Accidental Death Benefit – In a life insurance policy, benefit in addition to the death benefit paid to the beneficiary, should death occur due to an accident. There can be certain exclusions such hazardous activities, dangerous occupations, military service, as well as time and age limits.
Activities of Daily Living (ADLs) – Bathing, preparing and eating meals, moving from room to room, getting into and out of beds or chairs, dressing, using a toilet. Not being able to do 2 or more ADLs triggers long-term care insurance benefits.
Actual Cash Value – Cost of replacing damaged or destroyed property with comparable new property, minus depreciation and obsolescence. For example, a 10-year-old sofa will not be replaced at current full value because of a decade of depreciation.
Agent – individual who sells and services insurance policies in either of two classifications:
1. Independent agent represents at least two insurance companies and services clients by searching the market for the most advantageous price for the most coverage.
2. Direct or career agent represents only one company and sells only its policies. This agent is paid on a commission basis in much the same manner as the independent agent.
Ambulatory Care Facility (ACF). A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.
Annual Crediting Cap – The maximum rate that the equity-indexed annuity can be credited in a year. If a contract has an upper limit, or cap, of 7 percent and the index linked to the annuity gained 7.2 percent, only 7 percent would be credited to the annuity.
Annuitization – Process by which you convert part or all of the money in a qualified retirement plan or nonqualified annuity contract into a stream of regular income payments, either for your lifetime or the lifetimes of you and your joint annuitant. Once you choose to annuitize, the payment schedule and the amount is generally fixed and can’t be altered.
Annuity – An agreement by an insurer to make periodic payments that continue during the survival of the annuitant(s) or for a specified period.
Attained Age – Insured’s age at a particular time. For example, many term life insurance policies allow an insured to convert to permanent insurance without a physical examination at the insured’s then attained age. Upon conversion, the premium usually rises substantially to reflect the insured’s age and diminished life expectancy.
Benefit Period – In health insurance, the number of days for which benefits are paid to the named insured and his or her dependents.
Brand-name drug – prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on some health plans. (see “generic.”)
Broker – Insurance salesperson that searches the marketplace in the interest of clients, not insurance companies.
Broker-Agent – Independent insurance salesperson that represents particular insurers but also might function as a broker by searching the entire insurance market to place an applicant’s coverage to maximize protection and minimize cost. This person is licensed as an agent and a broker.
Carrier – insurance company or HMO insuring the health plan.
Certificate Booklet – the plan agreement. A printed description of the benefits and coverage provisions intended to explain the contractual arrangement between the carrier and the insured group or individual. May also be referred to as a policy booklet
Claim – A demand made by the insured, or the insured’s beneficiary, for payment of the benefits as provided by the policy.
COBRA (Consolidated Omnibus Budget Reconciliation Act) – Federal legislation that requires group health plans to provide health plan members the opportunity to purchase continued coverage in the event their insurance is terminated. Applies only to employer groups with 20 or more employees. Learn more about COBRA at the Department of Labor’s website.
Coinsurance– For health insurance, it is a percentage of each claim above the deductible paid by the policyholder. For example, a 30% health insurance policy with 30% coinsurance, the policyholder pays for the deductible plus 30% of his covered medical expenses. After paying 70% of expenses up to a specified out of pocket maximum, the insurer starts paying 100% of medical expenses.
Coverage – The scope of protection provided under an insurance policy. In health insurance, coverage lists medical services insured against, conditions covered, locations covered, individuals insured, and the limits of indemnification. In life insurance, living and death benefits are listed.
Co-payment – A predetermined, flat fee an individual pays for health-care services, in addition to what insurance covers. For example, some PPOs require a $30 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.
Creditable Coverage – Term means that benefits provided by other drug plans are at least as good as those provided by the new Medicare Part D program. This may be important to people eligible for Medicare Part D but who do not sign up at their first opportunity because if the other plans provide creditable coverage, plan members can later convert to Medicare Part D without paying higher premiums than those in effect during their open enrollment period.
Credit for prior coverage – any pre-existing condition waiting period met under an employer’s prior (qualifying) coverage will be credited to the current plan, if any interruption of coverage between the new and prior plans meets state guidelines.
Death Benefit – The limit of insurance or the amount of benefit that will be paid in the event of the death of a covered person.
Deductible – the portion of the claims the insured must pay before the insurer begins to pay. Health insurance deductibles for family policies are either:
1. aggregate – family must attain the family amount of deductible before any individual family member is fully covered.
2. or embedded – any family member that meets the individual deductible will be fully covered.
Disease Management – A system of coordinated health-care interventions and communications for patients with certain illnesses.
Dividend – The return of part of the policy’s premium for a policy issued on a participating basis by either a mutual or stock insurer. A portion of the surplus paid to the stockholders of a corporation.
