Accredited Adviser in Insurance, a designation awarded by the Insurance Institute of America to people who have completed a three-semester educational program designed for insurance producers.
- accelerated benefits
Benefits available in some life insurance policies before death, usually triggered by long-term, catastrophic or terminal illness. Also known as living benefits.
An event that is unforeseen, unexpected, and unintended.
- accidental bodily injury
Physical injury sustained as the result of an accident.
- accident report form
An accident report form is used to record key information about the accident.
- accidental death benefits
A provision added to a life insurance policy for payment of an additional benefit in case of death that results from an accident. This provision is often called “double indemnity.”
- account analyst
See Administrative Assistant.
- account current
An account current is the billing statement an insurance company sends to its producer.
- account selling
Account selling is trying to handle all of a client’s insurance needs, rather than providing for only a portion of those needs.
- accounts receivable insurance
Pays for the cost of reconstructing accounts receivable records that have been damaged or destroyed by a covered peril. Even more important, it covers any payments that cannot be collected because records cannot be reconstructed.
- accredited adviser in insurance
- actual cash value (ACV)
The value of property as figured by determining what it would cost to replace the property (see Replacement Cost) and then adjusting this replacement cost by subtracting an amount that reflects depreciation.
See Actual Cash Value.
- accumulation period
The time during which a person pays money into an annuity contract and builds up a fund to provide a deferred annuity.
Someone professionally trained in the technical aspects of insurance and related fields, particularly in the mathematics of insurance (the calculation of premiums, reserves and other values). An actuary uses complex mathematical methods, often with the aid of computers, to analyze past loss data and other statistics and develop systems for determining future premiums.
See Claims Adjuster.
- adjustable life insurance
A type of insurance that allows the policyholder to change the plan of insurance, raise or lower the face amount of the policy, increase or decrease the premium and lengthen or shorten the protection period.
- administrative assistant
The administrative assistant supports the sales efforts of the producer. Other titles for this position include agency underwriter, insurance placer, customer service representative, marketing specialist, account analyst, and office manager.
- administrative services only (ASO) agreement
Contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, in which the insurer provides certain administrative services. These services may include actuarial support, plan design, claims processing, data recovery and analysis, benefits communications, financial advice, medical care conversions, data preparation for governmental reports, and stop-loss coverage.
- adverse selection
When people with a very high probability of loss purchase insurance to a greater extent that people with average or below average probabilities of loss. Underwriters’ major goal is to avoid adverse selection.
- age limits
Ages below and above which an insurance company will not accept applications or renew policies.
- agency billing
See Producer Billing.
- agency underwriter
See Administrative Assistant.
An authorized representative of an insurance company who sells and services insurance contracts. See Producer, Exclusive Agent, Independent Agent.
- aggregate indemnity
The maximum amount that may be collected for any disability, or period of disability, under an insurance policy.
- allocated benefits
Maximum amount for specific services as itemized in an insurance contract.
“All Risks” property policies, often called “special” policies, cover any loss unless it is caused by an excluded peril listed in the policy.
- alternate delivery system
Health services that are more cost-effective than inpatient, acute-care hospitals, such as skilled and intermediary nursing facilities, hospice programs, and in-home services.
- ambulatory care
Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation.
Document changing the provisions of an insurance contract signed jointly by the insurer and the policyholder.
The person entitled to receive annuity payments or who now receives them.
Annuities are contracts sold by life insurance companies (the seller must be a licensed insurance entity in your state). In their simplest form, you pay a sum of money (either a lump sum or a series of payments) and the insurance company makes periodic payments to you, beginning on the date in your contract and continuing for the rest of your life. The earnings on your annuity payments are not taxable during the accumulation phase of your agreement; the annuity payments are taxable as income when you receive them. Variable annuities permit you to place your payments in professionally managed funds, similar to mutual funds, and to control how these payments are invested during the life of your contract. Unlike mutual funds, variable annuities have insurance provisions and guarantees to preserve the value of the principal you pay into the annuity. They also generally carry higher fees than mutual funds. Annuities may entail extensive taxation and estate issues, and annuity buyers should make sure they’re aware of such issues.
- annuity certain
A contract that provides an income for a specified number of years, regardless of life or death.
- annuity consideration
The payment, or one of the regular periodic payments, an annuitant makes for an annuity.
A statement of information made by someone applying for life insurance. The information gathered helps the life insurance company assess whether the risk presented by the applicant is acceptable to underwriters.
Signifies the legal acceptance of forms by a state when policy information is filed;
Signifies the insurer’s acceptance of risks as set forth in an application for insurance (as originally made or modified by the insurer); or
Signifies the acceptance of a request from an applicant or policyholder for new insurance, reinstatement of a terminated policy, a policy loan, or other request.
- assigned risk plans
See Automobile Insurance Plans.
The legal transfer of one person’s interest in an insurance policy to another person.
- association group
A group formed from members of a trade or professional association for insurance under one master health insurance contract.
During an audit, members of the home office staff underwriting department examine files to see whether the underwriting guidelines are being followed. Also see Premium Auditor.
- audited premium
See Premium Auditor.
- auto liability
Pays for damages that you cause to other people and their property. If you cause an accident and you bang up your car or yourself, your auto liability insurance will not pay for your medical bills or the repairs to your car. (Auto medical payments coverage would.) But it will pay for the other guy’s, up to the limits of your policy. Without the coverage, your assets would be subject to seizure to pay the medical bills, car repairs and other damages that you caused in an accident. Once the insurance company pays out the limits of your policy, you’re liable for the rest, which is why it’s advisable to purchase higher limits than what your state requires. Auto liability coverage has three parts: bodily injury per person, bodily injury per accident, and property damage. Limits for liability are usually written like “20/40/10.” That means a policy will pay bodily injury losses up to $20,000 per person, and up to $40,000 per accident (if more than one person was hurt). It will also pay property damage losses up to $10,000 per accident.
