| A | B |
|---|
| Insurance | A method of handling pure risk, by spreading it over a large number of similar individuals |
| Law of Large Numbers | Shows us that we can predict, fairly accurately, what will happen to a large group of similar individuals in a given time period |
| Risk pools | Large groups of similar individuals |
| Actuaries | People who make mathematical predictions about probability in a given risk pool |
| Principle of indemnity | Assumes that an insured, who has suffered a loss, should only be restored to the approximate financial condition that existed prior to the loss, no better and no worse |
| Insurable interest | Lawful, substantial, and economic interest in the life, health, property, or object being covered under the insurance contract |
| Risk | The possibility (uncertainty) that a loss might occur and is the reason that people buy insurance |
| Pure Risks | A situation where there is only the possibility of a loss, there is never the possibility of a profit or financial gain |
| Speculative Risks | A situation where either a profit or loss is possible and therefore are non-insurable |
| Static Risk | Historical factors that do not frequently fluctuate and are insurable |
| Dynamic Risk | Risk associated with change and is not insurable |
| Fundamental Risk | Risks that affect entire groups of people or property within society |
| Particular Risk | Risks that affect only the individual person or family and not the entire community or society and are usually insurable |
| Peril | The actual cause of a loss |
| Hazard | Any condition that increases the possibility, or severity of a loss |
| Physical Hazards | The material, structural, environmental, or operational features of an insured risk that may create or increase the opportunity for injury or damage |
| Moral Hazard | A condition that increases the probability that a person will “intentionally” cause, create, or inflate a loss |
| Morale Hazard | A condition of inattention to, or disregard for, one’s own life, health, property, or behavior, that increases the frequency or severity of a loss. Attitudinal and involves an apathetic disregard |
| Risk Avoidance | Avoiding the hazard |
| Transfer of Risk | Most common and most popular method of handling risk. Transfer risk to an insurance company, in exchange for paying a regular premium to the company |
| Sharing a Risk | The insured accepts responsibility for a small portion of the risk, while transferring the larger portion of the risk to the insurer |
| Assumption of Risk | Risk retention or self-insurance |
| Risk Reduction or Risk Control | Employing loss prevention methods |
| Underwriting | The process of selecting certain types of risks that have historically produced a profit and rejecting those risks that have historically produced a loss |
| Adverse selection | The tendency of insureds with a greater-than-average chance of loss to purchase insurance |
| Spreading the risk | Insuring, during the same underwriting period, either a very large number of similar risks, multiple insured locations, or activities with dissimilar risks |
| Reinsurance | Insurance purchased by an insurance company, from another insurance company |
| Four elements of a contract | C - Competent Parties/Capacity to Contract, L - Legal Purpose, O - Offer and Acceptance, C - Consideration |
| Four sections of a contract: | D - Declarations, I - Insuring Agreement, C - Conditions, E - Exclusions |
| Aleatory Contract | Contingent upon an uncertain (random) event, that provides for an unequal transfer of value between the parties. |
| Contract of Adhesion | The contract is drafted by one party with stronger bargaining power (the insurance company) and accepted by another party with weaker bargaining power (the insured). |
| Executory Contract | Outlines the duties of both the insured and the insurance company, and states that those duties must be performed, before the contract will be fully executed |
| Conditional Contract | An insurance company will pay claims under an insurance policy, based on the conditions specified in the contract. |
| Unilateral Contract | A “one-sided contract”. |
| Personal Contract | Bound to the “personal insurable interest” of the named insured in the policy. |
| Contract of Indemnification | Restore the insured to the financial position previously held before the loss. |
| The Doctrine of Utmost Good Faith | To form an insurance contract, each party to the contract must substantially rely on the honesty and integrity of the other party. |
| The Doctrine of Reasonable Expectations | An insurance contract (policy) should cover the policyholder and/or his beneficiaries to the extent that the average person would expect. |
| Warranty | Statements made by an applicant for insurance that are guaranteed to be true, and if later found to be untrue, will void the policy. |