Effective date – the date requested by an applicant to begin insurance coverage
Elimination Period – The time which must pass after filing a claim before policyholder can collect insurance benefits. Also known as “waiting period.”
Exclusions – Items or conditions that are not covered by the general insurance contract.
Explanation of Benefits (EOB) – a carrier’s written response to a claim for benefits. Sometimes accompanied by a benefits check.
Future Purchase Option – Life and health insurance provisions that guarantee the insured the right to buy additional coverage without proving insurability. Also known as “guaranteed insurability option.”
Generic drug – the chemical equivalent to a “brand name drug.” These drugs cost less, and the savings is passed onto health plan members in the form of a lower co-pay.
Grace Period – The length of time (usually 31 days) after a premium is due and unpaid during which the policy, including all riders, remains in force. If a premium is paid during the grace period, the premium is considered to have been paid on time. In Universal Life policies, it typically provides for coverage to remain in force for 60 days following the date cash value becomes insufficient to support the payment of monthly insurance costs.
Group insurance – an insurance contract made with an employer or other entity that covers individuals in the group.
Guaranteed Renewable – A policy provision in many products which guarantees the policy owner the right to renew coverage at every policy anniversary date. The company does not have the right to cancel coverage except for nonpayment of premiums by the policy owner; however, the company can raise rates if they choose.
Hazard – A circumstance that increases the likelihood or probable severity of a loss. For example, the act of sky-diving increases the risk of broken bones or death.
Health Maintenance Organization (HMO) – Prepaid group health insurance plan that entitles members to services of participating physicians, hospitals and clinics. Emphasis is on preventative medicine, and members must use contracted health-care providers.
Health Reimbursement Arrangement – Owners of high-deductible health plans who are not qualified for a health savings account can use an HRA.
Health Savings Account – Plan that allows you to contribute pre-tax money to be used for qualified medical expenses. HSAs, which are portable, must be linked to a compatible high-deductible health insurance policy.
HIPAA – Health Insurance Portability and Accountability Act of 1996, P.L. 104-91. This law relates to underwriting, pre-existing limitations, guaranteed renewal, COBRA and certification requirements in the event someone terminates from the plan. The new law, commonly known as the “Kennedy-Kassebaum Bill,” establishes new requirements for self-funded, fully-insured group plans (including church plans) and Individual Health policies.
ID card/identification card – card given to insured individuals which advises medical providers that a patient is covered by a particular health insurance plan.
Indemnity – Restoration to the insured of a loss by payment, repair or replacement. Generally means to make whole again.
Indemnity insurance plans – traditional insurance plans (not HMOs or PPOs) which permit insured individuals to choose their doctors and hospitals. Insured individuals do not have to choose doctors or hospitals from a specific list of providers. Also called “fee-for-service” plans.
Inflation Protection – An optional property coverage endorsement offered by some insurers that increases the policy’s limits of insurance during the policy term to keep pace with inflation.
In-network – describes a provider or health care facility which is part of a health plan’s network. When applicable, insured individuals usually pay less when using an in-network provider.
Lifetime Reserve Days – Sixty additional days Medicare pays for when you are hospitalized for more than 90 days in a benefit period. These days can only be used once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance amount.
Lifetime maximum benefit – the maximum amount a health plan will pay in benefits to an insured individual.
Living Benefits – This feature allows you, under certain circumstances, to receive the proceeds of your life insurance policy before you die. Such circumstances include terminal or catastrophic illness, the need for long-term care, or confinement to a nursing home. Also known as “accelerated death benefits.”
Long-term disability (LTD) – insurance which pays employees a percentage of monthly earnings in the event of disability.
Managed care – the coordination of health care services in the attempt to produce high quality health care for the lowest possible cost. Examples are the use of primary care physicians as gatekeepers in HMO plans and pre-certification of care.
Medicaid – Medicaid is a federal medical assistance program for low income individuals and families who lack access to private health insurance. It was enacted in 1964 under Title XIX of the Social Security Act.
Multiple Employer Trust (MET) – an arrangement created to obtain health and other benefits for participating employer groups. Small employers can pool their contributions to receive the advantages of large group underwriting.
Network – a group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees. Provider networks can cover large geographic markets and/or a wide range of health care services. If a health plan uses a preferred provider network, insured individuals typically pay less for using a network provider.
Noncancellable – Contract terms, including costs that can never be changed.
Out-of-Pocket Limit – A predetermined amount of money that an individual must pay before insurance will pay 100% for an individual’s health-care expenses.
Own Occupation – A disability insurance contract provision that allows policyholders to collect benefits if they can no longer work in their own occupation.