- 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.
- automobile insurance plans
Formerly known as assigned risk plans–are residual market programs providing
auto insurance. See Residual Market.
- auto medical payments
If you cause an accident, the coverage works like this: Auto liability coverage pays the bodily injury and property damage losses of the other person. Collision coverage pays for repairs to your own vehicle. Auto medical payments coverage pays medical and funeral expenses for you and your passengers. If you already have health and disability insurance, the coverage may be redundant.
- auto physical damage coverage
Insures against loss resulting from damage to an auto owned by the insured; also provides coverage if the car is stolen.
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 policyholder’s death.
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
- binding receipt
A receipt given for the payment which accompanies an application for insurance. If the policy is approved, the payment “binds” the company to make the policy effective from date of receipt.
- blanket contract
Contract for health insurance that covers a class of persons. It is used for groups such as athletic teams and for employee travel.
- blanket medical expense
A provision that entitles the insured person to collect up to a maximum for all hospital and medical expenses, without limitations on specific types of medical expenses.
- blue cross
Nonprofit corporation providing protection to its members against the cost of hospital care in a limited geographic area.
- blue shield
Nonprofit corporation providing protection to its members against the cost of surgery and other items of medical care in a limited geographic area.
A sales and service representative who handles insurance for clients, generally selling insurance of various kinds and for several companies. Brokers resemble agents, except for the fact that, in a legal sense, brokers represent the party seeking insurance rather than the insurance company. See Agent, Producer.
- business insurance
A policy that provides coverage to a business. It is often purchased to indemnify a business for the loss of services if a key employee (such as a partner) becomes disabled.
- business life insurance
Life insurance purchased by a business enterprise on the life of a member of the firm. It is often bought by partnerships to protect the surviving partners against loss caused by the death of a partner, or by a corporation to reimburse it for loss caused by the death of a key employee. (Also known as key person insurance.)
- cancer insurance
A very narrow form of health insurance that covers the policyholder in the event he or she contracts cancer. Policies often exclude skin cancer. Some policies won’t pay for cancer treatments until several years after the policy was purchased. Consumer groups and insurance regulators have said cancer insurance policies are more expensive than they’re worth, since the insurance companies pay out a rather small percentage of the premiums they collect.
Method of payment whereby a physician or hospital is paid a fixed amount for each person in a particular plan regardless of the frequency or type of service provided.
- cash value
The amount available in cash upon surrender of a policy before it becomes payable upon death or maturity.
A statement issued to individuals insured under a group policy, setting forth the essential provisions relating to their coverage.
Notification to an insurance company that payment of an amount is due under the terms of the policy. A claim is a demand by a person or business who is seeking to recover for a loss. A claim may be made against an individual. A claim may also be made against an insurance company, when an insured asks the insurance company to pay for a loss that may be covered by an insurance policy.
Arrangement by which the insurer and the insured share, in a specific ratio, payment for losses covered by the policy, after the deductible is met.
- combination plans
Life insurance policies that combine features of term and whole life policies.
- comprehensive medical expense insurance
Insurance that provides coverage, in one policy, for basic hospital expense and major medical expense.
- computer insurance
Covers computer equipment and peripherals beyond the normal coverage provided in homeowner’s insurance policies. Usually, homeowner’s policies only cover up to between $1,000 and $3,000 in computer equipment. With more people owning expensive computers and peripherals, and even using them for home-based businesses, riders and separate policies are becoming more popular. Some policies are also designed to cover damage and/or theft of portable equipment, such as laptop computers, and even the costs of data recovery.
- consolidate omnibus budget reconciliation act (COBRA)
Requires employers with more than 20 employees to make group health care coverage available for 18 months, at the employee’s expense, to employees who leave the employer for any reason other than gross misconduct.
- consideration clause
Stipulation that states the basis on which an insurer issues an insurance contract.
- contributory plan
Group plan under which the insured shares in the cost of the plan with the policyholder.
- conventional health plan
Plan that provides all benefits and issues certificates containing the insurance company’s guarantees.
- conversion privilege
Right given to an insured person under a group insurance contract to change coverage, without evidence of medical insurability, to an individual policy upon termination of the group coverage. The conditions under which conversion can be made are defined in the master policy.
- convertible term insurance
Term insurance that offers the policyholder the option of exchanging it for a permanent plan of insurance without evidence of insurability.
- coordination of benefits (COB)
Method of integrating benefits payable under more than one health insurance plan so that the insured’s benefits from all sources do not exceed 100 percent of allowable medical expenses or eliminate incentives to contain costs.
- cost containment
Reduction of inefficiencies in the consumption, allocation, or production of health care services. Inefficiencies can occur when health services are used inappropriately; when health services could be delivered in less costly settings; and when the costs could be reduced by using a different combination of resources.
- cost index
A way to compare the costs of similar plans of life insurance. A policy with a smaller index number is generally a better buy than a comparable policy with a larger index number.
- covered expenses
Health care charges that an insurer will consider paying under the terms of a health insurance policy.
- cost-of-living rider
An option that permits the policyholder to purchase increasing term insurance coverage. The death proceeds increase by a stated amount each year to coincide with an estimated increase in the cost of living.
- credit insurance
Optional coverage that pays off the balance of an outstanding loan in the event you become disabled, unemployed or die. Exact coverage depends on the particular policy. Variations include credit life (pays if you die), credit health or disability (pays if you get sick or become disabled) and credit unemployment insurance (pays if you involuntarily lose your job). Usually offered with credit cards, auto loans and mortgages.
- credit life insurance
Term life insurance issued through a lender or lending agency to cover payment of a loan, installment purchase or other obligation, in case of death.
- current assumption whole life insurance
A variation of universal life insurance, this product involves fixed premiums and fixed death benefits. Its cash value growth depends on market conditions. If they are favorable and if premiums paid in the policy’s first year are large enough, premiums for one or more years may be reduced to zero.
