to afford health care. Since the program is administered by the individual states under federal guidelines, the benefits offered and eligibility requirements vary widely. About 36 million people around the U.S., including children, the elderly, the blind and the disabled, are currently covered by Medicaid. Usually, Medicaid recipients pay no part of costs for covered medical expenses, although a co-payment is sometimes required.

Medicare: Medicare is a federal insurance program which primarily serves those over 65 years old and disabled people under 65 who qualify for Social Security Disability benefits. It also covers dialysis patients. It currently covers about 47 million Americans. Medicare is divided into Part A, which covers inpatient hospital services, nursing home care, home health care and hospice care; and Part B, which helps pay the cost of doctors’ services, outpatient hospital services, medical equipment and supplies, and other health services and supplies. Recipients pay some part of the costs through deductibles. Since Medicare doesn’t cover all expenses, recipients often supplement their coverage through separate Medigap or Medicare Supplement policies.

Medicare supplement insurance: Also known as Medigap. This health coverage pays for services that are not covered under the government’s basic Medicare plan. Some Medigap policies sold before January 1, 2006 may include prescription drug coverage, but after that date new Medigap policies could not be sold with drug coverage. This time frame coincides with the introduction of the Medicare Part D benefit.

Medigap Insurance Policies: Medigap insurance is offered by private insurance companies, not the government. It is not the same as Medicare or Medicaid. These policies are designed to pay for some of the costs that Medicare does not cover.

Modified life insurance: A type of whole life policy with a premium that is relatively low in the first several years but that increases in later years.

Multiple Employer Trust (MET): A trust consisting of multiple small employers in the same or similar industries, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to each of the employers individually.

N

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance company’s customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.

Noncontributory plan: Group insurance plan under which the employer does not require employees to share in its cost.

Non-participating policy: A life insurance policy in which the company does not distribute to policyholders any part of its surplus. Note that premiums for non-participating policies are usually lower than for comparable participating policies. Note also that some non-participating policies have both a maximum premium and a current lower premium. The current premium reflects anticipated experience that is more favorable than the company is willing to guarantee, and it may be changed from time to time for the entire block of business to which the policy belongs.

Nonrenewal clause: Provision in a policy that states the circumstances under which an insurer may elect not to renew someone’s policy.

O

Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional’s services under a traditional indemnity plan.

Ordinary life insurance: Life insurance usually issued in amounts of $1,000 or more with premiums payable on an annual, semi-annual, quarterly or monthly basis.

Out-of-Plan (Out-of-Network): This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered at a lower rate by an individual’s insurance company.

Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own funds before an insurance company or (self-insured employer) will pay 100 percent for an individual’s health care expenses. The out of pocket maximum normally runs though a calendar year.

Outpatient: An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.

P

Partial disability: A disability that prevents a person from performing one or more functions of his or her regular job on a full time basis.

PEO: Professional employee organization (PEO) that small businesses may join in order to gain access to more affordable health insurance premiums

Permanent life insurance: A phrase used to cover any form of life insurance except term, that generally accrues cash value and is designed to remain in force for the insured’s entire life, such as Whole Life or Universal Life.

PIP: Personal injury protection (PIP), coverage to pay basic expenses for an insured and his or her family in states with no-fault auto insurance.

Plan Administration: Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums, and similar duties.

Policyholder: The person who owns a life insurance policy. This is usually the insured person, but it may also be a relative of the insured, a partnership or a corporation.

Policy loan: Under an insurance policy, the amount that can be borrowed at a specified rate of interest from the issuing company by the policyholder, who uses the value of the policy as collateral for the loan. If the policyholder dies with the debt unpaid, the insurance company deducts the remaining balance, plus any accumulated interest, from the amount payable to the beneficiaries.

Policy term: The period for which an insurance policy provides coverage.

POS: POS (Point of Service) plans are more flexible than HMOs, but they also require you to select a Primary Care Physician (PCP). Depending on your insurance company’s rules, you may choose to visit a doctor outside the network and still receive coverage but the amount covered will be substantially less. These plans tend to offer more preventive care and well-being services, such as workshops on smoking cessation, and discounts to health clubs.

PPACA:Patient Protection and Affordable Care Act (Obamacare) is the national health care reform law passed in 2010 which is scheduled to be implimented in 2014.

PPO: Preferred provider organization. PPOs give policyholders a financial incentive of reasonable co-payments(also called co-pays) to stay within the group’s network of practitioners. You may go to any specialist without permission, as long as the doctor participates in the network. If you see an out-of-network doctor, you may have to pay the entire bill yourself, then submit it for reimbursement. You may have to pay a deductible if you choose to go outside the network, or pay the difference between what network doctors vs. out-of-network doctors charge.

Pre-Admission Certification: Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance for non-emergency procedures. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate insurance company employee. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).

Pre-Admission Review: A review of an individual’s health care status or condition, prior to an individual being admitted to an inpatient health care facility, such as a hospital. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or health care provider, and hospitals.

