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Flashcards in Accident & Health Insurance Policies Deck (27):

Total Disability

some policies use a relatively strict definition such as the "any occupation" definition, similar to social security. this definition requires the insured to be unable to perform any occupation for which he or she is reasonably suited by reason of education, training or experience. Other policies have a more liberal definition and defines it to be the "inability to perform the duties of one's own occupation".


Partial Disability

often defined as the inability to perform one or more of the regular duties of one's own occupation or the inability to work on a full-time basis, which results in a decrease of income. Either paid in flat or residual amount.


Residual Disability

provides benefits for loss of income when a person returns to work after a total disability, but is still not able to work as long or at the same level he/she worked before becoming disabled.


Presumptive Disability

provision that is found in most policies which specifies conditions that will automatically qualify the insured for full disability benefits.


Recurrent Disability

is generally expressed in a policy provision that specifies the period of time during which the recurrence of an injury or illness will be considered as a continuation of a prior period of disability.


Elimination Period

is a waiting period that is imposed on the insured from the onset of the disability until the benefit payments commence. It is a deductible measured in days, instead of dollars. They can range from 30 to 180 days


Probationary Period

another type of waiting period that is imposed under some policies in addition to the elimination period. Can range from 10-30 days from policy issue date during which benefits will not be paid for illness-related disabilities. only applies to sickness not injury. this helps guard the insurer against those trying to purchase disability income shortly after developing a disease or health condition.


Benefit Period

length of time over which the monthly payments will last for each disability after the elimination period has been satisfied.



accidental body injury - means damage to the body is unexpected and unintended (broader coverage)

accidental means - means cause of the accident must be unexpected and unintended.


Benefit Limitations

usually 66% of the average earnings over the past two years prior to the disability.


Social Insurance Supplement (SIS) or Social Security Riders

used to supplement or replace benefits that may be payable under social security disability.
*insured is eligible but before benefits begin, black out period
*if insured has been denied SS benefits
*amount payable under SS is less than that of the rider


Business overhead expense policy

BOE - sold to small business owners who must continue to meet overhead expenses following a disability. Does not cover loss of salary or compensation, elimination period of 15-30 days; limited to 1-2 years; premium is tax deductible; benefit payments are taxable.


Business Disability Buyout Policy

just like a buy-sell agreement, specifies who will purchase the partner's interest and legally obligates that person to buy upon disability. Long elimination period 1-2 years to determine if the disability is permanent; the premiums are not tax deductible but benefit is received tax free, usually lump-sum.


Group Disability Income Policy

specify benefits based on a percentage of the worker's income
short-term plans provide maximum benefit periods of 13-26 weeks
long-term plans provide maximum benefit periods of more than 2 years
minimum participation requirements 30-90 days
benefits are supplemental to other programs ie workers comp
limit coverage to nonoccupational disabilities


Medical Expense Insurance

Basic Medical Expense
basic medical expense; basic surgical expense; relative value;
Major Medical Expense - more comprehensive (broader coverage)
supplemental major medical - kicks in after basic medical policy
comprehensive major medical



each policy as a dollar amount that once the insured as come out of pocket for that amount the insurance company will pay 100% of medical expenses.


Hospital Indemnity

pays a per diem while the insured is in the hospital regardless of the medical expense.


Managed Care

any plan that attempts to contain costs by controlling the behavior of participants.
* controlled access of providers
* comprehensive case management
* preventive care
* risk sharing
* high quality care


Indemnity Health Plan

"fee-for-service" individual pays a predetermined percentage insurance co pays the remaining percentage



Point of service use PPO HMO or self directed



Exclusive Provider Organizations - more restrictive than HMOs


Guaranteed Issue

and insurance co or HMO will issue coverage to an applicant regardless of prior medical history



for continuation of coverage the Federal Consolidated Omnibus Budget Reconcilliation Act allows retiring people and those who leave or lose their jobs to retain health coverage up to 36 months. the premium can be up to 100% of the total premium plus 2% processing fee.



Health Insurance Portability and Accountability Act



allowing time under previous coverage to reduce any waiting period for a pre-existing condition under a new group plan a person wishes to join.


Cafeteria plan

is a way of financing employee benefits, allowing the employee to select which benefits they want. Including FSAs; Premium Conversion Plans; Dependent Care FSAs



Employee Retirement Income Security Act