Amount that must be paid by the insured before benefits will be paid by the
The rejection by a life insurance company of an application for life insurance, usually for reasons of health or occupation.
- deferred annuity
Annuity payments that will begin at some future date.
- deferred group annuity
A type of group annuity providing for the purchase each year of a paid-up deferred annuity for each member of the group, the total amount received by the member at retirement being the sum of these deferred annuities.
- deposit administration group annuity
A type of group annuity providing for the accumulation of contributions in an undivided fund out of which annuities are purchased as the members of the group retire.
- deposit term insurance
A form of term insurance, not really involving a “deposit,” in which the first-year premium is larger than subsequent premiums. Typically, a partial endowment is paid at the end of the term period. In many cases the partial endowment can be applied toward the purchase of a new term policy or, perhaps, a whole life policy.
- diagnosis-related groups (DRG)
System of determining reimbursement fees based on the medical diagnosis of a patient.
Physical or mental condition that prevents a person from performing one or more occupational duties temporarily (short-term), long-term, or totally (total disability).
- disability benefit
A feature added to some life insurance policies providing for waiver of premium, and sometimes payment of monthly income, if the policyholder becomes totally and permanently disabled.
- disability income insurance
Insurance that provides periodic payments when an insured person is unable to work as a result of illness or injury.
- disability insurance
A form of health insurance that pays the policyholder in place of his or her usual income if the policyholder can’t work because of illness or accident. Usually, policies begin paying after a waiting period stipulated in the policy, and pay a certain percentage of the policyholder’s usual income. Sometimes this is provided by employers, but it’s also available as a separate coverage.
Accidental loss of limb or sight.
- disposable personal income
Personal income less personal tax and nontax payments; the income available to people for spending and saving.
An amount of money returned to the holder of a participating policy. The money is a partial refund of the premium paid. It results from actual mortality, interest and expenses that were more favorable than expected when the premiums were set.
- dividend addition
An amount of paid up insurance purchased with a policy dividend and added to the face amount of the policy.
- double indemnity
Payment of twice the policy normal benefit for specific kinds of losses under certain conditions.
- dual life insurance
Another name for second-to-die insurance.
- duplication of coverage
Coverage under two or more policies for the same potential loss.
- earned premium
Portion of a premium for which protection has already been provided by the insurer.
- earthquake insurance
Earthquake policies are similar to regular homeowner’s policies but without the liability coverage. You choose a dollar ceiling for the dwelling coverage, and a percentage of this ceiling is then applied to coverages for personal property and additional living expenses (hotel expenses if your home becomes uninhabitable). Premiums for these policies are usually rather steep in the places where you would need to buy one. Until recently, the only place Californians could buy the coverage was from the California Earthquake Authority, which offered skimpy coverage. But the market is opening up again and some other companies are offering old-fashioned policies with better coverage (at higher rates, of course).
- effective date
Date when insurance coverage begins.
- eligible employees
Employees who meet the eligibility requirements for insurance set forth in a group policy.
- eligibility date
Date when a member of an insured group applies for insurance.
- eligibility period
Time following the eligibility date (usually 31 days) during which a member of a group may apply for insurance without evidence of insurability.
- elimination period
Days at the beginning of a period of disability when no benefits are paid.
- employee retirement income security act of 1974 (ERISA)
- Federal law that affects pension and profit-sharing plans. Among other provisions, this law specifies a published summary plan must be distributed to participants within 120 days after adoption of the plan and within 90 days after an employee becomes a participant. The law requires that a summary plan description be issued every 5 years.
Life insurance payable to the policyholder if living, on the maturity date stated in the policy, or to a beneficiary if the insured dies before that date.
- enrollment card
Document signed by an eligible person indicating a desire to participate in a group insurance plan. The document or card authorizes an employer to deduct contributions from an employee’s pay. If life and accidental death and dismemberment coverage are involved, the card usually includes the beneficiary’s name and relationship.
- evidence of insurability
A statement or proof of physical condition and/or other factual information affecting a person’s eligibility for insurance. In group insurance, evidence of insurability is required only in specific situations: when a person fails to enroll during the open enrollment period; when a person applies for reinstatement after having previously withdrawn from the plan when receiving an overall maximum benefit; or when a person applies for excess amounts of group life or disability insurance.
- exclusions (exceptions)
Conditions or circumstances, listed in the policy, for which the insurer will not provide benefits.
- exclusive provider organizations (EPO)
Form of managed care in which participants are reimbursed only for care received from affiliated providers.
- expectation of life
See life expectancy.
Relationship, usually expressed as a percent or ratio, of claims to premiums for a stated period.
- experience rating
Process of determining the premium rate for a group based wholly or partially on that risk’s experience.
- experience refund
Amount returned by an insurer to a group policyholder when the financial experience of a particular group (or class to which the group belongs) has been more favorable than anticipated.
- extended term insurance
A form of insurance available as a non-forfeiture option. It provides the original amount of insurance for a limited period of time.
- face amount
The amount stated on the face of 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 accidental death or other special provisions.
- family policy
A life insurance policy providing insurance on all or several family members in one contract, generally whole life insurance on the principal breadwinner and small amounts of term insurance on the other spouse and children, including those born after the policy is issued.
- flat schedule
A type of group insurance schedule under which everyone is insured for the same benefits regardless of salary, position, or other circumstances.
- flexible premium deferred annuity
An annuity contract that permits varying premium payments from year to year and is often used for individual retirement accounts.
- flexible premium policy or annuity
A life insurance policy or annuity under which the policyholder or contract holder may vary the amounts or timing of premium payments.
- flexible premium variable life insurance
A life insurance policy that combines the premium flexibility feature of universal life insurance with the equity-based benefit feature of variable life insurance.
