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Mississippi Health and Life Insurance
Accident - Answer-An unplanned, unforeseen event which occurs suddenly and at an unspecified place. Accident Insurance - Answer-A type of insurance that protects the insured against loss due to accidental bodily injury Accidental Death and Dismemberment - Answer-An insurance policy which pays a specified amount or a specified multiple of the insured's benefit if the insured dies, loses sight, or loses two limbs due to an accident Accidental Death Benefits - Answer-A policy rider that states that the cause of death will be analyzed to determine if it complies with the policy description of accidental death Actual Charge - Answer-The amount a physician or supplier actually bills for a particular service or supply Adhesion - Answer-A contract offereed on a take it or leave it basis by an insurer, in which the insured's only option is to accept or reject the contract. Any ambiguities in the contract will be settled in favor of the insured
Admitted (Authorized) Insurer - Answer-An insurance company authorized and licensed to transact insurance in a paricular state Adult Day Care - Answer-A program for impaired adults that attempts to meet their health, social, and functional needs ins a setting away from their homes Adverse Selection - Answer-The tendency of risks with higher probability of loss to purchase and maintain insurance more often than the risks who present lower probability Aleatory - Answer-A contract in which participating parties exhange unequal amounts. Insurance contracts are aleatory in that the amount the insured will pay in premiums is unequal to the amount the insurer will pay in the event of a loss Alien Insurer - Answer-An insurance company that is incorporated outside the United States. Apparent Authority - Answer-The appearance or the assumption of authority based on the actions, words, or deeds of the principal or because of circumstances the principal created. Approved Amount - Answer-The amount Medicare determines to be reasonable for a service that is covered under part B of Medicare. Assignment - Answer-A claim to a provider or medical supplier to receive payments directly from Medicare Attained Age - Answer-The age of the insured at a determined date. Attending Physician's Statement (APS) - Answer-A statement usually obtained from the applicant's doctor.
Capital Amount - Answer-A % of the principal amount of a policy paid to the insured if he/she suffered the loss of an appendage Carriers - Answer-Organizations that process claims and pay benefits in an insurance policy cease and desist order - Answer-A demand of a person to stop committing an action that is in violation of a provision. Cerificate of Insurance - Answer-A written document that indicated that an insurance policy has been issued, and that states both the amounts and types of insurance provided claim - Answer-A request for payment of the benefits provided by and insurance contract Coercion - Answer-An unfair trade practice in which an insurer uses physical or mental force to persuade an applicant to buy insurance. Coinsurance Clause - Answer-A provision that states that the insurer and the insured will share the losses covered by the policy in a proportion agreed upon in advance. Commissioner - Answer-The chief executive and administrative officer of a state insurance department. Comprehensive Policy - Answer-A plan that provides a package of health care services, including preventive care, routine physicals, immunization, outpatient services and hospitalization. Comprehensive Major Medical - Answer-A combination of basic coverage and major medical coverage that features low deductibles, high maximum benefits, and coinsurance. Concealment - Answer-The withholding of known facts which, if material, can void a contract.
Conditional Contract - Answer-A type of an agreement in which both parties must perform certain duties and follow rules of conduct to make the contract enforceable. Consideration - Answer-The binding force in a contract that requires something of value to be exchanged for the transfer of risk. The consideration on the part of the insured is the representations made in the application and the payment of premium; the consideration on the part of the insurer is the promise to pay in the event of loss. Consideration Clause - Answer-A part of the insurance contract that states that both parties must give something of value for the transfer of risk, and specifies the conditions of the exchange. Consolidated Omnibus Budget Reconciliation Act (COBRA) - Answer-Continues group health car for up to 18 months Consumer Report - Answer-A written and/or oral statement regarding a consumer's credit, character, reputation, or habits collected by a reporting agency from employment records, credit reports, and other public sources. contract - Answer-An agreement between two or more parties that is enforceable in court Contributory - Answer-A group insurance plan that requires the employees to pay part of the premium. coordination of benefits - Answer-A provision that helps determine the primary provider in situations where an insured is covered by more than one policy, thus avoiding claims overpayments. Copayment - Answer-An arrangement in which an insured must pay a specified amount for services "up front" and the provider pays the remainder of the cost.