| Representation | Statements made on an application for insurance that are true to the applicant’s best knowledge and belief. |
| Misrepresentation | Untrue statements made by the insured (Lie) |
| Concealment | The failure to reveal known material facts, when applying for insurance. (Hide) |
| Fraud | An intentional act designed to deceive and induce another party to part with something of value |
| Waiver | The intentional relinquishment of a known right, or intentional conduct inconsistent with claiming a known right. |
| Expressed waiver | Purposely gives up a known right under the contract |
| Implied waiver | Any parts of an investigation not performed prior to the completing an investigation. |
| Estoppel | A legal doctrine that prevents or “stops” a party from contradicting its own previous actions, if those actions have been reasonably relied upon by another party. |
| Accident | A sudden and unforeseen event resulting in a financial loss |
| Occurrence | A sudden and unforeseen event resulting in a financial loss which can also include a continuous or repeated exposure to an event that results in a financial loss |
| Ambiguous Language | language that is vague and creates doubt |
| Application for Insurance | The form on which a prospective insured provides answers to the questions requested by the insurer. |
| Apportionment Clause | How much two or more policies covering a loss, will pay on the claim. |
| Arbitration Clause | Requires the parties to an insurance contract to resolve coverage disputes through arbitration as opposed to mediation or litigation. |
| Arbitration | The process of bringing a contract dispute before a disinterested third party for resolution. |
| Binder | Serves as temporary evidence that coverage is in effect until the policy is issued |
| Mid-term Cancellations | Cancellation which occurs before a policy has expire |
| Certificate of Insurance | General summary of the coverage |
| Coinsurance Clause | States that the insurance company and the insured person will share in the expenses incurred by the insured. |
| Deductible | self-insured retention; the insured must bear this loss before an amount is remitted to the claimant |
| Definitions | Explain the important terms used in the policy language |
| Endorsements/Riders | A written amendment or addition to a policy |
| Entire Contract Clause | The entire agreement between the insured and the insurer is limited to the terms of the contract, and not any other stipulations outside of the contract |
| Exposure | The state of being subject to loss because of some type of hazard |
| Fiduciary | Any person or institution that has responsibility for the money, property, or financial affairs of another. |
| Liberalization Clause | If any policies or endorsement forms currently in use, are broadened by legislation or rulings from ratings authorities, then all existing similar policies will provide the broadened coverage to all existing policyholders, without additional premium. |
| Loss | The actual injury or damage sustained by the insured due to one or more accidents or misfortunes that are covered under an insurance policy. |
| Malfeasance | An outright act of sabotage by one party to a contract, who intentionally causes damage |
| Other Insurance Clause | If the insured has other sources of recovery for a covered claim, this clause is activated. |
| Policy Provisions | The clauses in an insurance contract that include such details as the policy period, conditions, endorsements, riders, exclusions, that determine whether coverage applies and in what amount. |
| Policy Territory/coverage territory | Identifies where coverage applies |
| Excess Insurance | Pays only when coverage under other applicable insurance policies has been exhausted |
| Proof of Loss | Completed by the insured claimant, listing the details of a loss |
| Pro-rata Share | Each insurer will pay its percentage of the claim, based on the proportion of the coverage it provided. |
| Subrogation Clause | Recoup the money it has paid on the claim by suing the negligent party |
| Third-Party Administrators | Handle many different administrative responsibilities for insurers, such as claims handling and risk management consulting. |
| Transacting Insurance | The solicitation, inducement and preliminary negotiations affecting a contract of insurance, and the subsequent business pertaining to carrying out the terms of the contract |
| Tort | A civil wrong that violates the rights of others |
| Tortfeasor | A person who has committed a tort |
| Unearned Premium | The portion of the policy premium that has not yet been “earned” because the policy is still in force for a period of time before its expiration |
| Unearned Premium Reserve | The amount of unexpired premiums on policies or contracts as of a certain date that should be maintained in “reserve” |
| Public Law 15/McCarren-Ferguson Act | The authority of insurance regulations is granted to state government |