- flood insurance
A regular homeowner’s policy will not pay for damages caused by flooding. In order to get the coverage, you’ll have to go to some outfit that writes for the National Flood Insurance Program. Outside of fire, flooding is the most widespread natural disaster. If your community participates in NFIP’s floodplain management program, you should be eligible to buy the coverage. The only people who may have trouble finding flood coverage are residents of “coastal barrier resource system” areas and communities that do not participate in NFIP’s programs. Flood insurance is also available to renters, condominium owners, and co-op owners.
- franchise insurance
Insurance contracts issued to members of a specific group (such as employees of a common employer or members of an association) under a group-like arrangement in which the employer or the association collects and remits premiums.
- fraternal life insurance
Life insurance provided by fraternal orders or societies to their members.
- grace period
A period (usually 31 days) following each premium due date, other than the first due date, during which an overdue premium may be paid. All provisions of the policy remain in force throughout this period.
- group annuity
A pension plan providing annuities at retirement to a group of people under a master contract. It is usually issued to an employer for the benefit of employees. The individual members of the group hold certificates as evidence of their annuities.
- group life insurance
Life insurance that usually does not require medical examinations, on a group of people under a master policy. It is typically issued to an employer for the benefit of employees, or to members of an association, for example, a professional membership group. The individual members of the group hold certificates as evidence of their insurance.
- guaranteed insurability
An option that permits the policyholder to buy additional stated amounts of life insurance at stated times in the future without evidence of insurability.
- guaranteed renewable contract
Contract under which an insured has the right, commonly up to a certain age, to continue the policy by the timely payment of premiums. Under renewable contracts, the insurer reserves the right to change premium rates by policy class.
- health insurance
Coverage that provides benefits as a result of sickness or injury. Policies include insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.
- health maintenance organization (HMO)
Organization that provides a wide range of comprehensive health care services for a specified group for a fixed periodic prepayment.
Care provided to terminally ill patients and their families that emphasizes emotional needs and coping with pain and death rather than cure.
- hospital indemnity insurance
Health insurance that provides a stipulated daily, weekly, or monthly payment to an insured person during hospital confinement, without regard to the actual confinement expense.
- hospital medical insurance
Coverage that provides benefits for the cost of any or all hospital services normally covered under various health care plans.
- incurred claims
Claims paid during the policy year plus the claim reserves as of the end of the policy year, minus the corresponding reserves as of the beginning of the policy year. The difference between the year end and beginning of the year claim reserves is called the increase in reserves and may be added directly to the paid claims to produce the incurred claims.
Benefits of a predetermined amount paid for a loss.
- individual insurance
A policy that provides protection to a policyholder and/or his or her family; sometimes called personal insurance as distinct from group and blanket insurance.
- individual policy pension trust
A type of pension plan, frequently used for small groups, administered by trustees who are authorized to purchase individual level premium policies or annuity contracts for each member of the plan. The policies usually provide both life insurance and retirement benefits.
- individual retirement account (IRA)
An account set up by an individual that in some cases allows contributions to be deducted from income and permits earnings on contributions to accumulate tax-deferred until retirement, regardless of whether the contributions are deductible. Under the 1986 tax law, only those who do not participate in a pension plan at work or who do participate and meet certain income guidelines can make tax-deductible contributions to an IRA. All others can make contributions to an IRA on a non-deductible basis.
- industrial life insurance
Life insurance issued in small amounts, usually less than $1,000, with premiums payable on a weekly or monthly basis. The premiums are generally collected at the home by an agent of the company. Sometimes referred to as debit insurance.
- injury independent of all other means
An injury resulting from an accident that was not caused by an illness.
- inland marine insurance
A broad type of insurance, generally covering articles that may be transported from one place to another as well as bridges, tunnels and other means of transportation. It includes goods in transit (generally excepting transoceanic) as well as numerous “floater” policies such as personal effects, personal property, jewelry, furs, fine arts and other such items.
Acceptability to the company of an applicant for insurance.
- insurable risk
The conditions that make a risk insurable are
(1) the peril insured against must produce a definite loss not under the control of the insured,
(2) there must be a large number of homogeneous exposures subject to the same perils,
(3) the loss must be calculable and the cost of insuring it must be economically
(4) the peril must be unlikely to affect all insureds simultaneously,
(5) the loss produced by a risk must be definite and have a potential
to be financially serious.
Risk management plan that, for a price, offers the insured an opportunity to share the costs of possible financial loss through an insurer.
- insuring clause
Stipulation in an insurance policy that states the type of loss the policy covers and lists the parties to the contract.
- insurance examiner
The representative of a state insurance department assigned to participate in the official audit and examination of the affairs of an insurance company.
The person on whose life the policy is issued.
The combining of two or more benefit plans to prevent duplication of payments.
- Keogh plan
A type of tax-favored retirement plan for self-employed people.
- key-person insurance
Insurance designed to protect a business against the loss of income resulting from the disability or death of an employee in a significant position.
Termination of coverage because of nonpayment within a specified time period.
- lapsed policy
A policy terminated at the end of the grace period because of non-payment of premiums.
- legal reserve
The minimum reserve, as calculated under the state insurance code, which a company must keep to meet future claims and obligations.
- legal reserve life insurance company
A life insurance company operating under state insurance laws specifying the minimum basis for the reserves the company must maintain on its policies.
- level premium
Rating structure under which the premium level remains the same throughout the life of the policy.
- level premium insurance
Insurance for which the cost is distributed evenly over the premium payment period. The premium remains the same from year to year and is more than the actual cost of protection in the earlier years of the policy and less than the actual cost in the later years. The excess paid in the early years builds up a reserve to cover the higher cost in the later years.
- life annuity
A contract that provides an income for life.
- lifetime disability benefit
A provision making benefits payable for an insured’s lifetime as long as the insured person is totally disabled.
- life expectancy
The average number of years of life remaining for a group of people of a given age according to a particular mortality table.