Point-of-Service Plan – Health insurance policy that allows the employee to choose between in-network and out-of-network care each time medical treatment is needed.
Pre-certification – Pre-admission review and approval of appropriateness and medical necessity of hospitalization or other medical treatment.
Pre-Existing Condition – A coverage limitation included in many health policies which states that certain physical or mental conditions, either previously diagnosed or which would normally be expected to require treatment prior to issue, will not be covered under the new policy for a specified period of time.
Preferred Provider Organization (PPO) – Network of medical providers who charge on a fee-for-service basis, but are paid on a negotiated, discounted fee schedule.
Premium – The price of insurance protection for a specified risk for a specified period of time.
Provider – any person or entity providing health care services, including hospitals, physicians, home health agencies and nursing homes. Usually licensed by the state.
Qualified High-Deductible Health Plan – A health plan with lower premiums that covers health care expenses only after the insured has paid each year a large amount out of pocket or from another source. To qualify as a health plan coupled with a Health Savings Account, the Internal Revenue Code requires the deductible to be at least $1,000 for an individual and $2,000 for a family. High-deductible plans are also known as catastrophic plans.
Qualified Versus Non-Qualified Policies – Qualified plans are those employee benefit plans that meet Internal Revenue Service requirements as stated in IRS Code Section 401a. When a plan is approved, contributions made by the employer are tax deductible expenses.
Renewal – The automatic re-establishment of in-force status effected by the payment of another premium.
Rider – a modification to a Certificate of Insurance regarding clauses and provisions of a policy. A rider usually adds or excludes coverage.
Risk – uncertainty of financial loss.
Risk Class – Risk class, in insurance underwriting, is a grouping of insureds with a similar level of risk. Typical underwriting classifications are preferred, standard and substandard, smoking and nonsmoking, male and female.
Risk Management – Management of the pure risks to which a company might be subject. It involves analyzing all exposures to the possibility of loss and determining how to handle these exposures through practices such as avoiding the risk, retaining the risk, reducing the risk, or transferring the risk, usually by insurance.
Section 1035 Exchange – This refers to a part of the Internal Revenue Code that allows owners to replace a life insurance or annuity policy without creating a taxable event.
Section 7702 – Part of the Internal Revenue Code that defines the conditions a life policy must satisfy to qualify as a life insurance contract, which has tax advantages.
Short-term medical – temporary health coverage for an individual for a short period of time, usually from 30 days to six months.
Skilled Nursing facility (SNF) – a medical care facility where rehabilitation and recovery services are given.
Stop-loss – the dollar amount of claims filed for eligible expenses at which the insurance begins to pay at 100% per insured individual. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
Surrender Period – A set amount of time during which you have to keep the majority of your money in an annuity contract. Most surrender periods last from five to 10 years. Most contracts will allow you to take out at least 10% a year of the accumulated value of the account, even during the surrender period. If you take out more than that 10%, you will have to pay a surrender charge on the amount that you have withdrawn above that 10%.
Term Life Insurance – Life insurance that provides protection for a specified period of time. Common policy periods are one year, five years, 10 years or until the insured reaches age 65 or 70. The policy doesn’t build up any of the nonforfeiture values associated with whole life policies.
Third Party Administrator (TPA) – An organization responsible for marketing and administering small group and individual health plans. This includes collecting premiums, paying claims, providing administrative services and promoting products.
Underwriter – The individual trained in evaluating risks and determining rates and coverages for them.
Underwriting – The process of selecting risks for insurance and classifying them according to their degrees of insurability so that the appropriate rates may be assigned. The process also includes rejection of those risks that do not qualify.
Universal Life Insurance – A combination flexible premium, adjustable life insurance policy.
Variable Life Insurance – A form of life insurance whose face value fluctuates depending upon the value of the dollar, securities or other equity products supporting the policy at the time payment is due.
Variable Universal Life Insurance – A combination of the features of variable life insurance and universal life insurance under the same contract. Benefits are variable based on the value of underlying equity investments, and premiums and benefits are adjustable at the option of the policyholder.
Viatical Settlement Provider – Someone who serves as a sales agent, but does not actually purchase policies.
Waiver of coverage – a section on the enrollment form which states that an employee was offered insurance coverage but opted to waive this coverage.
Waiver of Premium – A provision in some insurance contracts which enables an insurance company to waive the collection of premiums while keeping the policy in force if the policyholder becomes unable to work because of an accident or injury. The waiver of premium for disability remains in effect as long as the ensured is disabled.
Whole Life Insurance – Life insurance which might be kept in force for a person’s whole life and which pays a benefit upon the person’s death, whenever that might be.
Worker’s Compensation Insurance – insurance coverage for work-related illness and injury. All states require employers to carry this insurance