| Certificate of Authority | A certificate issued to an insurance company by a state Department of Insurance granting them the power to write contracts of insurance in that state. |
| Admitted/Authorized | When an insurance company has received a certificate of authority and can conduct business in the state. |
| Nonadmitted/Unauthorized | When an insurance company does not have a certificate of authority and cannot conduct business in the state. |
| Surplus Lines Companies | Circumstances when a nonadmitted company without a certificate of authority is permitted to conduct business within a state. |
| The National Association of Insurance Commissioners (NAIC) | creates and maintains model laws that establish standards for how insurance is offered and delivered in the United States |
| The Interstate Insurance Product Regulation Commission (IIPRC) | produces standardized forms for Life insurance, Annuities, Disability Income, and Long-Term Care insurance products |
| The National Council on Compensation Insurance (NCCI) | duces standardized Workers Compensation forms |
| The National Uniform Claim Committee (NUCC) | produces and maintains the universal claim form, the CMS-1500, to submit medical expense claims to private health insurers, government insurers, and workers compensation insurers. |
| The Surety & Fidelity Association of America (SFAA) | produces a number of standardized bond forms to provide for surety data standards. |
| The American Association of Insurance Services (AAIS) | provides property and casualty standardized forms, including some forms providing specialty coverages. |
| The Insurance Services Office, Inc. | provides property and casualty standardized forms that are the most widely used throughout the country. |
| Accidental Bodily Injury | Injury to the body of the insured, as the result of an “accident”. |
| Accident | A sudden and unforeseen event, resulting in a loss. |
| Accidental Means | Takes into account both the cause and the effect of the event, rather than just the injurious result of the event. |
| Sickness Insurance | Covers losses resulting from illness or disease, it does not cover accidental injury |
| Hospital and Medical Expense policies | Reimburse the insured, totally or partially, for the medical costs in treating a disability or an illness. |
| Long-Term Care Expense policies | Cover the type of care that an individual may require if he or she is unable to attend to their daily needs due to prolonged sickness, disability, or degenerative diseases or illnesses. |
| Individual Accident & Health policies | Personally owned by the insured and purchased through a private insurance carrier. |
| Group Accident & Health policies | Provide coverage to members of a group |
| Private Accident & Health policies | Offered through an individual’s employer, or purchased by the individual and premiums are paid entirely or in part by the individual insured |
| Government (Public) Accident & Health policies | Subsidized or paid for entirely by government (public) funds. |
| Limited Benefit (Supplemental) Accident & Health policies | Cover expenses that are not included in a medical expense policy (dental care, disability income, and specified dread disease. |
| Comprehensive Major Medical Accident & Health policies | Include all of the basic medical expense coverages into a single policy, ranging from hospital and surgical coverage, to dental and miscellaneous medical expenses. |
| Fully-Insured Accident & Health policies | Cover groups of an employees while their employer pays the premium to the insurance company. The employer’s premiums will stay fixed for a year, unless the number of employee’s covered under the plan changes. |
| Self-Insured (Self-Funded) Accident & Health plans | Operated by the employer and allows them to save the profit-margin that an insurance company adds to the premium it charges. |
| Accident-Only policies | Cover insureds for death, dismemberment, disability, or hospital and medical care that was caused by an accident. |
| Hospital Indemnity Insurance | Provides weekly or monthly income benefits to an insured to pay the expenses of daily living while the insured is hospitalized |
| Dental Insurance policies | Usually provide what is known as “100-80-50” coverage. This means the policy usually covers 100% of the preventive care, 80% of fillings and root canals, and 50% for crowns, bridges, and major dental care. |
| Specified (Dread) Disease policies | Provide benefits for a single disease, or group of diseases, to supplement major medical coverage in the case that high costs are incurred in treating a serious illness such as cancer. |
| Vision Coverage (Eye Care Policies) | Provides supplemental coverage for eye examinations, contact lenses, eyeglasses, and/or eye glass frames. |
| Common Exclusions | Workers Compensation, Cosmetic Procedures, Experimental Treatment, and Medically Necessary Treatments |