- life insurance in force
The sum of the face amounts, plus dividend additions, of life insurance policies outstanding at a given time. Additional amounts payable under accidental death or other special provisions are not included.
- limited payment life insurance
Whole life insurance on which premiums are payable for a specified number of years or until death, if death occurs before the end of the specified period.
- limited policy
Policy that covers only specified accidents or sicknesses.
- living benefits
Another name for accelerated death benefits.
Any sales fees or charges paid in purchasing an annuity contract.
- long-term care
A continuum of maintenance, custodial, and health services for the chronically ill or disabled. Such services may be provided on an inpatient (rehabilitation facility, nursing home, mental hospital) or outpatient basis, or at home.
- Long term care insurance
A health-insurance variation designed to cover the costs of long term care at home or in a nursing home. These policies offer a specified nursing home benefit and home-care benefit. Some policies also account for inflation. The popularity of long term care insurance has grown as federal laws have changed, making it less likely that Medicaid will pick up the tab for long term care. These policies are usually rather expensive, and grow even more costly as the policyholder ages.
- long-term disability income insurance (LTD)
Plan that helps replace income lost through inability to work because of disability caused by an accident or illness.
- major medical expense insurance
Insurance that provides benefits for most types of medical expenses up to a high maximum benefit. Such contracts often contain internal limits and usually are subject to deductibles and co-insurance.
- managed care
Systems that integrate the financing and delivery of appropriate health care services by means of arrangements with selected providers to furnish a comprehensive set of health-care services to members; explicit criteria for the selection of health-care providers; formal programs for ongoing quality assurance and utilization review; and significant financial incentives for members to use providers and procedures associated with the plan.
- manual premium rate
Premium for a group developed from the insurer’s standard rate tables; it is the cost usually quoted in an insurer’s underwriting manual.
Simply put, Medicaid is health insurance for the poor. It was created in 1965 as a joint federal/state public assistance program for those too poor to afford health care. Since the program is administered by the individual states under federal guidelines, the benefits offered and eligibility requirements vary widely. About 36 million people around the U.S., including children, the elderly, the blind and the disabled, are currently covered by Medicaid. Usually, Medicaid recipients pay no part of costs for covered medical expenses, although a co-payment is sometimes required.
Medicare is a federal insurance program which primarily serves those over 65 years old and younger, disabled people and dialysis patients. It currently covers about 37 million Americans. Medicare is divided into Part A, which covers inpatient hospital services, nursing home care, home health care and hospice care; and Part B, which helps pay the cost of doctors’ services, outpatient hospital services, medical equipment and supplies, and other health services and supplies. Recipients pay some part of the costs through deductibles. Since Medicare doesn’t cover all expenses, recipients often supplement their coverage through separate Medigap policies.
- medsup (aka: medigap)
Private insurance that can be purchased to supplement Medicare.
- minimum group
The fewest number of employees permitted under a state law to constitute a group for insurance purposes; the purpose of establishing minimums is to maintain a distinction between individual and group insurance.
- minimum premium plan
The employer self-funds a fixed percentage (e.g. 90 percent) of the estimated monthly claims, and the insurer covers the remainder. This self-funded approach avoids payment of a premium tax required in most states.
- miscellaneous expense
Expenses connected with hospital insurance; hospital charges other than room and board such as x-rays, drugs, laboratory fees, and other charges.
- modified life insurance
A type of whole life policy with a premium that is relatively low in the first several years but that increases in later years.
Frequency and severity of sicknesses and accidents in a well-defined class or classes of persons.
- mortality table
A statistical table showing the death rate (probability of death) at each
- mortgage insurance
There are actually two types of mortgage insurance. Usually, people mean private mortgage insurance, or PMI, which protects a mortgage company against a defaulted loan. PMI does not benefit the homeowner. If you bought your home with a down payment of less than 20 percent of its value, your bank probably made you take out PMI. At some point, you won’t have to pay for PMI any more, but don’t expect the bank to let you know when that is. Mortgage insurance can also mean a type of life insurance, which pays off the balance of a mortgage when the policyholder dies or, in some cases, becomes disabled. As a homeowner, you want to get rid of the first type as soon as you can. You might want to consider the second type.
- multiple employer trust (MET)
A trust established by a sponsor that brings together a number of small, unrelated employers for the purpose of providing group medical coverage on an insured or self-funded basis.
- mutual life insurance company
A life insurance company owned by policyholders who share in the company’s surplus earnings.
- national association of insurance commissioners (NAIC)
National organization of state officials charged with regulating insurance. It has no official power but wields significant influence. NAIC was formed to provide national uniformity in insurance regulations.
- no-fault insurance
No-fault insurance (sometimes known as PIP or PPI) is designed to pay for the financial losses associated with minor accidents as quickly as possible. Under a no-fault system, your own insurance company will pay medical expenses and lost wages caused by an accident, regardless of who was at fault. In the long run, this system saves time and money that would otherwise be spent litigating petty claims. Usually, that means less expensive auto insurance. In exchange, no-fault systems limit the right to sue under certain circumstances. Not every state has no-fault, and systems vary quite a bit from state to state. In Michigan, there is no limit to the amount that you can collect under no-fault. In other states, you may only be able to collect $5,000. Once no-fault runs out, motorists can turn to their uninsured motorist/underinsured motorist coverage to make up the difference.
- noncancellable policy
A policy that can be maintained through timely payment of the premiums until the policyholder is at least age 50 or, in the case of a policy issued after age 44, for at least five years from the date of issue. The insurer may not unilaterally change any provision of the in-force policy, including premium rates.
- noncontributory plan
Group insurance plan under which the employer does not require employees to share in its cost.
- nondisabling injury
Any injury that may require medical care but does not result in the loss of working time or income.
- non-forfeiture option
One of the choices available if the policyholder discontinues payments on a policy with a cash value. This may be taken in cash as extended term insurance or as reduced paid-up insurance.
