Flashcards in Chapter 8 Deck (108)
define the indemnity method of benefit payments
a set follar amount and is not based on the specific services required or the expenses incured.
- payment is made if the cx is eligible for benefits and the services recevied are covered by the policy
define the expense incurred method of benefit payouts
benefits are paid if the insured is eligible for benefits and the claim is folr eligible services,
- pays the lesser of the expense incurred or the dollar limit of the policy
define the diability method of benefit payouts
once the insured meets the benefits eligible criteria, the full daily benefit is paid even if the insured is not receiving any long-term care services
How long is the waiting period on LTC, and the benefit period?
1 year to a lifetime.
most common options are 3-5 years.
General exclusion riders and limitations are applicable to long-term care products. Benefits are generally not payable if a claim is incurred as a results of what conditions? (8)
1. pariticaption in war/hostile action.
2. military or naval services
3. intentional self-inflicting injury or illness, while sane or insane
4. commiting or attempting to commit a felony or to engage in an illegal occupation
5. chronic alcoholism or drug dependency.
6. being legally intoxicated or under the influence of any narcotic unless being taken under supervision
7. nervous or mental disorders, without demonstrable organic cause
8. any tx paid for by the govenement
What is the best predictors of long-term care use?
is functional status, which includes the baility to perform the ADLS and the instrumental activities of daily living.
Name some examples of ADLS
What are Instrumental activities of daily living ( IADLs)
social survival skills that must be performed either for a household or on an individual.
- using the phone
- managing finances
- using transportation
- medication administration
- meal prep
What some some medical disorders that require careful consideration when evaluating LTC
1. osteoporosis + fall hx, fractures or frailty
2. cardiac disease
3. emphysema or COPD + SM
4. chronic illness
5. co-morbid conditions that in combination are more sig
6. polupharmacy or the use of multiple px medications
7. treatment protocols
8. chronological age vs. physiological age.
What are some factors that play an important role in maintaining an individuals personal independance?
1. working FT or PT
2. living with a spouse who is in good health or living with other familymembers
3. participating in hobbies and activities outside the home
4. Abillity to drive, travel, or visit wihtout accompaniment or assistance.
What is cognitive impairement?
refers to the problems with attention, affect, money or other loss of intellectual capacity that results in the need for personal supervision and/or assistance.
What are some commonly used tools in the assessment of Cognitive impairment of an . applicant.
1. Delayed word recall (DWR) memory exercise designed to be used as a screening instrument for ST memory loss.
2. Enhanced mental skill test (EMST) memmory processing test by docusing on the encoding and retrieval of information. Can also distinguish between cognitive impairement and lapses in attention d/t depression
3. Short Portable Mental Status Questionnaire (SPMSQ) includes 10 STD ? testing LT memory, PArtical survical skills, and mathamatical ability. - used for mdoerate and severe dementia.
4. tele-phone or in person interview -
What are the medical requirements for LTC?
rely on applications and APS and supplemental questions if required. Cognitive tests are usually used.
How would avocation and occupation affect LTC UW?
-possible consequences resulting from sport or hobby.
What are the financial considerations to review when u/w LTC?
1. premiums should be affordable to relative income
2. Most insurers have cap max
When u/w LTC, what are some examples of counteroffers one may see?
1. adding an extra premium rating
2. increasing the waiting period
3. decreasing the benefit period, decreasing the benefit amount
4. some combination of the above.
True or False:
Exclusion riders are generally used for long-term care products?
there can be the option of removing home care form the policy contract.
What is the purpose of critical illness policies?
product designed to help the insured recover financially from burdens that could present themselves while suffering from a CI.
What happens to the CI plan once the benefit is paid out?
the policy is terminated unless only partial benefits were paid.
True or False: Individuals who do not qualify for disability insurance due to income, type of occupation, or certain non-critical illness related histories can qualify for CI insurance.
What are the 10 most commonly covered conditions in a CI policy?
1. heart attack
4. Kidney failure
8. Life threatening cancer
10. lost of limbs
some companies cover up to 40 conditions,
some CI policies contain a 90 day moratorium for cancer. what is this?
no benefit is payable for cancer dx wihtin 90 days of issue or reinstatgement of the policy.
Most CI insurance policies contain a general exlcusion rider. Benefits would not be payable for a covered condition incurred secondary to what?
1. self-inflicted injury while sane or insane
2. use of illegal or illicit drugs
3. commission of or the attempt to comimit a criminal offence
4. act of declared or undeclared war
The contract contains a definition for each of the covered conditions. What must be included in the definition?
1. clear and precise description of the event for which a benefit is payable
2. evidencfe required for claims validation
3. any exclusion specific to the definition for which benefits would not be payable.
What is u/w a CI more critical then LI or LTC?
UW must consider the special risk factors that increase the incidence of a CI.
neither death or disability has to occur, the pt is still living.
APS are very important here
What type of medical risk selection is more important when underwriting CI over LI/LTC?
Fx , CAD- risks, cancer risks,
CAD risks: BP, build, lipids, BS, and SM
Cancer risks: dysplastic nevi,
What are the most common avocations of concern to the u/w when assessing CI risk?
car racing, skydiving, scuba, mountain climbing.
Should also consider sport/hobby risk.
>> can accomodate risk assessment with ratings/exlcusions
What is an accelerated death benefit?
an advance cash payment made by a life insurance company to an insured who has been determined to be termanlly ill from a medical perspective.
When will an accelerated benefit payout option be made available?
when a cx is dx with a terminal illness with death expected in 12-24 months,.
- paid out in lump sum or monthly installments.
- some compnies do not charge for the option unless used.