| CMS-1500 | Universal claim form for Health insurance policies and maintained by the National Uniform Claim Committee (NUCC). |
| CPT | Current Procedural Terminology |
| ICD | Classification of Diseases indicating a diagnosis |
| Medical Expense Insurance | Basic hospital, surgical and medical policies and major medical policies grouped together. |
| Basic Hospital Expense Coverage | Covers hospital room and board, and miscellaneous hospital expenses, such as lab and x-ray charges, medicines, use of operating room and supplies, while the insured is confined to a hospital, with no deductible and the limits on room and board are set at a specified dollar amount per day up to a maximum number of days. |
| Miscellaneous Hospital Expenses | Usually expressed as a multiple of the daily room and board limit for example 10 or 15 times the daily room and board limit. However, it can also be expressed as a flat benefit or as a percentage of participation. The benefits provided by this coverage are drugs, x-rays, and laboratory expenses |
| Basic Medical Expense Coverage | This is often referred to as Basic Physicians Nonsurgical Expense Coverage because it provides coverage for nonsurgical services a physician provides. The benefits are usually limited to visits to patients confined in the hospital and some policies will also pay for patient office visits. |
| Basic Surgical Expense Coverage | These pay for the costs of surgeon’s services, whether the surgery is performed in or out of the hospital. Each contract has a surgical schedule which lists the types of surgery it will cover and the amount that will be paid for that surgery. No deductible, but coverage is limited so most people would be better off purchasing a major medical policy. |
| Major Medical Policies | These policies provide comprehensive coverage for hospital expenses. These policies are intended to provide the insured with catastrophic medical expense protection. Include deductibles, but have high maximum limits. Policies are usually written on a lifetime basis, provide coverage under one policy up to a stated limit for the “lifetime” of the policy |
| Major Medical Policy Exclusions | Injuries due to war or military conflict; Elective cosmetic surgery; Dental care (except due to accident); Eye examinations and eyeglasses, hearing examinations and hearing aids; Pregnancy and childbirth (except complications of pregnancy); Treatment received in a federal or state hospital; Accidents that would be covered under Workers Compensation; War; Self-inflicted injury; Military Duty; Eye refractions |
| Comprehensive Medical Expense | Combination of basic medical expense coverage plus a major medical plan |
| Corridor | Deductible that connects a first dollar plan to a major medical plan |
| Impairment Rider | Indicates who/what is not covered |
| Guaranteed Insurability Rider | Provides the insured with the right to purchase additional disability income benefits without evidence of insurability |
| Multiple Indemnity Rider | Provides double or triple benefits if injury is sustained under certain circumstances |
| Fee for Service | A payment system for health care in which the provider is paid for each service given. |
| Prepaid Plans | Plan subscribers pay a set fee, usually each month, for medical services covered under the plan. Blue Cross and Blue Shield plans are prepaid plans |
| Benefit Scheduled versus Nonscheduled Plans: | Scheduled benefit plans include a schedule that lists major commonly performed operations and benefits payable for each |
| Cancellable | Health insurance policies provide the insurer with the right to cancel at any time by giving the insured a specified number of days notice (usually as little as five days notice). |
| Noncancellable | Contract cannot be cancelled by an insurer for any reason except nonpayment of premium. Insureds may cancel these policies if and when they wish. Noncancellable contracts provide the insured with a stated amount of coverage for a stated period of time (usually to age 65) at a guaranteed premium rate |
| Guaranteed Renewable | These contracts will continue health protection, but may not continue at the same premium charge. |
| Conditionally Renewable | These policies provide the insurer with the right to refuse to renew coverage for certain conditions stated in the policy. |
| Optionally Renewable | These policies provide the insurer with the right or option to renew or terminate an individual policy at the time of premium payment |
| Commercial Insurers | Function on the reimbursement approach; that is policyowners obtain medical treatment from whatever source they choose and are reimbursed |
| Blue Cross & Blue Shield | Their policyholders are called subscribers and those subscribers visit medical care providers that have an agreement as to the charges for this care |