- non-forfeiture values
The value of the policy if canceled, either in cash or in another form of insurance. Also available to the policyholder if required premium payments are not paid.
- non-medical limit
The maximum face value of a policy that a given company will issue without the applicant taking a medical examination.
- nonoccupational policy
Policy that covers only non-job-related accidents or sicknesses not covered under any workers’ compensation law.
- non-participating insurance
Insurance on which no dividends are paid.
- nonparticipating policy
Policy that does not provide for payment of a dividend.
- nonprofit insurers
Corporations organized under special state laws to provide medical benefits on a not-for-profit basis (for example, Blue Cross Blue Shield and Dental Service Corporations).
- occupational hazards
Factors inherent in the insured person’s occupation that expose him or her to greater-than-normal physical danger.
- optional renewable policy
Contract that grants the insurer the right to terminate a policy on any anniversary, or, in some cases, on a premium date.
- ordinary life insurance
Life insurance usually issued in amounts of $1,000 or more with premiums payable on an annual, semi-annual, quarterly or monthly basis.
- overhead expense insurance
Insurance for Businesses owners to help offset continuing business expenses if the owner is disabled.
- paid-up insurance
Insurance on which all required premiums have been paid.
- partial disability
A disability that prevents a person from performing one or more functions of his or her regular job.
- participating insurance
Insurance on which the policyholder is entitled to share in the surplus earnings of the company through policy dividends that reflect the difference between the premium charged and the cost to the company of providing the insurance.
- participating policy
Policy under which the policyholder is eligible to receive dividends.
- payout period
The period during which you receive the income from your annuity contract.
- permanent life insurance
A phrase used to cover any form of life insurance except term; generally insurance that accrues cash value, such as whole life or endowment.
- personal injury protection (no-fault)
This coverage provides medical expenses as well as work loss, funeral expenses, essential services expenses and survivor’s loss coverage as outlined in your state’s statutory No-Fault laws.
- physician’s expense insurance
Coverage that provides benefits toward the cost of doctor’s fees – for surgical care in the hospital, at home, or in a physician’s office, and for x-rays or laboratory tests performed outside of a hospital. (Also called Regular Medical Expense Insurance).
- point of service plan (POS)
Plan that offers a full range of health services through a combination of HMO and PPO features. Members can choose to either use the defined managed care program (with 100 percent coverage) or go out-of-plan for services (with 80 percent coverage).
The printed document issued to the policyholder by the company stating the terms of the insurance contract.
- 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 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.
- policy reserves
The measure of the funds that a life insurance company holds specifically for fulfillment of its policy obligations. Reserves are required by law to be calculated so that, together with future premium payments and anticipated interest earnings, they will enable the company to pay all future claims.
The person who owns a life insurance policy. This is usually the insured person, but it may also be a relative of the insured, a partnership or a corporation.
- policy term
The period for which an insurance policy provides coverage.
A utilization management program that requires the insured or the health care provider to notify the insurer prior to a hospitalization or surgical procedure. The notification allows the insurer to authorize payment, as well as to recommend alternate courses of action.
- preexisting condition
Any physical and/or mental condition or conditions that exist prior to the effective date of health insurance coverage.
- preferred provider organization (PPO)
Plan through which a sponsoring group negotiates price discounts with providers in exchange for patients. The sponsor may be an insurer, employer, or third-party administrator.
The payment, or one of the regular periodic payments, that a policyholder makes to own an insurance policy.
- premium loan
A policy loan made for the purpose of paying premiums.
- prepaid group practice plan
A plan under which specified health services are rendered by participating physicians to an enrolled group of persons, with a fixed periodic payment made in advance by (or on behalf of) each person or family. If a health insurance carrier is involved, a contract to pay in advance for the full range of health services to which the insured is entitled under the terms of the health insurance contract. An HMO is an example of a prepaid group practice plan.
The amount you pay into your annuity contract as distinguished from the interest that is credited to it.
- principal sum
Amount payable in a lump sum in the event of accidental death and, in some cases, accidental dismemberment.
- professional standards review organization (PSRO)
Organization responsible for determining whether care and services provided are necessary and meet standards for reimbursement under the Medicare and Medicaid programs.
Modification of policy benefits because of changes in the insured’s occupation or the purchase of other insurance.
- prospective payment
Payment of a lump-sum to an institution for care of an insured person based on a predetermined amount correlated with a diagnosis.
- qualified annuity
An annuity that is sold as part of a tax-qualified Keogh plan or company pension plan.
- qualified impairment insurance
A form of substandard or special class insurance that restricts benefits for an insured person’s particular condition.
- rated policy
Sometimes called an “extra-risk” policy, an insurance policy issued at a higher-than-standard premium rate to cover the extra risk where, for example, an insured has impaired health or a hazardous occupation.
- reasonable and customary charge (R & C)
Amounts charged by health care providers that are consistent with charges from similar providers for identical or similar services in a given locale.
- recurring claim provision
A provision in some health insurance policies that specifies a length of time during which the recurrence of a condition is considered to be a continuation of a previous period of disability or hospital confinement.
- reduced paid-up insurance
A form of insurance available as a non-forfeiture option. It provides for continuation of the original insurance plan but for a reduced amount.
Process and goal of restoring disabled persons to maximum physical, mental, and vocational independence and productivity (commensurate with their limitations). Rehabilitation is achieved by identifying and developing residual capabilities, job modification, or retraining. A “rehabilitation provision” appears in some long-term disability policies; this provides for continuation of benefits or other financial assistance during the rehabilitation period.
The restoration of a lapsed policy to full force and effect. The company requires evidence of insurability and payment of past due premiums plus interest.
Acceptance by one insurer (the reinsurer) of all or part of the risk or loss underwritten by another insurer (the ceding insurer).
Continuance of coverage beyond original terms signified by acceptance of a premium payment for a new term.
