ffGlossary of Insurance Terms

 

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A

Activities of daily living (ADLs)

Activities that are a normal part of everyday life, such as bathing, continence, dressing, eating, toileting, and transferring.

Actual cash value (ACV)

The value of the property when it is damaged or destroyed. This is usually figured by taking the replacement cost and subtracting depreciation.

Actual charge

The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves.

Additional living expenses

If your home is so damaged that you are unable to live there, most homeowner insurance policies pay for some additional living expenses while repairs are being made. This could include limited motel, restaurant, and warehouse storage expenses.

Adjuster

An insurance company representative who seeks to determine the extent of the firm's liability for loss when a claim is submitted.

Administrative services only (ASO)

An arrangement whereby an organization (usually an employer) hires an outside firm to perform specific administrative services, such as providing claim forms and processing claims, for a group health insurance program. The organization retains financial responsibility for paying claims.

Adult day care

Care given in a nonresidential facility, community-based group program designed to meet the needs of functionally impaired adults. It is a structured, comprehensive program that may provide a variety of health, social, and related support services during any part of a day.

Adverse selection

Occurs when the applicants for insurance represent a sample of the population that is biased toward those with a greater loss exposure rather than a true random sample. In flood insurance, those persons and businesses with serious flood exposures are likely to purchase flood insurance.

Agent

A person licensed by a state insurance department who solicits, negotiates, or effects insurance contracts on behalf of one or more insurers.

All risks coverage

The term "all risk" means there is coverage for all perils except those excluded. A particular exposure would be insured against economic loss by any peril that is not specifically excluded under the terms of the contract.

Allowable charge

The amount Medicare considers a reasonable charge for medical services or supplies based on the usual or customary charges in your area (Medicare pays 80% of the amount).

Alternative plan of care

If you otherwise qualify for benefits, this provision allows you to qualify for benefits not specifically listed in the policy upon the agreement of you, your physician, and the company.

Amendment

A formal document changing the provisions of an insurance policy signed jointly by the insurance company and by the policyholder or his or her authorized representative.

Annual "out-of-pocket" maximum

The most you will have to pay in any given year for all services received under an insurance policy. This amount includes copayments, coinsurance and deductibles. If you exceed this amount, the insurance company will pay all other expenses for the remainder for that year.

Annuity

An investment that provides an income over a specified period of time, often used as a device for retirement income.

Appeal

An appeal is a special kind of complaint you make if you disagree with any decision about your health care services. This complaint is made to your health plan. There is usually a special process you must use to make your complaint.

Application

A statement of information made by someone applying for insurance. The information gathered helps the insurance company assess whether the risk presented by the applicant is acceptable.

Appraisal

A review of a property claim to determine the value of a particular item, or the value of the loss to the damaged property.

Approved amount or charge

Also called the allowable, eligible, or accepted charge, this is the maximum fee set by Medicare that it will approve for a particular service or procedure, of which Medicare will reimburse 80%.

Appurtenant structures

Buildings on the same premises as the main building insured under a property insurance policy. A detached garage, a tool shed or a gazebo would be called an appurtenant structure.

Arbitration clause

Clause of a policy that provides that if a policyholder and the company cannot agree on the amount of a claim settlement, each appoints an appraiser. The appraisers select a neutral umpire. When at least two of the three, appraisers and umpire, agree on the settlement amount, it is binding on both the insured and the insurer.

Assisted living facility

A facility certified or registered by the Wisconsin Department of Health and Family Services (DHFS). These facilities exist to bridge the gap between independent living and nursing homes and provide a variety of services depending on the needs of the residents.

Attained age

This means that as you age, your premiums will change to meet your age range and your premiums will become higher.

Auto insurance

A type of insurance that protects the policyholder against losses involving automobiles. Different coverages can be purchased depending on the needs and wants of the insured.

Automatic premium loan

A provision in a life insurance policy that any premium not paid by the end of the grace period (usually 31 days) is automatically paid by a policy loan if there is sufficient cash value.

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B

BadgerCare

Wisconsin’s program to provide health care coverage for uninsured families.

Bed reservation

This benefit is payable if you are receiving nursing home care and need to spend time in a hospital. The company will cover any charge made by the nursing home for reserving your bed during your hospitalization.

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 insured's death.

Benefit period

In health insurance, the number of days for which benefits are paid to the named insured and his or her dependents. For example, the number of days that benefits are calculated for a calendar year consist of the days beginning on January 1 and ending on December 31 of each year.