Pre-existing Conditions: A medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the insurance company.

Preadmission Testing: Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.

Precertification: A utilization management program that requires the insured or the health care provider to notify the insurer prior to a hospitalization or surgical procedure. The notification allows the insurer to authorize payment, as well as to recommend alternate courses of treatment.

Preferred Provider Organizations (PPOs): You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.

Premium: The payment, or one of the regular periodic payments, that a policyholder makes to own an insurance policy.

Primary Care Provider (PCP): A health care professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.

Private Health Insurance: Private health insurance – insurance plans marketed by the private health insurance industry – currently dominates the U.S. health care landscape, with approximately two-thirds of the non-elderly population covered by private health insurance. Coverage includes policies obtained through employer-sponsored insurance, with approximately 62 percent of non-elderly Americans receiving insurance provided as a benefit of employment. Another 5 percent of the non-elderly group bought coverage outside of the workplace on the individual health insurance market.

Property casualty: Property insurance covers damage to or loss of the policyholder’s property. Casualty covers the policyholder’s legal liability for damages and injuries caused to others.

Provider: Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.

Q

Qualified annuity: An annuity that is sold as part of a tax-qualified Keogh plan, IRA or company pension plan.

R

Rated policy: Sometimes called an “extra-risk” policy, an insurance policy issued at a higher-than-standard premium rate to cover the extra risk where, for example, an insured has impaired health or a hazardous occupation.

Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.

Reinsurance: Acceptance by one insurer (the reinsurer) of all or part of the risk or loss underwritten by another insurer (the ceding insurer).

Renewal: Continuance of coverage beyond original terms signified by acceptance of a premium payment for a new term.

Rescission: is a controversial insurance industry practice that has come under fire as an unfair tactic used to deny coverage to policy holders. If you’ve been a victim of rescission, your insurance company has received a claim from you, and then reviewed your application and medical history for undisclosed conditions or inconsistencies. If inconsistencies are found your policy may be cancelled and the claim denied. This practice is also referred to as underwriting at time of claim.

Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).

Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications’ side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. For example, an individual increases his or her risk of getting cancer if he or she chooses to smoke cigarettes.

S

Second Opinion: It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.

Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician, when one physician recommends surgery to an individual.

Self-insurance: A program financed entirely by the employer for insuring employees instead of purchasing coverage from a commercial carrier.

Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual’s full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.

Short-Term Health Insurance: Temporary coverage for an individual for a short period of time, usually from 30 days to six months.

Single-premium whole life insurance: A whole life policy that provides protection for the duration of the insured’s life in exchange for the payment of the total premium in one lump sum at the time of application.

Small Employer Group: Generally means groups with 1 to 99 employees. The definition may vary between states.

Standard risk: Person who, according to an insurer’s underwriting standards, is entitled to purchase insurance without paying an extra premium or special restrictions.

State Mandated Benefits: When a state passes laws requiring that health insurance plans include specific benefits.

Stop-loss: The dollar amount of claims filed for eligible expenses at which point you’ve paid 100 percent of your out-of-pocket amount and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.

Straight life annuity: An annuity whose periodic payments stop when the annuitant dies.

Student Health Insurance: In recent years, many colleges have begun requiring proof of health insurance for students. Coverage options include insurance through family policies and coverage through school-sponsored student health plans, now offered by more than 80 percent of public four-year colleges. Students may also seek coverage through an employer’s plan if they’re employed full time, or they can purchase their own individual health insurance plan from a licensed health insurance provider. Depending on the state in which a student resides, the student may also be eligible for coverage by a state-sponsored risk pool, a program that provides coverage for individuals denied insurance by private insurers because of their health condition.

T

Term insurance: A plan of life insurance that covers the insured for only a certain period of time (term), not for his or her entire life. The policy pays death benefits only if the insured dies during the term.

Title insurance: Title insurance protects against the various financial losses associated with having the title on your home challenged, including court costs and loss of the property. For a one-time fee, most title insurers will investigate public records to make sure that your property is free of title defects. This coverage can benefit either the homeowner or the mortgage company.

Third-party administrator (TPA): An outside person or firm (not a party to a contract) that maintains all records of persons coverage under an insurance plan. The TPA normally also pays claims, collects premiums, does the underwriting and other administrative duties for a portion of the premiums paid.

Travel accident policies: In some states, limited contracts covering accidents that occur only while an insured person is traveling on business for an employer, away from the usual place of business and on named conveyances.

Triple-Option: Insurance plans that offer three options from which an individual may choose. Usually, the three options are traditional indemnity, an HMO, and a PPO.

U

Underwriter: The company that assumes responsibility for the risk, issues insurance policies and receives premiums.

Usual, Customary and Reasonable (UCR) An amount customarily charged for covered services and supplies which are medically necessary, recommended by a doctor, or required for treatment of specific procedures.

W

Waiting Period: A period of time when you are not covered by insurance for a particular problem.