AIC 48 Flashcards
(151 cards)
1
Q
Split limits
A
Separate limits for bodily injury and property damage liability coverage.
2
Q
Umbrella liability policy
A
A liability policy that provides excess coverage above underlying policies and may also provide coverage not available in the underlying policies, subject to a self-insured retention.
3
Q
Excess liability policy
A
A policy that covers liability claims in excess of the limits of an underlying policy or a stated retention period
4
Q
lien
A
A creditor’s legal right or interest in another’s property, usually lasting until satisfaction of the specific debt or duty that the lien secures.
5
Q
Subrogation
A
The process by which an insurer can, after it has paid a loss under the policy, recover the amount paid from any party (other than the insured) who caused the loss or is otherwise legally liable for the loss.
6
Q
Cost shifting
A
The practice of charging higher fees to payment sources that impose fewer controls.
7
Q
Three ways multiple coverages for BI claims may be identified
A
- When coverages apply under the same policy (e.g. med-pay and BI)
- When multiple coverages apply on different policies (e.g. workers comp and auto policy)
- When one insured has 2 policies from different insurers that cover the same loss (e.g. two personal auto policies with BI)
8
Q
Interpolicy stacking v. Intrapolicy stacking
A
Interpolicy stacking: involves 2 or more separate policies, with which thel imit of one policy is added to (stacked on) the limit of the other policy)
Intrapolicy stacking: A single policy that covers more than one vehicle, with all limits stacked
9
Q
Compare responsibilities of medical liens with Medicare liens
A
Medical liens: Hospitals, doctors, and other healthcare providers.
Medicare liens: must be reported when the auto policy is primary to Medicare.
10
Q
In what government programs is property-casualty considered to be the primary payor and the program secondary?
A
.
11
Q
Subrogation
A
.
12
Q
Why do most patients not attempt to control or question their treatments?
A
.
13
Q
Compensatory damages
A
A payment awarded by a court to reimburse a victim for actual harm.
14
Q
Special damages
A
A form of compensatory damages that awards a sum of money for specific, identifiable expenses associated with the injured person’s loss, such as medical expenses or lost wages.
15
Q
Loss of earnings capacity
A
The reduction in a worker’s earning ability as a result of an injury.
16
Q
General damages
A
A monetary award to compensate a victim for losses, such as pain and suffering, that does not involve specific, measurable expenses.
17
Q
Loss of consortium
A
The loss of benefits that one spouse is entitled to receive from the other, including companionship, affection, and sexual relation resulting from the injury or death of a spouse.
18
Q
Punitive damages (exemplary damages)
A
A payment awarded by a court to punish a defendant for a reckless, malicious, or deceitful act to deter similar conduct; the award need not bear any relation to a part’s actual damages.
19
Q
Tangible loss v. intangible loss
A
.
20
Q
Two (2) types of assistance that can be compensable after an insured event
A
.
21
Q
How are general damages determined if settled by an insurer
A
.
22
Q
Five (5) different types of family members who might make a loss of consortium after BI to another family member
A
.
23
Q
Why do a court award punitive damages
A
.
24
Q
How does an injured person’s compensation for interest and fees differ between states?
A
.
25
Utilization Review
A cost-containment method that evaluates the appropriateness of treatment in terms of necessity, frequency, and cost.
26
Medical bill audit
An analysis of the bills from healthcare providers to ensure that they bill for proper services and that the charges for these services are appropriate.
27
State fee schedule
A listing of fixed relative values for medical service and treatment that limits the amounts charges by healthcare providers. Services are measured in terms of number of units with a predetermined price per unit.
28
Usual, customary, and reasonable (UCR) charges
Charges for which physicians are reimbursed on the basis of their usual fee as long as the fee is reasonable and customary.
29
Hospital bill audit
An analysis of services ordered by the doctor, services actually performed by the hospital, and services billed by the hospital to ensure the appropriateness of hospital charges.
30
Retrospective review (peer review)
The review of a medical provider's records by another medical provider who practices in a similar discipline. Alternatively referred to as a records review.
31
Treatment guidelines
Common protocols for treatment or therapy that are developed using data provided by healthcare providers.