Benefit triggers

A term used to describe when to pay benefits. One type of benefit trigger is an activity of daily living (ADL). Insurance companies may use different events or types of benefit triggers to determine when benefits will begin to be paid. The triggers are described in the eligibility criteria of the policy.

Betterment

The increase in the dollar value of physical property which often occurs when new property replaces old property after a loss covered by property insurance. For example, betterment means that your repaired vehicle is better than it was before the accident. The application of the principle of indemnity would require the adjuster to reduce the insurer's payment to the insured by the amount of the recognized betterment.

Binder

A temporary or preliminary agreement to provide immediate insurance coverage until a policy can be written or delivered. May be oral or written and sets forth conditions of coverage. Often used during the interval between the coverage becoming effective and the time a formal policy is prepared and delivered. Normally it is issued for a limited period of time.

Broker

A marketing specialist who represents buyers of property and liability insurance and who deals with either agents or companies in arranging for the coverage required by the customer.

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C

Cancellation

Termination of an insurance policy or bond by an insurance company or a policyholder before its expiration date.

Capitation

A compensation plan used in some health maintenance organizations (HMOs) in which a physician is paid a flat amount per year per subscriber who elected to use that physician. For that amount, the physician must treat the subscriber as often as necessary during that year. Physicians are not reimbursed for services that exceed the allotted amount.

Captive agent

An agent who sells insurance for only one company, as opposed to an independent agent who represents several companies.

Care coordination

Services provided by a licensed or certified health care professional designated by the insurance company to perform an assessment and develop a plan to meet your long-term care needs.

Caregiver training

Training provided in order to assist an informal and unpaid caregiver to care for you at home.

Carrier

An insurance company that actually underwrites and issues the insurance policy. The term is used because the insurance company assumes or carries the risk for policyowners.

Case management

A process by which an enrollee with a serious, complicated, or chronic health condition is identified by a managed care organization and a plan of treatment is established in order to achieve optimum health in a cost-effective manner.

Cash value

In a life insurance policy, the amount of money, before adjustment for factors such as policy loans or late premiums, that the policy owner will receive if the policy owner allows the policy to lapse or cancels the coverage and surrenders the policy to the insurance company. Cash values are a feature of most types of permanent life insurance, such as whole life and universal life.

Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs the Medicare program.

Certificate of insurance

The formal document received by an employee that describes the specific benefits covered by the policyholder’s group health care contract with the insurance company. The certificate contains copayment and/or deductible requirements, specific coverage details, exclusions and the responsibilities of both the certificate holder and the insurance company.

Claim

A request by an insured for payment under the terms of an insurance policy.

Claimant

The person or party making a formal request for payment of benefits due under the terms of an insurance contract.

Classification

The grouping, for underwriting, rating or other purposes, of policyholders or properties having the same general characteristics. Your insurance rate would be changed if you were reclassified.

Closed panel

A type of health plan that requires enrollees to seek care from a medical provider who is either employed by or under contract to the health maintenance organization or limited service health organization.

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)

The federal law that requires companies with 20 or more employees to offer separating employees the option to continue their group health-care coverage at their own expense.

Cognitive impairment

A deficiency in your short-term or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.

Coinsurance

A provision in insurance policies that requires the insured to share in the cost of covered services on a percentage basis. A typical coinsurance arrangement is 80% by the insurer and 20% by the insured.

Collision

An optional auto insurance coverage that pays for damage to the policyholder's car caused by its collision with another vehicle or object.

Community Based Residential Facility (CBRF)

These facilities are licensed, registered, or certified by the Department of Health and Family Services (DHFS). CBRFs are covered only if your policy identifies these facilities as a covered benefit and the facility has been licensed as a CBRF by DHFS.

Comprehensive coverage or other than collision

An optional auto insurance coverage that pays for damage to the policyholder’s car for losses caused by fire, theft, vandalism, falling objects and various other perils. Damage from striking a deer is a relatively frequent accident in Wisconsin. Most policies cover hitting an animal under comprehensive, not collision, insurance.

Conditions

Provisions of an insurance policy that state the rights and duties of the insured or the insurance company. Typical conditions have to do with such things as the insured's duties in the event of loss, cancellation provisions, and the rights of the insurer.

Contingent nonforfeiture or contingent benefit upon lapse

In a long-term care insurance policy, if you reject the mandatory offer of a nonforfeiture benefit, the insurance company must provide a "contingent benefit upon lapse." This means that when the premiums increase to a certain level (based on a table of increase provided to you in the policy information), the benefit will take effect. You will then be offered, within 120 days of the due date of the new premium, the opportunity to accept one of the following options: 1) reduce your benefits provided by the current policy so that your premium will stay the same, or 2) convert your policy to a paid-up status with a shorter benefit period.