Eligibility Period - Answer-The period of time in which an employee may enroll in a group health care plan without having to provide evidence of insurability. Elimination Period - Answer-A waiting period that is imposed on the insured from the onset of disability until benefit payments begin. Endodontics - Answer-An area of dentistry that deals with diagnosis, prevention and treatment of the dental pulp within natural teeth at the root canal. Enrollment Period - Answer-The amount of time an employee has to sign up for a contributory group health plan. Estoppel - Answer-A legal impediment to denying a fact or restoring a right that has been previously waived. excess charge - Answer-The difference between the Medicare approved amount for a service or supply and the actual charge. Explanation of Benefits (EOB) - Answer-A statement that outlines what services were rendered, how much the insurer paid, and how much the insured was billed. Explanation of Medicare Benefits - Answer-A statement sent to a Medicare patient indicating how the Medicare claim will be settled. exposure - Answer-A unit of measure used to determine rates charged for insurance coverage. Express Authority - Answer-The authority granted to an agent by means of the agent's written contract. extended care facility - Answer-A facility which is licensed by the state to provide 24 hour nursing care.
Extension of Benefits - Answer-A provision that allows coverage to continue beyond the policy's expiration date for employees who are not actively at work due to disability or who have dependents hospitalized on that date. This coverage continues only until the employee returns to work or the dependent leaves the hospital. Fair Credit Reporting Act - Answer-A federal law that established procedures that consumer-reporting agencies must follow in order to ensure that records are confidential, accurate, relevant and properly used. Fiduciary - Answer-An agent/broker who handles insurer's funds in a trust capacity. Flexible Spending Account (FSA) - Answer-A salary reduction cafeteria plan that uses employee funds to provide various types of health care benefits. Foreign Insurer - Answer-An insurance company that is incorporated in another state. Fraternal Benefit Societies - Answer-Life or health insurance companies formed to provide insurance for members of an affiliated lodge, religious organization, or fraternal organization with a representative form of government. fraud - Answer-The intentional misrepresentation or deceit with intent to induce a person to be part with something of value Free Look - Answer-A period of time, usually required by law, during which a policyowner may inspect a newly issued individual life or health insurance policy for a stated number of days and surrender it in exchange for a full refund of premium if not satisfied for any reason. Gatekeeper Model - Answer-A model of HMO and PPO organizations that uses the insured's primary care physician (the gatekeeper) as the initial contact for the patient for medical care and for referrals.
Home Health Agency (HHA) - Answer-An entity certified by the insured's health plan that provides health care services under contract home health care - Answer-Type of care in which part-time nursing or home health aide services, speech therapy, physical or occupational therapy services are given in the home of the insured. home health services - Answer-A covered expense under Part A of Medicare in which a licensed home health agency provides home health care to an insured. Hospice - Answer-A facility for the terminally ill that provides supportive care such as pain relief and symptom management to the patient and his/her family. Hospice care is covered under Part A of Medicare. Hospital Confinement Rider - Answer-An optional disability income rider that waives the elimination period when an insured is hospitalized as an inpatient. Implied Authority - Answer-Authority that is not expressed or written into the contract, but which the agent is assumed to have in order to transact the business of insurance for the principal. Income Replacement Contracts - Answer-Policies which replace a certain percentage of the insured's pure loss of income due to a covered accident or sickness. indemnify - Answer-To restore the insured to the same condition as prior to loss with no intent of loss or gain. Insolvent organization - Answer-A member organization which is unable to pay its contractual obligations and is placed under a final order of liquidation or rehabilitation by a court of competent jurisdiction.