32
Palliative care
Care provided to relieve a patient's pain
33
Restorative care
Care provided to restore a patient's functional abilities.
34
Preadmission certification
A process for establishing preapproval for hospital admission or services (prospective review).
35
Fee-for-service (FFS) system
A payment arrangement under which a healthcare provider sets its fee and the insurer or patient pays the fee after the service is rendered.
36
Preferred provider organization (PPO)
An administrative organization that meets the common needs of healthcare providers and clients and that identifies networks of providers and contracts for their medical services at discounted rates.
37
Health maintenance organization (HMO)
An organization that provides all the care needed by its members in exchange for a fixed fee.
38
Concurrent review
A direct intervention technique for monitoring the appropriateness of inpatient services and the length of a hospital stay and for determining whether a doctor's order are being followed.
39
Discharge planning
The process of establishing a program for the type and amount of treatment after a patient is discharged from the hospital.
40
Independent medical examination (IME)
A direct intervention technique that includes a brief review of the patient's history and treatment and a physical examination of the patient. Insurers use this technique in disputed claims for determining causation, current physical impairment, and the need for present or future treatment.
41
Activity modification
An injury management technique for allowing patients to continue enough physical activity to avoid complete disability while maintaining a tolerable comfort level.
42
Return-to-work initiative
A program with which the patient, the doctor, the patient's employer, and the insurer all try to help the patient recover and return to work.
43
Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation establishing standards for health insurance information exchanges and health coverage protection when jobs are lost or changed.
44
Maximum medical improvement (MMI)
The point at which no further medical progress or recovery is expected.
45
Medical record
Any document that identifies a patient and describes the healthcare and services provided to that patient.
46
Medicolegal report
Any document, prepared for attorneys, claim reps, or industrial commission, that describes the patient's injury, current physical and mental condition, and the expected outcome of the patient's treatment.
47
Narrative report
A document prepared for healthcare providers to summarize the course of a patient's treatment and state the diagnosis; usually accompanied by supporting documentation.
48
Ambulatory care records
Documents, prepared by centers providing outpatient surgical and diagnostic treatment, that include patient identification, history of illness or injury, physical findings, diagnostic and therapeutic orders, clinical observations, disposition of the patient, and follow-up care.
49
X-ray
An imaging tool that provides one-dimensional pictures of the comparative densities of the body; used to diagnose broken bones and other internal conditions.
50
Computerized tomography (CT) scan
A diagnostic imaging tool that takes a series of x-rays at various angles and converts resulting images into digital codes that a computer interprets and reproduces on a video screen. Used to diagnose problems of the brain and spine.
51
Myelography
A diagnostic imaging procedure in which a radio-opaque dye is injected into the spinal column so that x-rays can outline the spinal cord and nerves. This procedure detects herniated discs, tumors and inflammations in the spinal structure, and congenital deformities.
52
Magnetic Resonance Imaging (MRI)
A diagnostic imaging tool that uses a superconductive magnet, electromagnetic waves, and a sophisticated computer system to crease detailed images of the body's interior.
53
Thermography
A diagnostic imaging procedure that measures the surface temperature of the skin, detecting injured areas.
54
Job modification
A change in a job's physical demands, number of duties, emotional demands, and/or hours required.
55
Labor market survey
A formal study of job openings in a local community based on local employment listings, newspaper ads, and direct employer contracts.
56
Orthopedic surgeon
A medical doctor who performs surgery on bones, joints, and related supporting structures and prescribes medicine.
57
Registered nurse (RN)
A registered medical professional who specializes in hospital-based patient care.
58
Licensed practical nurse (LPN)
A licensed medical professional who specialized in hospital-based patient care.
59
Audiologist
A medical specialist who evaluates, diagnoses, and treats patients for hearing loss.
60
Certified orthotist
A certified specialist who evaluates the orthotic needs of patients, formulates the development and fitting of orthoses, and maintains patients' orthotic records.
61
Social worker
A medical specialist who identifies a patient's nonmedical psychosocial, financial, and discharge needs; provides counseling; and serves as an advocate and referral agent for continuing care needs.
62
Psychiatrist
A medical doctor who counsels patients in overcoming emotional or psychological reactions, prescribes medication, and authorized admissions for psychiatric evaluation and treatment.