Contract

The formal legal document, also known as the "policy" that describes the agreement between the policyholder and the insurance company. This document contains the specific responsibilities of the policyholder and the insurance company in relation to the benefits provided under the contract.

Coordination of benefits (COB) clause

A provision in a group health insurance policy that applies when a person is covered under more than one group medical program. It requires the payment of benefits to be coordinated by all insurance companies who cover that person in order to eliminate overinsurance or duplication of benefits.

Copayment

A provision in insurance policies that requires the insured to pay a flat fee for certain medical expenses.

Coverage

The scope of protection provided under an insurance contract.

Custodial care

The level of care required to assist an individual in the activities of daily living. This care helps meet personal needs and can be provided by persons without professional licenses or extensive training.

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D

Declarations page

The page attached to the front of a property or liability insurance policy that includes information such as the name and address of the insured, the property insured, its location and description, the policy period, the amount of insurance coverage, the deductible, applicable premiums, and other related policy information provided by the insured.

Deductible

The amount of an insured loss paid by the policyholder. For example, if you select a deductible of $250 for your auto insurance policy, you agree to pay the first $250 worth of damages to your car if you are in an accident. In health insurance, it is the portion of eligible medical expenses that the insured must pay before the plan with make any benefit payments.

Defined network plan

A term used in Wisconsin law to refer to any health benefit plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the plan. This type of plan is sometimes referred to as a managed care plan.

Dependent

An individual--usually a child or a spouse--who relies on another person for support and who obtains health coverage through that person (usually a spouse or parent).

Depreciation

A decrease in the value of property over a period of time resulting from use, obsolescence, or wear and tear.

Disability benefit

A feature added to some life insurance policies providing for waiver of premium, if the policyholder becomes totally and permanently disabled.

Disability insurance

A type of health insurance that pays a monthly income to the policyholder when he or she is unable to work because of an illness or accident.

Dividend

An amount of money returned to the holder of a participating policy. The money is partial refund of the premium paid. It results from actual mortality, interest and expenses that were more favorable than expected when the premiums are set.

Drug formulary

Many defined network plans establish a list of prescription drugs that the plan considers medically appropriate and cost effective. The defined network plan will provide coverage for only those prescription drugs named in the list. However, your doctor may present medical evidence to the insurer to obtain an exception that will allow coverage for a prescription drug not routinely covered by the plan.

Durable medical equipment (DME)

Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds.

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E

Effective date

The date on which insurance coverage goes into effect. (Not always the same as the date the application is completed.)

Elimination period

The number of days you must wait after receiving long-term care before receiving insurance benefits.

Emergency care

A medical emergency includes severe pain, an injury, sudden illness, or suddenly worsening illness that would cause a reasonably prudent layperson to expect that delay in treatment may cause serious danger to the person's health if he/she does not get immediate medical care.

Endorsement

Written agreement attached to a policy to add or subtract insurance coverages.

Enrollment period

The amount of time an employee has to sign up for a contributory health plan.

ERISA (Employee Retirement Income Security Act of 1974)

The federal law that mandates reporting and disclosure requirements for self-insured health plans. It also prohibits states from regulating insurance plans offered by employers to their employees if the employer is self-insured.

Excess charge

The difference between a doctor's or other health care provider's actual charge and the Medicare-approved payment amount.

Exclusions or limitations

Specific situations, conditions, or circumstances that are listed in the insurance policy as not being covered.

Experience rating

The process of using a group’s own premium and claims experience to calculate premium rates. If the claims experience for the previous year was favorable, the insurer considers reducing the premium rates for the coming year. If the experience was unfavorable, the insurer attempts to discover the reason and may propose higher premiums for the next year.

Explanation of Medicare Benefits (EOMB)

A notice that is sent to you after the doctor files a claim for Part B services that explains what the provider billed, the Medicare-approved amount, how much Medicare paid, and the amount you must pay.

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F

Face amount

The amount stated on the insurance policy that will be paid in case of death or at maturity. It does not include dividend additions or additional amounts payable under other special provisions.

Fee-for-service

The traditional health care payment system (also known as indemnity insurance) under which physicians and other providers receive a payment that does not exceed their billed charge for each unit of service provided. Under a fee-for-service insurance plan, insureds usually may choose to go to any provider they want, as long as the provider is willing to accept the insurance company's payments.