Insurability - Answer-The acceptability of an applicant who meets an insurance company's underwriting requirements for insurance. Insuring Clause - Answer-A general statement that identifies the basic agreement between the insurance company and the insured, usually located on the first page of the policy. intentional injury - Answer-An act that is intended to cause injury. Self-inflicted injuries are not covered under accident insurance; intentional injuries inflicted on the insured by another are covered. Intermediaries - Answer-Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services. Intermediate Care - Answer-A level of care that is one step down from skilled nursing care; provided under the supervision of physicians or registered nurses. Investigative Consumer Report - Answer-A report similar to consumer report, but one that also provides information on the consumer's character, reputation and habits. lapse - Answer-Termination of a policy because the premium has not been paid by the end of the grace period. Law of Large Numbers - Answer-A principle stating that the larger the number of similar exposure units considered, the more closely the losses reported will equal the underlying probability of loss. Limited Policies - Answer-Health insurance policies that cover only specific accidents or diseases. limiting charge - Answer-The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment of the Medicare approved amount.
Medical savings account - Answer-An employer-funded account linked to a high deductible medical insurance plan. Medicare - Answer-The United States federal gov. plan for paying certain hospital and medical expenses for persons who qualify Medicare Supplement Insurance - Answer-A type of individual or group insurance that fills the gaps in the protection provided by Medicare, but that cannot duplicate any Medicare benefits. Medigap - Answer-Medicare supplement plans issued by private insurance companies that are designed to fill some of the gaps in Medicare. Misrepresentation - Answer-A false statement or lie that can render the contract void. morbidity rate - Answer-The ratio of the incidence of sickness to the number of well persons in a given group of people over a given period of time. Morbidity Table - Answer-A table showing the incidence of sickness at specified ages. Multiple Employer Trust (MET) - Answer-A group of small employers who do not qualify for group insurance individually, formed to establish a group health plan or self-funded plan. Multiple Employer Welfare Association (MEWA) - Answer-Any entity of at least two employers, other than a duly admitted insurer, that establishes an employee benefit plan for the purpose of offering or providing accident and sickness or death benefits to the employees. Mutual Companies - Answer-Insurance organizations that have no capital stock, but are owned by the policyholders.
Nonadmitted (Nonauthorized) - Answer-An insurance company that has not applied for, or has applied and been denied a Certificate of Authority and may not transact insurance in a particular state. Nonauthorized (Nonadmitted) - Answer-An insurance company that has not applied for, or has applied and been denied a Certificate of Authority and may not transact insurance in a particular state. Noncancellable - Answer-An insurance contract that the insured has a right to continue in force by payment of premiums that remain the same for a substantial period of time. Nonmedical - Answer-A life or health insurance policy that is underwritten based on the insured's statement of health rather than a medical examination. Nonmedical - Answer-A life or health insurance policy that is underwritten based on the insured's statement of health rather than a medical examination. Nonrenewal - Answer-A termination of a policy by an insurer on the anniversary or renewal date. Nonresident Agent - Answer-An agent licensed in a state in which he or she is not a resident. Notice of Claim - Answer-A provision that spells out an insured's duty to provide the insurer with reasonable notice in the event of a loss. Omnibus Budget Reconciliation Act (OBRA) - Answer-A federal law which extends the minimum COBRA continuation of group health care coverage from 18 to 29 months for qualified beneficiaries who are disabled at the time of qualification. reduced limits in qualified retirement programs Out-of-pocket costs - Answer-Amounts an insured must pay for coinsurance and deductibles before the insurer will pay its portion.