| ultiple Employer Trusts and Multiple Employer Welfare Arrangements | Under this type of program, a small business can subscribe and this puts the business in a “group” with the lower premium benefit of a group. |
| Preferred Provider Organizations (PPOs) | Physicians are paid fees for their services rather than a salary, but the member is encouraged to visit approved member physicians that have previously agreed upon the fees to be charged. |
| Health Maintenance Organizations (HMOs) | Provide coverage to patients “in-network”. Meaning, subscribers can only visit health care providers that belong to the organization |
| Open-panel HMO | All health care providers can work for the HMO as long as they agree to the requirements. They usually work out of their own offices and usually represent the HMO on a part-time basis, seeing both HMO patients and non-HMO patients |
| Closed-panel HMO | Providers work for the HMO and provide services at an HMO facility |
| Group Model of HMO | The HMO contracts with an independent medical group that specializes in a variety of medical services |
| Staff Model of HMOs | Physicians are actually paid employees of the HMO |
| Network Model of HMOs | Similar to the group model except that the HMO contracts with two or more medical groups instead of just one. |
| Independent Practice Association Model of HMO | Physicians are actually paid employees of the HMO. The physicians are paid on a fee-for-service basis whereby the fees have been negotiated in advance |
| Skilled nursing care | Daily nursing and rehabilitative care that can only be provided by medical personnel, under the direction of a physician |
| Intermediate care | Occasional nursing and rehabilitative care provided by medical personnel. Patient needs care daily, but not 24-hour care. |
| Custodial care | Care for meeting personal needs such as assistance in eating, dressing, or bathing, provided under a doctor’s orders, but by non-medical personnel |
| Home health care | Care provided in one’s home |
| Home Convalescent care | Care provided in the insured’s home under a planned program established by his or her attending physician. |
| Residential Care | Care provided while the insured resides in a retirement community |
| Adult day care | Care provided for functionally impaired adults on less than a 24-hour basis. It could be provided by a neighborhood recreation center or a community center. Care includes transportation, and a variety of health, social and related activities. Meals are usually included as a part of the service |
| Respite care | Designed to provide relief to the family care giver, and can include a service such as someone coming to the home while the care giver goes out for a while |
| Medicare Supplement Insurance/ Medigap | Policies issued by private insurance companies that are designed to fill in some of the gaps in Medicare |
| Medicaid | A federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care |
| Contributory | At least 75% of all eligible employees must participate and both the employer and the employee contribute to the premium payment |
| Non-contributory | 100% of the eligible employees must be included, and the employees do not pay any part of the premium |
| Association-Sponsored Group | Eligible groups include but are not limited to trade associations, professional associations, college alumni associations, veteran associations, customers of large retail chains, and savings account depositors |
| Requirements of Association-Sponsored Groups | Have at least 100 members, Be organized for a reason other than buying group insurance, Have been active for at least two years, Have a constitution, by-laws, and must meet at least annually |
| Master Contract | The actual policy |
| Certificates of insurance | Proof of coverage under a group health insurance policy |
| Individual Health Insurance | “guaranteed renewable” so there is underwriting to determine insurability |
| Group Health Insurance | Everyone is insured underwriting is less restrictive |
| Conversion Privilege | Allows individuals within a group policy to convert their group certificate to an individual Medical Expense policy with the same insurer, if and when they leave their employment. This typically must take place within 30 or 31 days from employment ending |
| Managed Care | Any medical expense plan that attempts to contain costs by controlling the behavior of its participants. |
| Characteristics of managed care plans | Controlled access of providers, Comprehensive case management, Preventive care, Risk sharing, High quality care |
| Endodontics | Treatment of the dental pulp of the natural teeth. An example is root canal treatment. |
| Periodontics | Treatment of the surrounding and supporting tissue of the teeth. An example is the treatment of gum disease. |
| Prosthodontics | The replacement of missing teeth with artificial devices. Examples include bridgework or dentures |