Financial responsibility law

A law in some states under which a person involved in an automobile accident may be required to furnish security up to certain minimum dollar limits. Wisconsin has a financial responsibility law.

Fiscal intermediary

A private insurance company that has contracted with Medicare to process bills (claims) for Part A services.

Floater

Coverage for property that moves from location to location either on a scheduled or unscheduled basis. If the floater covers scheduled property, coverage is listed for each item. If a floater covers unscheduled property, all property is covered for the same limits of insurance.

Formulary

(See Drug formulary)

Free look period

The period of time after the delivery of an insurance policy when you can review the policy. If you change your mind about keeping the policy during this time period, you can canel the policy and get your initial premium back.

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G

Gatekeeper

A primary care physician responsible for overseeing and coordinating all aspects of a patient’s medical care. The gatekeeper may have to preauthorize other specialty care or hospital admission.

Grace period

A period of time after a premium becomes due in which you can still pay for the insurance and keep it in force. Wisconsin law requires that for health insurance it is 7 days for weekly premium policies, 10 days for monthly premium policies, and one month for all other policies.

Grievance

Any written statement of dissatisfaction with a managed care plan or limited service health organization submitted by or on behalf of a plan enrollee.

Group insurance

Any insurance plan under which a number of persons and their dependents are insured under a single policy, issued to their employer or an association with which they are affiliated, with individual certificates given to each insured person.

Group life insurance

Life insurance provided for members of a group. It is most often issued to a group of employees but may be issued to any group provided it is not formed for the purpose of buying insurance. The cost is lower than for individual policies because administrative expenses per life are decreased, there are certain tax advantages, and measures taken against adverse selection are effective.

Guaranteed issue policy

A policy of insurance that will be issued regardless of health condition. Small group and individual policies cannot be denied to any person who wishes to purchase one.

Guaranteed issue rights

Rights you have in certain situations when insurance companies are required to accept your application for insurance. In these situations, an insurance company can't deny you insurance coverage or place conditions on a policy, must cover you for all preexisting conditions, and cannot charge you more for a policy because of past or present health problems.

Guaranteed purchase

A rider to a policy that allows you to increase the benefits during specific periods of time without proof of insurability.

Guaranteed renewable policy

An individual health insurance policy that specifies that the insurer will continue the policy until the insured reaches a specified age if premium payments are made when due. The insurer can change premium rates for broad classes of insureds.

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H

Health Employer Data and Information Set (HEDIS)

HEDIS enables purchasers and consumers to readily compare the performance of managed care plans. HEDIS is a standardized set of performance measures that assesses plans’ performance on a number of elements, including such things as financial stability, access and quality of care. It has been used extensively by private sector purchasers to judge the quality of care provided by plans to their employees. It is sponsored, supported and maintained by the National Committee for Quality Assurance (NCQA).

Health insurance

A general term for insurance against loss by sickness or bodily injury. This usually includes coverage for medical expenses such as doctor visits and hospital stays and can cover normal and preventive care such as check-ups, prenatal care, and well-baby care.

Health Insurance Risk Sharing Plan (HIRSP)

Wisconsin’s high risk health insurance pool. HIRSP offers health insurance to Wisconsin residents who either are unable to find adequate health insurance coverage in the private market due to their medical conditions or who have lost their employer-sponsored group health insurance. Applicants are required to meet HIRSP eligibility criteria to qualify.

Health maintenance organization (HMO)

A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific plan providers.

High Risk Health Insurance Pool

(See Health Insurance Risk Sharing Plan)

Home health care

A wide variety of skilled nursing care and supportive services for individuals who do not need institutional care. The services are available through intermittent visits and may include nursing care, physical therapy, speech and hearing therapy, occupational therapy, social services, and other support services.

Homeowner’s insurance policy

Package policy that combines (1) coverage against the insured’s property being damaged by various perils, and (2) coverage for liability exposure of the insured. Homeowner's policies cover both individuals as well as property.

Hospice care

A specially designed package of social and medical services that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families.

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I

Incontestable clause

A clause in a policy providing that after a policy has been in effect for a given length of time (two or three years), the insurer shall not be able to contest the statements contained in the application. A health insurance provision also states that after that time no claim shall be denied or reduced on the grounds that a condition not excluded by name at the time of issue existed prior to the effective date. In life policies, if an insured lied as to the condition of his health at the time the policy was taken out, that lie could not be used to contest payment under the policy if death occurred after the time limit stated in the incontestable clause.