Policyowner - Answer-The person who is entitled to exercise the rights and privileges in the policy. This person may or may not be the insured. Preferred Provider Organization (PPO) - Answer-An organization of medical professionals and hospitals who provide services to an insurance company's clients for a set fee. Preffered Risk - Answer-An insurance classification for applicants who have a lower expectation of incurring loss, and who, therefore, are covered at a reduced rate Premium - Answer-A periodic payment to the insurance company to keep the policy in force. Presumptive Disability - Answer-A provision that is found in most disability income policies which specifies the conditions that will automatically qualify the insured for full disability benefits. Primary Policy - Answer-A basic, fundamental insurance policy which pays first with respect to other outstanding policies. principal amount - Answer-The full face value of a policy private insurance - Answer-Insurance furnished by nongovernmental insuring organizations. Pro Rata Cancellation - Answer-Termination of an insurance policy, with an adjustment of the premium charge in proportion to the exact coverage that has been in force. probationary period - Answer-The period of time between the effective date of a health insurance policy and the date coverage for all or certain conditions begins. Producer - Answer-Insurance agent or broker
Proof of Loss - Answer-A claim form that a claimant must submit after a loss occurs. Prosthdontics - Answer-A special are of dentistry that involves the replacement of missing teeth with artificial devices like bridgework or dentures provider - Answer-Any group or individual who provides health care services. Pure Risk - Answer-The uncertainty or chance of a loss occurring in a situation that can only result in a loss or no change. Rate Service Organization - Answer-An organization that is formed by, or on behalf of, a group of insurers to develop rates for those insurers, and to file the rates with the insurance department on behalf of its members. They may also act as a collection point for actuarial data. Rebating - Answer-Any inducement offered in the sale of insurance products that is not specified in the policy. reciprocal exchange - Answer-An unincorporated group of individuals who mutually insure one another, each separately assuming a share of each risk. Reciprocity - Answer-A situation in which two parties provide the same help or advantages to each other (for example, Producer A living in State A can transact business as a nonresident in State B if State B's resident producers can transact business in State A). Recurrent Disability - Answer-A policy provision that specifies the period of time during which the recurrence of an injury or illness will be considered a continuation of a prior period of disability. reduction - Answer-Lessening the possibility or severity of a loss.
risk - Answer-Uncertainty as to the outcome of an event when two or more possibilities exist. Risk, Pure - Answer-The uncertainty or chance of a loss occurring in a situation that can only result in a loss or no change. Risk Retention Group - Answer-A liability insurance company owned by its members, which are exposed to similar liability risks by virtue of being in the same business or industry. Risk, Speculative - Answer-The uncertainty or chance of a loss occurring in a situation that involves the opportunity for either loss or gain. Risk, Standard - Answer-An applicant or insured who is considered to have an average probability of a loss based on health, vocation and lifestyle. Risk, Substandard - Answer-An applicant or insured who has a higher than normal probability of loss, and who may be subject to an increased premium. Service Plans - Answer-Insurance plans where the health care services rendered are the benefits instead of monetary benefits. Short Rate Cancellation - Answer-Canceling the policy with a less than proportionate return of premium. Short-Term Disability Insurance - Answer-A group or individual policy that covers disabilities of 13 to 26 weeks, and in some cases for a period of up to two years. Skilled Nursing Care - Answer-Daily nursing care or skilled care, such as administration of medication, diagnosis, or minor surgery that is performed by or under the supervision of a skilled professional.
Standard Provisions - Answer-Requirements approved by state law that must appear in all insurance policies. Standard Risk - Answer-An applicant or insured who is considered to have an average probability of a loss based on health, vocation and lifestyle. Stock Companies - Answer-Companies owned by the stockholders whose investments provide the capital necessary to establish and operate the insurance company. Subrogation - Answer-The legal process by which an insurance company seeks recovery of the amount paid to the insured from a third party who may have caused the loss. Substandard Risk - Answer-An applicant or insured who has a higher than normal probability of loss, and who may be subject to an increased premium. Total Disability - Answer-A condition which does not allow a person to perform the duties of any occupation for payment as a result of injury or sickness. Twisting - Answer-A form of misrepresentation in which an agent persuades an insured/owner to cancel, lapse, or switch policies, even when it's to the insured's disadvantage. Underwriter - Answer-A person who evaluates and classifies risks to accept or reject them on behalf of the insurer. Underwriting - Answer-the process of reviewing, accepting or rejecting applications for insurance Unearned Premium - Answer-The portion of premium for which policy protection has not yet been given.