- renewable term insurance
Term insurance providing the right to renew at the end of the term for another term or terms, without evidence of insurability. The premium rates increase at each renewal as the age of the insured increases.
- replacement vs. actual cash value
The actual cash value of an item can be depressingly small after only a brief period of ownership. And, if your homeowner’s coverage entitles you to only the actual cash value of any damaged property, you could be out of luck when you go to replace the property with only your claim check as payment. Replacement-cost coverage permits you to claim the cost of replacing an insured item. Its most important use is on your home and, secondly, the personal property in your home.
The amount required to be carried as a liability in the financial statement of an insurer to provide for future commitments under policies outstanding.
- residual disability benefits
A provision that provides benefits in proportion to a reduction of earnings as a result of disability, as opposed to the inability to work full-time.
An amendment to an insurance policy that modifies the policy by expanding or restricting its benefits or excluding certain conditions from coverage.
The probable amount of loss foreseen by an insurer in issuing a contract. The term sometimes applies to the person insured or to the hazard insured against.
- risk classification
The process by which a company decides how its premium rates for life insurance should differ according to the risk characteristics of individuals insured (for example, age, occupation, sex, state of health) and then applies the resulting rules to individual applications. (See underwriting.)
- second-to-die life insurance
A form of insurance, traditionally used as an estate planning tool, that pays a death benefit only upon the death of the insured who survives the longest. Its main purpose is to pay estate taxes upon the death of the second insured. Because it is based on joint life expectancy, its premium is less than the total premiums for individual policies on the same lives. This type of insurance is available in many forms, including policies with interest-rate features and flexible premiums.
- self administration
Maintenance of all records and assumption of responsibility, by a group policyholder, for those covered under its insurance plan. Responsibilities include preparing the premium statement for each payment date and submitting it with a check to the insurer. The insurance company, in most instances, has the contractual prerogative to audit the policyholder’s records.
- self insurance
A program financed entirely by the employer for insuring employees instead of purchasing coverage from a commercial carrier.
- senior citizens policies
Policies insuring persons 65 years of age or older; in most cases, these policies supplement the coverage provided under Medicare.
- separate account
An asset account established by a life insurance company separate from other funds, used primarily for pension plans and variable life products. This arrangement permits wider latitude in the choice of investments, particularly in equities.
- settlement options
One of several ways, other than immediate payment in a lump sum, in which the insured or beneficiary may choose to have policy proceeds paid.
- short-term disability income insurance
Insurance that provides benefits only for loss from illness or disease and excludes loss from accident or injury.
- single-premium whole life insurance
A whole life policy that provides protection for the duration of the insured’s life in exchange for the payment of the total premium in one lump sum at the time of application.
- social security freeze
A long-term disability provision that guarantees that Social Security benefits will not be changed regardless of changes in the Social Security law.
- special risk insurance
Coverage for risks or hazards of a special or unusual nature.
- specified disease insurance
Insurance providing an unallocated benefit, subject to a maximum amount, for expenses in connection with the treatment of specified diseases, such as cancer, poliomyelitis, encephalitis, and spinal meningitis. These policies are designed to supplement major medical policies.
- state regulation of insurance
The complexity and cost variations of insurance stems directly from state regulation of the industry. Unlike the securities and banking industries, the insurance industry does not have a strong federal oversight role. Instead, through the 1945 McCarran-Ferguson Act, the domestic industry faces 55 sets of overseers (the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam and American Samoa). With so many different sites of regulation, and so many sources of local sales outlets for insurance policies, it’s not surprising that insurance policies are hardly the standardized commodities that you find when trading stocks or opening a bank account. This is particularly true in property/casualty coverage and less so in life insurance. Added to the maze of different products is the fact that state-based regulation means that insurers may base their rates in each state on their business profile in that state. Auto rates, for example, reflect accident and theft trends in local territories. The up hot is that there is great pricing variation along with lots of different types of policies. Lastly, insurers have increasing freedom to price their policies for whatever the market will bear. Even if an insurer has to file its rates in your state, you shouldn’t assume that state regulators are poring over the rates to review their fairness.
- standard insurance
Insurance written on the basis of regular morbidity underwriting assumptions and issued at normal rates.
- standard provisions
Provisions setting forth the rights and obligations of and insurers and insured persons under health insurance policies. Originally introduced in 1912, these provisions were replaced by the Uniform Policy Provisions Law (UPPL).
- standard risk
Person who, according to an insurer’s underwriting standards, is entitled to purchase insurance without paying an extra premium or special restrictions.
- state (compulsory) disability plan
Plan of short-term income replacement required by some states to cover eligible persons employed within that state.
- state insurance department
An administrative agency that implements state insurance laws and supervises (within the scope of these laws) the activities of insurers operating within the state.
- stock life insurance company
A life insurance company owned by stockholders who share in the company’s surplus earnings.
- stop-loss insurance
Protection purchased by self-funded buyers against the risk of large losses or a severe adverse claim experience.
- straight life annuity
An annuity whose periodic payments stop when the annuitant dies.
- straight life insurance
Whole life insurance on which premiums are payable for life.
- substandard insurance
Insurance issued with an extra premium or special restriction to persons who do not qualify for insurance at standard rates.
- substandard risk
Persons who cannot meet the health requirements of a standard health insurance policy.
- supplementary contract
An agreement between a life insurance company and a policyholder or beneficiary by which the company retains the cash sum payable under an insurance policy and makes payments in accordance with the settlement option chosen.
- surgical expense insurance
Insurance policies that provide benefits toward physicians’ or surgeons’ operating fees. Benefits may consist of scheduled amounts for each procedure.
- surgical schedule
List of maximum amounts payable for various types of surgery; amounts are based on the complexity of the operation.
- survivorship insurance
Another name for second-to-die insurance.