Indemnity

A type of insurance in which the insured pays for services at the time they are received, submits bills and copies of paid receipts to the insurance company, and the insurance company reimburses the insured for a set portion of the covered health care expenses.

Independent agent

An independent agent represents several different insurance companies and searches the market for the best place for a client's business.

Independent review

An appeal process in which a health care professional with no connections to an enrollee’s health plan reviews a dispute over whether treatment is medically necessary or experimental.

Individual Practice Association (IPA)

An association of physicians that contracts with a health maintenance organization, limited service health organization, or preferred provider plan to provide health care services.

In-Network

A provider, hospital, pharmacy, or other facility is "in-network" when it has contractually accepted the health insurance company’s terms and conditions for payment of services.

Instrumental activities of daily living

Basic functional activities necessary for you to remain in your home, such as meal preparation, shopping, light housekeeping, laundry, telephoning, and handling money and paying bills.

Insurability

Acceptability by the insurance company of an applicant for insurance.

Insurable interest

A condition in which the person applying for an insurance policy and the person who is to receive the policy benefit will suffer an emotional and financial loss if the event insured against occurs. Without the presence of insurable interest, an insurance contract is not formed for a lawful purpose and, thus, is void from the start.

Insurance

A formal device for reducing the chance of loss by transferring the risks of several individual entities to insurance companies.

Insurance to value

Insurance written in an amount approximating the value of the property insured.

Insured

The party covered by an insurance arrangement, to whom an insurance company agrees to indemnify for losses, provide benefits, or render services.

Intermediate care

Less intensive care than skilled nursing care. Its definition may vary from policy to policy. It usually includes assistance with activities of daily living with the availability of any on-duty registered nurse.

Issue age

Premiums are set at the age you are when you buy the policy and will not increase because you get older. Premiums may increase for other reasons.

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L

Lapsed policy

A policy terminated at the end of the grace period because of nonpayment of premiums and no value to be loaned against to cover the due premium.

Liability

Individual responsibility for causing, through negligence, injury to another person or damage to another person’s property.

Liability insurance

Insurance covering the policyholder’s legal liability for injuries to another person or damages to another person’s property for which the insured is legally liable.

Licensed health care practitioner

Any physician, registered nurse, licensed or certified social worker, or any other individual who meets such requirements as may be prescribed by the Secretary of the Treasury.

Lifetime benefit maximum

The total amount an insurance company will pay for health care services over your lifetime. If the cost of the benefits you receive since enrolling in a plan exceeds this amount, your coverage ends and no additional services will be covered.

Like kind and quality parts

Refers to the use of replacement parts which are of the same kind and quality as the original parts.

Limited Service Health Organizations (LSHO)

A health care plan that makes available to its enrollees a limited range of health care services, such as dental or eye care, performed by providers selected by the organization.

Limiting charge

The maximum a physician who does not accept assignment may legally charge for a Medicare-covered service.

Lock-in

A contractual provision by which members, except in cases of unforeseen out-of-area urgently needed care or emergency care, are required to receive all their care from the managed care plan’s network or health care providers.

Loss settlement provision

Section of the insurance policy that specifies how insured losses will be settled or adjusted.

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M

Mandated benefits

Benefits that health insurance plans are required by state or federal law to provide to policyholders and eligible dependents.

Managed care

Generally a health care delivery system that links doctors, hospitals and an insurance plan to deliver care to the plan's members with the intent of improving quality and reducing costs. Health insurance can manage care in a number of ways, including requiring members to choose a primary care provider, to obtain the primary care provider's permission to see a specialist and to use only providers with the plan's network of providers.

Managed care plan

Any health plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the health benefit plan.

Market value

A real estate term that describes what the current value of your home would be if you were to sell it--including the price of the land. This amount generally is not involved in determining what amount to purchase under a homeowner’s policy. Since the object of most property insurance policies is to pay the insured the actual cash value or the cost to repair or replace the damaged or destroyed property, the "market" or "book" values are not used in loss settlements.

Medical payments coverage

Provision of liability policies and the liability sections of package insurance policies, such as the personal automobile policy, that pays medical expenses without regard to fault. The insured does not admit liability for bodily injury to another party, nor does an injured party forfeit the right to sue the insured.

Medically necessary

Services or supplies that meet the following: (1) they are appropriate and necessary for symptoms, diagnosis, or treatment of the medical condition; (2) they are provided for the diagnosis or direct care and treatment of medical conditions; (3) they meet the standards of good medical practice within the medical community in the service area: (4) they are primarily for the convenience of the patient or provider; (5) they are the most appropriate level or supply of service that can safely be provided.