63
Functional overlay
Psychological factors involved in a patient's symptoms that are interwoven with the patient's physical condition.
64
Pain
Suffering that may be produced by physical factors, such as tissue damage, or psychological factors, such as personality, expectations, age, or sociocultural background.
65
Depression
The psychological diagnosis characterized by sadness or grief. Severe symptoms include the loss of pleasure and interest in life and feelings of complete helplessness.
66
Defense mechanism
Any reaction that serves to protect a person against something harmful or to resolve or conceal anxieties.
67
Denial
A defense mechanism in which a person does not acknowledge some aspect of reality.
68
Displacement
A defense mechanism in which a person directs emotionally significant feelings away from their real source or object and towards some other object.
69
Isolation
A defense mechanism in which a person separates thoughts about an event or situation from his or her feelings.
70
Projection
A defense mechanism in which a person attributes his or her own thoughts an feelings to another.
71
Repression
A defense mechanism in which a person tries to forget an unpleasant anxiety-producing event or emotion.
72
Mental disorder
A syndrome or pattern of behavior that is a manifestation of some pshycho9logica dysfunction.
73
Mood
A pervasive an sustained emotion that in the extreme can affect a person's perception of reality.
74
Anxiety disorder
A mental condition characterized by symptoms of anxiety or behaviours that are performed to relieve anxiety, such as post-traumatic stress disorder, panic disorders, phobias, obsessions, compulsions, an generalized anxiety disorder.
75
Post-traumatic stress disorder (PTSD)
An anxiety disorder characterized by a person's persistent reexperiences of an unusual event, persistent avoidance of anything associated with the event, or persistent symptoms of arousal.
76
Generalized anxiety disorder
An anxiety disorder characterized by a variety of physical and behavioural symptoms that crease unrealistic and excessive anxiety.
77
Somatoform disorder
A mental disorder characterized by physical symptoms when no medical condition is present
78
Malingering
A behaviour characterized by feigning symptoms
79
Hypochondriasis
A somatoform disorder characterized by the fear of, or belief that one has, a serious illness, despite an absence of physical evidence.
80
Somatization disorder
A somatoform disorder characterized by the presence of multiple complaints over several years for which the person has sought medical attention
81
Pain disorder
A somatoform disorder that impairs a patient's social and occupational functioning and that becomes that major focus of that patient's life
82
Antisocial personality disorder
A disorder characterized by a pattern of socially irresponsive, truant, cruel, and often deviant behavior
83
Borderline personality disorder
A disorder characterized by a pervasive pattern of instability of self-image, mood, and interpersonal relations
84
Narcissistic personality disorder
A disorder characterized by simultaneous feelings of grandiosity and hyper-sensitivity, along with a lack of empathy.
85
Obsessive-compulsive personality disorder
A disorder characterized by perfectionism and inflexibility; the persona is preoccupied by details and procedures and rigidly expects things to be done his or her way.
86
Paranoid personality disorder
A disorder characterized by interpretations of the actions of others as deliberately demeaning or threatening, expectations of exploitation and harm, and the use of projection as a defense mechanism.
87
Passive-aggressive personality disorder
A disorder characterized by resentment and anger that is expressed indirectly by resisting expected social and occupational performance and by beliefs that others' demands are unreasonable.
88
Factitious disorder
A physical condition characterized by symptoms that results from an unconscious psychological need to be sick.
89
Medical case management
A process in which a case manager, usually a healthcare or social work professional, assesses an individual's health needs; evaluates available resources, options and services; develops, implements, and monitors a plan; and communicates amount those involved, to promote a quality, cost-effective outcome.
90
Present values
The value today of money that will be received in the future.
91
Decedent
The deceased claimant in a death claim.
92
Tort
A wrongful act or an omission, other than a crime or a breach of contract, that invades a legally protected right.
93
Negligence
The failure to exercise the degree of care that a reasonable person in a similar situation would exercise to avoid harming others.
94
Damages
Money claimed by, or a monetary award to, a party who has suered bodily injury or property damage for which another party is legally responsible.