- tax treatment of life insurance payments
The death benefits of a life insurance policy are exempt from taxes. Even with recent tax-rate reductions and a phased-in increase in the amount of a person’s estate that is exempt from estate taxes, the tax-free nature of life insurance benefits makes them a powerful financial planning and wealth-preservation tool. Annuity payments are not tax exempt, although these products may include insurance “wrappers” with exempt benefits.
- term insurance
A plan of insurance that covers the insured for only a certain period of time (term), not for his or her entire life. The policy pays death benefits only if the insured dies during the term.
- term rider
Term insurance that is added to a whole life policy at the time of purchase or that may be added in the future.
- third-party administration (TPA)
An outside person or firm (not a party to a contract) that maintains all records of persons covered under an insurance plan. The TPA also may pay claims using the draft book system.
- time limit
A specified number of days in which a notice of claim or proof of a loss must be filed.
- title insurance
Title insurance protects against the various financial losses associated with having the title on your home challenged, including court costs and loss of the property. For a one-time fee, most title insurers will investigate public records to make sure that your property is free of title defects. This coverage can benefit either the homeowner or the mortgage company, so you should know which kind you’re paying for.
- total disability
A disability that prevents a person from performing all occupational duties. The exact definition varies among policies.
- travel accident policies
Limited contracts covering accidents that occur only while an insured person is traveling on business for an employer, away from the usual place of business, and on named conveyances.
- umbrella liability
If your auto and home are insured with the same carrier, you probably can get supplemental liability coverage from your insurer. This is generally a very good and affordable idea, but only if you have underlying wealth that needs to be shielded from lawsuits. By insuring your car and home, it is cost-effective for your insurer to extend bigger-dollar liability coverage to both areas (hence the “umbrella” concept). If, for example, you have 100/300 auto liability ($100,000 liability for each person insured in an accident; $300,000 total liability for the accident) and $100,000 liability on your homeowner’s insurance, you can extend this to $1 million for a few hundred bucks a year.
- unallocated benefits
Benefits with a maximum amount but without specific limits on the extent of benefit for each service rendered.
(1) A company that receives the premiums and accepts responsibility for the fulfillment of the policy contract
(2) The company employee who decides whether or not the company should assume a particular risk
(3) The agent who sells the policy
The underwriting process evaluates the likelihood an insured event will occur, determines its likely cost and develops an appropriate premium for the coverage that is competitive in the marketplace and remunerative to the insurance company writing the policy. For some standardized coverages that are highly competitive, underwriting may be somewhat besides the point — the policy has to be priced according to marketplace pressures if the insurer wishes to remain in that line of coverage. Underwriting still plays a substantial role for many coverages, however, even those in the increasingly competitive businesses of auto, home and term life insurance. Insurance companies don’t all target the same slice of the market in the same states, and thus often have different objectives in their underwriting efforts as well as different cost structures that determine operating profit margins in their underwriting calculations. Underwriting differences account in part for the substantial differences in insurance premiums or comparable coverages.
- unearned premium
That portion of a premium already received by the insurer for which protection has not yet been provided.
- uninsured/underinsured motorists coverage
In the best of all possible worlds, everyone would have adequate auto liability coverage. But there are people who drive around (often illegally) with no insurance or not enough insurance. If one of these folks happens to cause an accident, you might not be able to collect damages. Uninsured/underinsured motorists coverage — usually called UM/UIM coverage — will pay bodily injury costs caused by an uninsured or underinsured motorist. It’s a required coverage in some states, and a prudent coverage anywhere. Usually, the limits are the same as the bodily injury portion of your auto liability coverage. UM/UIM coverage can supplement the benefits you can receive under a no-fault system.
High-risk persons who do not have health care coverage through private insurance and who fall outside the parameters of risks of standard health underwriting practices.
- universal life insurance
Unlike traditional cash-value policies (known as “whole life”), universal life policy returns were freed from long-term, fixed-rate contracts and replaced with policies whose returns were tied to short-term interest rates and periodically adjusted. In addition, premiums and death benefits can be changed by the policyholder.
- variable annuity
An annuity contract under which the monthly payments will vary because they are linked to the values of investments, such as common stocks. This contrasts with the fixed dollar annuity, which guarantees a fixed amount monthly.
- variable life insurance
True investment characteristics were introduced with these policies, requiring that they be registered with the U.S. Securities and Exchange Commission. Policy investments are controlled by the policyholder and may be placed in a broad range of equity, bond and money-market instruments. Unlike universal life, premiums and death benefits are fixed in variable life policies.
- variable universal life insurance
Investments, premiums and death benefits may all be controlled by the policyholder. If you know what you want and how to get there, variable universal life products are hard to beat, and many financial advisors rate them more highly than variable annuities.
- waiting period
The time a person must wait from the date of acceptance into an eligible class (or from application) to the date the insurance becomes effective. While similar to elimination periods, waiting periods are often paid retroactively.
- waiver (exclusion endorsement)
An agreement, attached to the policy and accepted by the insured, to eliminate a specified preexisting physical condition or specified hazard.
- waiver of premium
A provision that sets certain conditions under which an insurance policy will be kept in full force by the 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
A plan of insurance for life, with premiums payable for a person’s entire life.
- windstorm insurance
Windstorm coverage pays for losses to your property that result from a windstorm. The coverage acts like a flood or earthquake policy in that it pays for damage to the dwelling, and, in some cases, for damage to your personal property and for living expenses if your home becomes uninhabitable. If you live in a coastal area, you’ll probably need to purchase separate windstorm coverage on your house. In areas where coverage is scarce, states sometime offer market assistance programs or joint underwriting associations to help homeowners find a carrier.
- workers’ compensation
Liability insurance requiring certain employers to pay benefits and furnish medical care to employees for on-the-job injuries, and to pay benefits to dependents of employees killed by occupational accidents.
- written premiums
The entire amount in premiums due in a year for all policies issued by an insurance company.
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