Medicare

A federal health insurance program for people age 65 and older and some younger disabled people. In original Medicare, a fee-for-service program, you can go to any doctor or hospital that participates in Medicare. Medicare will pay the doctor or hospital directly for eligible services they provide. Medicare has two parts: Part A, which covers hospital services and Part B, which covers doctor services.

Medicare+Choice

A federal program providing Medicare coverage through the private insurance market. These plans have a special arrangement between the federal Centers for Medicare & Medicaid (CMS) and certain HMOs. The federal government pays the HMO a set amount for each Medicare enrollee. The HMO agrees to provide all Medicare benefits. The HMO will also provide some additional benefits that may be at an additional cost.

Medicare Select

A Medicare supplemental health insurance product that will pay the Medicare deductibles and copayments and some additional benefits only if the covered services are obtained through specified health care professionals.

Misrepresentation

A significant misstatement in an application form. An insured is required to answer truthfully all questions on an insurance application. The insurance company can void the policy if it would not have issued a policy had it known the facts.

Misstatement of age

Life insurance wording that specifies the action the insurer will take if, at the insured's death, the insurer discovers that the insured's age was misstated in the application and the misstatement has resulted in an incorrect premium for the amount of insurance purchased.

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N

Named peril or specified peril

This is a peril indicated or identified in the contract as a cause of loss for which insurance is being provided. Under such contracts if a peril is not named or specified it is not covered.

National Committee for Quality Assurance (NCQA)

NCQA is a non-profit organization that evaluates and accredits managed care plans. It is also responsible for implementing the Health Employer Data and Information Set (HEDIS) data reporting system that provides standardized performance measures for managed care plans.

Network

A group of doctors, nurses and hospitals that work for a managed care plan to provide health care services to its members. To get the most benefits for the lowest cost to you, you generally have to use the plan’s network.

Nonparticipating physician

A doctor or supplier who does not accept assignment on all Medicare claims. A doctor or supplier who does not have a network agreement with a managed care plan.

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O

Open enrollment period

A period when new beneficiaries may elect to enroll in a policy of insurance regardless of health.

Open panel

A type of health plan other than a closed panel plan that provides incentives for the enrollee to use providers selected by the plan.

Ordinary life insurance

(See Whole life insurance)

Original equipment manufacturer (OEM) parts

Refers to the use of replacement parts which are made by the same manufacturer which produced the original parts.

Original Medicare

(See Medicare)

Out-of-pocket costs

The costs that you must pay on your own because they are not covered by insurance.

Outline of coverage

The document given to each individual policyholder or group health plan member that summarizes the benefits, copayment, coinsurance, deductibles and other requirements for obtaining services covered by the individual policy or group health plan that are listed in full detail in the contract.

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P

Package policy

Several basic property and/or liability policies combined to form a single policy. Contains a common declarations page, common policy conditions, and two or more agreement "coverage parts," such as dwelling coverage, other buildings, personal property, etc.

Paid-up survivor

In a long-term care insurance policy this optional rider provides for a noncancelable, paid-up policy upon payment of a single premium. If you select the single premium and nonforfeiture benefit, you may surrender your policy while it is in force for a cash nonforfeiture benefit.

Peril

A property insurance term referring to the possible cause of loss such as a fire or windstorm.

Personal liability

This coverage protects you against a claim or lawsuit resulting from bodily injury or property damage to others. The coverage applies to you and all family members who live with you.

Personal property

All tangible property not classified as real property.

Plan of care

A plan outlining the care you need and the length of time the care will be needed.

Point Of Service (POS) plan

A type of managed care plan that allows members to use out-of-network providers, but at additional cost (usually a higher copayment or a deductible).

Policy

A written contract for insurance between the insurance company and the policyholder and contains pertinent facts about the policy owner, the insurance coverage, the insured and the insurer.

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 cash value of the policy as collateral for the loan. In the event the policyholder dies with the debt partially or fully unpaid, the insurance company deducts the amount borrowed, plus any accumulated interest, from the amount payable.

Policyholder

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

Preauthorization/precertification

A provision in insurance policies that requires prior approval by a managed care plan or limited service health organization in order for services to be covered by the plan.

Preexisting condition

An illness, medical condition, or injury that has been diagnosed, or for which a person has been treated, before buying a new health care policy.

Preferred Provider Plan (PPP)

A type of managed care plan, where coverage for expenses incurred when services are provided by a network provider are paid at a higher level than the coverage available for services received from an out-of-network provider.