95
Financial responsibility law
Law enacted to ensure that motorists have the financial ability to pay for any property damage or bodily injury they might cause as a result of driving or owning an auto
96
Compulsory auto insurance law
Law that requires the owners or operators of automobiles to carry automobiles liability insurance at least equal to certain minimum limits before the vehicle can be licensed or registered.
97
Unsatisfied judgement fund
A fund designed to provide a source of recovery for victims of motor vehicle accidents when an at-fault motorist is unable to pay any judgment.
98
Uninsured motorists (UM) coverage
Coverage that provides a source of recovery for occupants of a covered auto or for qualify pedestrians who are injured in an accident caused by an at-fault motorist who does not have the state minimum liability insurance or by a hit-and-run driver.
99
Underinsured motorists (UIM) coverage
Coverage that applies when a negligent driver has liability insurance at the time of the accident but has limits lower that those of the injured persons coverage.
100
No-fault automobile insurance
Insurance that covers automobile accident victims on a first-party basis, allowing them to collect damages from their own insurers regardless of who was at fault.
101
No-fault laws
State statutes that require motorists to purchase (or require insurers to make available) insurance that provides minimum first-party benefits to injured persons regardless of fault.
102
Monetary threshold (dollar threshold)
In a no-fault system, a dollar limit in total medical expenses that must be exceed before an injured victim is permitted to sue for non-economic damages
103
Verbal threshold
In a no-fault system, the designated criteria that are verbally "set forth in the statutes that limit the right to sue for noneconomic loss".
104
Add-on plan
In a no-fault system, a plan that provides certain personal injury protection (PIP)-type benefits such as medical payments and disability coverages to injured victims, without regard to fault.
105
Choice no-fault plan
In a no-fault system, a plan that gives the insured the option, at the time an auto insurance policy is purchased or renewed, of choosing whether to be covered on a no-fault basis
106
Personal injury protection (PIP) coverage
Coverage that pays benefits, regardless of fault, for medical expense, income loss, and other benefits, resulting from bodily injury to occupants of a covered auto.
107
Bad faith claim
A claim that implies or involves actual or constructive fraud, a design to mislead or deceive another, or a neglect or refusal to fulfill some good-faith duty or some contractual good-faith obligation.
108
Doctrine of reasonable expectations
A legal doctrine that provides for an ambiguous insurance policy clause to be interpreted in the way that an insured would reasonably expect.
109
Public policy
In a given country, state, or other jurisdiction, the set of assumptions and principles (often instated) on which the laws and court decisions of that jurisdiction are based.
110
Good faith
The manner of handling claims that requires an insurer to give consideration to the insured's interest that is at least equal to the consideration it gives its own interests.
111
Declarations page
An insurance policy information page or pages providing specific details about the insured and the subject of the insurance.
112
Named insured
A person, corporation, partnership, or other entity identified as an insured party in an insurance policy's declarations page.
113
Policy period
The time frame, beginning with the inception date, during which insurance coverage applies.
114
Vehicle Identification Number (VIN)
A unique number that is assigned to each vehicle and that identifies certain vehicle characteristics.
115
Collision coverage
Coverage for direct and accidental loss or damage to a covered auto caused by collision with another object or by overturn.
116
Other than collision (OTC) coverage
Coverage for physical damage to a covered auto resulting from any cause of loss except collision or a cause of loss specifically excluded.
117
Proof of loss
A statement of facts about a loss for which the insured is making a claim.
118
Liberalization clause
A policy condition provided that if a policy form is broadened at no additional premium, the broadened coverage automatically applies to all existing policies of the same type.
119
Policy termination
The ending of the contractual relationship between the insured and insurer by cancellation, expiration, or non-renewal.
120
Cancellation
Termination of a policy, by either the insurer or the insured, during the policy term.
121
Pre-judgement interest
Interest that may accrue on damages before a judgment has been rendered
122
Supplementary payments
Carious expenses the insurer agree to pay under a liability insurance policy (in addition to the liability limits) for items such as premiums on bail bonds, and appeal bonds, loss of the insured's earning because of attendance at trials, and other reasonable expenses incurred by the insured at the insurer's request.
123
Attachment
The act of seizing property to secure a judgment.
124
Post-judgment interest
Interest that may accrue on damages after a judgment has been entered in a court and before the money is paid.