| Orthodontics | The treatment of natural teeth to prevent and/or correct dental anomalies. Examples: braces and appliances |
| COBRA (Stands for) | The Consolidated Omnibus Budget Reconciliation Act |
| COBRA | Requires any employer with 20 or more employees to extend Group Health coverage to terminated employees and their families for up to a period of 36 months after a qualifying event |
| ASO (Administrator Services Only) | A company can contract with an existing licensed insurance company for administrative services. |
| TPA (Third Party Administrator) | A company can contract with another company, not an insurance company, for administrative services. |
| Section 125 | The Internal Revenue Code permitting implementation of an FSA |
| Consumer Driven Health Plan (CDHP) | Allows employees to take more responsibility for their health care, pair a high-deductible catastrophic plan with a Health Savings Account (HSA) or a Health Reimbursement Account (HRA) |
| Medical Savings Account | Employer funded medical account linked to a high deductible medical indemnity plan. Usually, the employer purchases a high deductible medical plan and in return experiences a premium savings over the more traditional medical plan. A portion of the premium saved as a result of the high deductible plan is returned to savings account established for each employee |
| Health Savings Account | A tax sheltered trust account that is owned by an insured employee for the purpose of paying qualified medical expenses for the participating employee and dependents. Earns interest, allows tax-deductible contributions, allows participants to withdraw funds for non-medical purposes and is portable |
| Health Reimbursement Arrangement | An employer funded tax sheltered account to reimburse allowable medical expenses to participants. |
| Blanket Health Plans | Issued to cover a group who may be exposed to the same risks, but the composition of the group constantly changes. Examples: Airline, or a bus company to cover its passengers or to a school to cover its students |
| Franchise Health Plans | “Wholesale plans”, provide health insurance coverage to members of an association or professional society. |
| Elimination Period | A Time Deductible |
| Disability | The inability to work due to loss of physical or mental function; |
| Injury | A bodily injury by accident |
| Sickness | An illness or disease affecting the general soundness of health |
| Permanent Total Disability | The most severe type of disability, meaning the insured will never work again. |
| Temporary Total Disability | This type of disability renders an insured incapable of working for a given time, but recovery is seen |
| Permanent Partial Disability | Usually involves an injury that is permanent in nature (loss of an arm, leg, etc.), but will not stop the individual from returning to work |
| Temporary Partial Disability | The least severe classification of disability and usually characterized by an injury that keeps the individual out of work for a few days, for example a sprained neck |
| Accidental bodily injury | The damage to the body is unexpected and unintended |
| Accidental means | The cause of the accident must be unexpected and unintended |
| Total Disability Benefits | The full amount as specified in the insurance policy for the benefit period for which he or she is qualified |
| Partial Disability Benefits | The inability for the insured to carry on all the duties of his or her job. |
| Residual Disability Benefits | This benefit is based on the proportion of income that the insured has lost, taking into consideration the fact that he or she can work and earn a portion of his/her previous income |
| Lump Sum Benefits | Provide lump sum dollar benefits for various permanent partial injuries under a coverage known as Accidental Death & Dismemberment (AD&D). |
| Capital Sum | The percentage payment is of an AD&D claim |
| Social Insurance Supplement (SIS) or Social Security Riders | Provide payment of income benefits in the following |
| Waiver of Premium Rider | Exempts the policyowner from paying the policy’s premiums during periods of |
| Cost of Living Adjustment (COLA) Rider | Provides for indexing the monthly or weekly benefit payable under a Disability policy to changes in the Consumer Price Index |
| Additional Monthly Benefit Riders | Provides additional benefits during the first six months or 12 months of a claim |
| Rehabilitation Benefit | While totally disabled and receiving benefits, if the insured elects to participate in some form of vocational rehabilitation which is approved by the insurer, total disability benefits will be continued as long as the insured is actively participating in the training program and remains totally disabled |
| Guaranteed Insurability Rider | Guarantees the insured the right to purchase additional amounts of Disability Income coverage at predetermined times in the future without evidence of insurability |