Premium

The amount of money an insurance company charges, based on a given rate, to provide the coverage described in the policy, or simply stated, the price of insurance protection for a specified risk for a specified period of time, typically one year.

Preventive health care

Health care that seeks to prevent the occurrence of conditions by fostering early detection of disease and morbidity and which focuses on keeping patients well in addition to healing when they are sick.

Primary care provider

The first health care provider a managed care plan's member is required to contact when he or she needs health care services, usually a physician specializing in primary care services. The primary care provider is responsible for knowing the member's complete medical history, performing routine health care duties, and referring the member to a specialist when necessary.

Primary payer

An insurance policy, plan, or program that pays first on a claim for medical care. This could be Medicare or other health insurance.

Property/Casualty insurance

Property insurance covers damage to or loss of the policyholder's property. The terms "casualty" and "liability" insurance are often used interchangeably. Both cover the policyholder's legal liability for damages caused to other persons and/or their property.

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R

Rate

The cost of a unit of insurance as determined by insurance companies and state regulators. The rate serves as the basis for the premium.

Rated policy

A policy issued at a higher premium to cover a person classified as a greater-than-average risk, usually because of impaired health or a dangerous occupation or hobby.

Real property

Land and most things attached to the land such as buildings and vegetation.

Referral

A process by which the primary care physician makes a request to a managed care plan on behalf of the enrollee to receive medical care from a nonparticipating provider or specialist.

Reinsurance

An agreement between two or more insurance companies by which the risk of loss is proportioned. Thus the risk of loss is spread and a disproportionately large loss under a single policy does not fall on one insurance company. Acceptance by an insurer, called a reinsurer, of all or part of the risk of loss of another insurance company. An insurance company issuing an automobile liability policy, with a limit of $100,000 per accident may reinsure its liability in excess of $10,000. A fire insurance company which issues a large policy generally reinsures a portion of the risk with one or several other companies.

Replacement cost on contents

This additional coverage pays for your losses on the basis of how much it would cost to replace or repair the item at current costs without deducting for depreciation. If the item is not replaced or repaired, only the actual cash value is payable.

Residential Care Apartment Complexes (RCAC)

These facilities are certified by the Department of Health and Family Services (DHFS). RCACs are covered only if your policy identifies these facilities as a covered benefit and the facility has been certified as a RCAC by DHFS.

Respite care

The provision of personal care, supervision, or other services to a functionally impaired person in order to temporarily relieve a family member or other primary caregiver from caregiving duties. Respite care services are usually provided in the impaired person's home or in another home or homelike setting, but may also be provided in a nursing home.

Restoration of benefits

If you collect benefits from a policy and then recover to the point where you are not receiving care qualifying you for benefits for a certain period of time, you can have those benefits restored back to the original level. Look to see if this is a provision in the policy or if it is available as a rider for an additional premium.

Return of premium

A rider that provides that if you die after being insured for a specified period or if you have paid premiums for a specified period, the insurance company will return premiums paid minus any benefits paid.

Rider

A document or form containing special provisions that are not contained in the policy contract. Such forms are to be added or attached to the policy.

Risk

This word has two meanings for insurers: (1) the chance of loss such as from a peril; and (2) the person or entity that is insured by a policy.

Risk contract

A contract payment methodology between the federal Centers for Medicare & Medicaid (CMS) and a managed care organization (for example, an HMO) that requires the delivery of at least all Medicare-covered services to members as medically necessary in return for a fixed monthly payment from the government and sometimes an additional fee paid by the enrollee. The managed care organization is then liable for those contractually offered services without regard to cost.

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S

Secondary payer

An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation.

Selective screening

Accepting the best risks and declining the others - forces other insurers to practice selective screening or suffer poor loss experience.

Self-insured plan

An employer who offers health insurance to its employees, with the benefits paid for entirely by the employer. Self-insured plans are exempt from regulation by state laws, but are subject to certain federal requirements under ERISA.

Service area

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.

Settlement options

Methods for payment of the value of a policy. An insurance company can select one of three options in settlement of a loss: (1) make a cash payment; (2) take possession of damaged or destroyed property and replace it with property of like kind and quality, or (3) repair the property so that it is restored to its structural condition prior to the loss and return the repaired property to the insured. Usually insurance companies settle losses by a cash payment to the insured.

Skilled nursing care

Medically necessary care that can only be provided by, or under the supervision of, skilled, licensed, medical professionals such as registered nurses or professional therapists. All skilled services require a physician's order. Medicare's definition is often different from the definitions used in many Medicare supplement and long-term care insurance policies.