125
Public or livery conveyance
In case law, a method of transportation that is indiscriminately offered to the general public, such as a taxi or public bus.
126
Split-limits basis
Separate coverage limits that allow one limit for bodily injury to each person; a second, usually higher limit for bodily injury to all persons in each accident; and a third limit for all property damage in each accident.
127
Single-limits basis
One coverage limit that applies to all damages arising from bodily injury or property damage or both, resulting from a single accident.
128
Uninsured motor vehicle
A land motor vehicle or trailer that is not insured for bodily injured liability, is insured for less than the financial responsibility limits, is a hit-and-run vehicle, or whose insurer denies coverage or becomes insolvent.
129
Arbitration
An alternative dispute resolution (ADR) method by which disputing parties use a neutral outside party to examine the issues and develop a settlement, which an be final and binding.
130
Physical damage coverages
There are four (4) kinds;
1. comprehensive -- pays for loss to covered auto or its equipment from any cause not excluded, except collision or overturn;
2. specified causes of loss -- provides named peril coverage;
3. collision -- covers loss to a covered auto or its equipment by collision with another object or by overturn; and
4. towing -- provides coverage for towing and labor performed at the place of disablement.
131
Deductible
A portion of a covered loss that is not paid by the insurer.
132
Transportation expenses
Additional coverage in the PAP for substitute transportation costs incurred as the result of a covered physical damage loss.
133
Actual cash value
Cost to replace property with new property of like kind and quality, less depreciation.
134
Appraisal
A method of resolving disputes between insurers and insureds over the amount owed on a covered loss.
135
Transportation network company
A company that uses a mobile application or website to connect rides with drivers and arrange transportation in a personal auto for a fee.
136
Liability coverage
Coverage that protects the insured from damages owed because of legal liability to another party. For auto policies, it protect insured against liability arising out of the ownership or operation of automobiles.
137
Medical payments coverage
Coverage that pays necessary medical expenses incurred within a specified period by a claimant (and in certain policies, by an insured) for a covered injury, regardless of whether the insured was at fault.
138
Employee non-ownership liability
An employer's liability for its employees' operation of their autos in the employer's business.
139
Commercial package policy (CPP)
Policy that covers two or more lines of business by combining ISO's commercial lines coverage parts.
140
Monoline policy
Policy that covers only one line of business.
141
Garage-keepers coverage
Coverage for damage to customers' autos left in the named insured's care while the insured is attending, servicing, repairing, parking, or storing them.
142
Auto-dealers coverage form (ADCF)
The ISO coverage form designed to meet the auto, general liability, and errors and omissions liability insurance needs of auto and trailer dealers.
143
Customer limitation
That provision in the ADCF that severely restricts coverage for customer of the insured auto dealer.
144
False pretense coverage endorsement
The endorsement that deletes the False Pretense exclusion from the ADCF and agrees to pay for loss as a result of the named insured's (1) being tricked into voluntarily parting with an auto, or (2) acquiring an auto from a seller who did not have legal title.
145
Dealers driveway Collision coverage endorsement
The endorsement that modifies the auto Dealers Coverage From to cover damage to any covered auto while being driver or transported from the point of purchase or distribution to the destination if such points are more than fifty road miles apart.
146
Motor carrier coverage form (MCCF)
The coverage form filed by ISO that can be used to insure a person or an organization providing transportation by auto in the furtherance of a commercial enterprise.
147
Owner-operators
Individuals who lease themselves and their owned trucks to motor carriers to transport property for the motor carrier.
148
Hold-harmless agreement (or indemnity agreement)
A contractual provision that obligates one of the parties to assume the legal liability of another party.
149
Trailer interchange agreement
A contract under which two motor carriers agree to swap trailers and to indemnify each other for any damage that occurs to the other's trailer while it is in the borrowing motor carrier's possession.
150
Trailer interchange coverage
Coverage for a motor carriers liability for damage to trailers in its possession under a written trailer interchange agreement
151
MCS 90 endorsement
The commercial auto endorsement required by the Motor Carrier Act of 1980, in which the insurer agrees to pay, up to specified limits, damages that the insured becomes legally obligated to pay for liability resulting from negligence in the operation, maintenance, or use of any motor vehicle subject to that law.