| Delayed Disability Provision | Allows for a 30, 60, or 90 days after an accident as total disability does not always occur immediately after an accident, but may occur days or weeks later. |
| Non-Disabling Injury Rider | This benefit does not pay a disability benefit but rather provides for the payment of medical expenses incurred due to injury which does not result in total disability |
| Return of Premium Rider | Provides for the return of a percentage of premiums paid (usually 80%) during a specific term period (usually every 10 years) minus the claims paid during the term period |
| Annual Renewable Term Rider | Provides a death benefit as well as Disability Income coverage |
| Business Overhead Expense Coverage | This type of insurance does not replace the salary of the individual insured. It DOES provide a stated monthly maximum of benefits for specified eligible expenses required for the maintenance of the business |
| Key Employee Coverage | The person’s economic value to the business is determined in terms of the potential loss of business income which could occur as well as the expense of hiring and training a replacement |
| Disability Buy-Out Coverage | Specifies who will purchase a disabled partner’s interest and legally obligates that person or party to purchase such interest upon disability. |
| Two types of Disability buy-out coverage: | Cross Purchase & Entity Purchase |
| Cross Purchase | This type of agreement states that each owner must buy-out the disabled owner’s share of the business. |
| Entity Purchase | This type of agreement states that the business as an entity will purchase the disabled owner’s interest |
| Short-term Disability | Benefits are paid for a period of 13 weeks to no longer than 104 weeks (two years). |
| Long-term Disability | Benefits are paid for a period longer than 104 weeks is considered and referred to as a long-term plan |
| Non-Contributory | The employer pays the entire cost and income is taxed as ordinary income |
| Fully Contributory | The employee pays the entire cost and income benefits are received tax free |
| Partially Contributory | The cost is paid partially by the employer and partially by the employee. In this case, the |
| Key person Disability Insurance | Insurance for key employees in the event they become disabled and are unable to |
| Business Overhead Expense (BOE) | Reimburses the business owner for the overhead expenses that are incurred while the owner is disabled. The premiums that the business pays for the insurance is tax deductible to the business as a business expense. However, the benefits received are taxable to the business as received |
| Disability Buy-Sell Insurance | Provides funds for the business organization to purchase the business interest of a disabled partner. Premiums are not deductible to the business, but the benefits are received income tax free by the business |
| Medicare (Federal Level) | Provide hospital and medical expense protection to persons age 65 and older, to persons of any age suffering from end stage renal disease and those who are receiving Social Security benefits |
| Medicare (State Level) | Offers protection to financially needy persons and the state Workers Compensation program provide benefits for eligible workers who are victims of occupational injuries or illnesses |
| Medicare Part A | Hospital Insurance protection |
| Medicare Part B | Medical Insurance protection |
| Medicare Part C | Medicare Advantage - Options (like an HMO or PPO) approved by Medicare and offered by private companies. |
| Medicare Part D | Prescription Drug Benefit |
| Multi-Source Drugs | Brand drugs for which generic drugs are also available |
| True Out-of-Pocket (TROOP) | The cost a person pays out of pocket for eligible Medicare prescription drug coverage |
| The PACE (Programs of All-Inclusive Care for the Elderly) | Combines medical, social, and long-term care services for frail people and is only in states that have chosen to offer it under Medicaid |
| Four Principle benefits under Social Security | Retirement, Survivor, Medicare and Disability |
| Disability Insured Status under SSDIB | Earner has 40 quarters of coverage up to the year they become disabled |
| Definition of disability under SSDIB | The disabled worker must have a “physical or mental condition that prevents him or her from doing any substantial gainful work and it is expected to last at least 12 months or result in death. |
| Primary Insurance Amount (PIA) | The benefit SSDIB will pay based on a calculation of how much a worker has contributed to social security. |
| Health Insurance Portability & Accountability Act – HIPAA | Ensures “portability” of group insurance coverage, and includes various mandated benefits that affect small employers, the self-employed, pregnant women, and the mentally ill |