State Health Insurance Assistance Program (SHIP)

A state program that gets money from the federal government to give free health insurance counseling and assistance to people with Medicare.

Subrogation

The right of the insurance company to recover from a third party the amount paid under the policy. For example, if damage is done to your automobile, protected by a collision insurance policy, the insurance company may collect from the party whose automobile ran into your car, the amount of damages which was paid to you by the process of subrogation.

Surplus lines insurance

(1) A risk or part of a risk for which there is no normal insurance market available. (2) Insurance written by unauthorized insurance companies. Surplus lines insurance is insurance placed with unauthorized insurance companies through licensed surplus lines agents or brokers.

Surrender charges

Charges an insurance company may deduct if you cash in--or surrender--your life insurance policy or annuity. Companies also deduct these charges if you borrow money on your policy or your policy lapses for nonpayment.

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T

Term insurance

Life insurance under which the benefit is payable only if the insured dies during a specified period. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing.

Theft

The taking or removing of property with intent to deprive the rightful owner. It includes such crimes as robbery, burglary, and larceny.

Title insurance

Coverage for losses if a land title is not free and clear of defects that were unknown when the title insurance was written. Title insurance protects a purchaser if there is a defect in the title, such as lien against that property that is not discovered at the time of purchase.

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U

Umbrella liability

A form of insurance protection that provides additional liability coverage after the limits of your underlying policy are reached. An umbrella liability policy also protects you (the insured) in many situations not covered by the usual liability policies.

Unauthorized insurance company

An unauthorized insurance company is one that does not hold a valid certificate of authority to do business in Wisconsin.

Underinsured motorist (UIM) coverage

A coverage in an automobile insurance policy under which the insurance company will pay damages to the insured for which another motorist is liable if the motorist causing an accident has lower bodily injury liability limits than your UIM limits. The maximum dollars paid is then the difference between the two limits.

Underwriting

The process by which an insurance company selects and classifies risks according to their degree of insurability.

Uninsured motorists (UM) coverage

A coverage in an automobile insurance policy under which the insurance company will pay damages to the insured for which another motorist is liable if that motorist is unable to pay because he or she is uninsured. This coverage applies to bodily injury damages only. Injuries to the insured caused by a hit-and-run driver are also covered.

Universal life insurance

A combination flexible premium, adjustable life insurance policy. The premium payer may select the amount of premium he or she can pay and the policy benefits are those which the premium will purchase. Or, the premium payer may change the amount of insurance and pay premium accordingly.

Urgent care

Medically necessary care for an accident or illness that is needed sooner than a routine doctor's visit.

Usual, customary and reasonable (UCR) charge

A charge for health care based on the going rate in a certain geographic area for identical or similar services. This may also be referred to as reasonable and customary charge.

Utilization review

A method of claims review whereby the insurance company analyzes a case, either prospectively, concurrently, or retrospectively to determine if the treatment given is necessary and appropriate.

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V

Variable life insurance

A kind of insurance where the death benefits and cash values depend on the investment performance of one or more separate accounts, which may be invested in mutual funds or other investments allowed under the policy.

Vehicle identification number (VIN)

Also known as the vehicle's serial number. This number can be found on a small metal plate on the left side of the dashboard. The VIN must appear on the automobile insurance policy.

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W

Waiting period

A set period of time that an employer may make a new employee wait before enrolling in the company's health care plan. The health insurance policy cannot impose a waiting period, but the employer may.

Waiver of premium

A provision that sets certain conditions under which an insurance policy will be kept in full force by the insurance company without the payment of premiums. It is used most frequently for those policyholders who become totally and permanently disabled but may be available in certain other cases.

Whole life insurance

Life insurance that remains in force during the insured’s entire lifetime, provided premiums are paid as specified in the policy. Whole life insurance also builds a savings called the cash value.

Worker's compensation insurance

A policy conforming to state law which pays benefits to an employee (or an employee's family) if the employee suffers a job-related injury (including death) or occupational injury.

Write Your Own (WYO) Program

A cooperative undertaking of the insurance industry and the Mitigation Division of the Federal Emergency Management Agency (FEMA) begun in October 1983. The WYO Program allows participating property and casualty insurance companies to write and service the Standard Flood Insurance Policy in their own names. The insurance companies receive an expense allowance for policies written and claims processed while the Federal Government retains responsibility for underwriting losses. The WYO Program operates within the context of the National Flood Insurance Program (NFIP), and is subject to its rules and regulations.

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Updated: November 26, 2004