| Mandated Benefits under HIPPAA | Guarantees coverage for a 48-hour hospital stay for new mothers and their babies after a regular delivery (96 hours for a caesarean section birth). Expands coverage for mental illness by requiring similar coverage for treatment of mental and physical conditions. Further, small employers cannot be denied Group Health insurance coverage because one or more employees are in poor health |
| The Omnibus Budget Reconciliation Act of 1989 – OBRA | Extended the minimum COBRA continuation of coverage period from 18 to 29 months for qualified beneficiaries disabled at the time of termination or reduction of hours. |
| The Tax Equity and Fiscal Responsibility Act of 1982 – TEFRA | Applies to employers with 20 or more employees and is intended to prevent Group Term Life Insurance plans from discriminating in favor of “key employees”, and amended the Social Security Act to make Medicare secondary to Group Health plans. |
| The Employee Retirement Income Security Act of 1974 – | Stringent reporting and disclosure requirements intended to accomplish pension equality, and protects Group Insurance plan participants |
| Cafeteria Plans | A plan in which employees select health benefits from a variety of coverage options, based on their individual and family needs |
| Tricare (formerly CHAMPUS) | Provides benefits for military dependents when no military medical facility is available |
| Workers Compensation | Designed to help the person who suffers from loss of income due to injury or |
| Four types of benefits provide under WC | Medical, Income, Death, Rehabilitation |
| Authorized User | Any employee, contractor, agent or other person that participates in the business operations of a covered entity and is authorized to access and use any information systems and data of the covered entity. |
| Covered entity | Any person operating under or required to operate under a license, registration, charter, certificate, permit, accreditation or similar authorization under the banking law, the insurance law or the financial services law of New York |
| Cybersecurity Event | Any act or attempt, successful or unsuccessful, to gain unauthorized access to, disrupt or misuse an information system or information stored on the information system |
| Information System | A discrete set of electronic information resources organized for the collection, processing, maintenance, use, sharing, dissemination or disposition of electronic information, as well as any specialized system such as industrial/process controls systems, telephone switching and private branch exchange systems, and environmental control systems |
| Multi-Factor Authentication | Authentication through verification of at least two of the following types of authentication factors: (1) Knowledge factors, such as a password; or (2) Possession factors, such as a token or text message on a mobile phone; or (3) Inherence factors, such as a biometric characteristic |
| Risk-Based Authentication | Any risk-based system of authentication that detects anomalies or changes in the normal use patterns of a person and requires additional verification of the person’s identity when such deviations or changes are detected, such as through the use of challenge questions. |
| Third Party Service Provider | A person that (i) is not an affiliate of the covered entity, (ii) provides services to the covered entity, and (iii) maintains, processes or otherwise is permitted access to nonpublic information through its provision of services to the covered entity |
| Chief Information Security Officer (CISO) | A qualified individual responsible for overseeing and implementing the covered entity’s cybersecurity program and enforcing its cybersecurity policy |
| Violations under US Code 1033 | Overvalues any land, property or security in connection with financial reports or documents presented to an insurance regulatory official; willfully embezzles or misappropriates money, premiums or other property of an insurer; knowingly makes any false entry of material fact in report or statement of a person engaged in the insurance business with intent to deceive another person about the financial condition or solvency of the business |
| New York 1033 Waiver | Allow a felon, who was convicted under U.S. Code 1033 to be employed in the business of insurance in the state of New York |
| New York 1033 Waiver includes | Employment history, details of convection and the methods in which the applicant has been actively making restitution for his or her crime, and other personal history details. |
| Certificate of Relief from Disabilities (CRD) | Issued to 1033 waiver applicants who have been convicted of misdemeanors but have not been convicted of more than one felony |
| Certificate of Good Conduct (CGC) | Grants a legal finding that the felon is reformed after a conviction and removes some of the collateral consequences of a criminal conviction to a 1033 waiver applicant who had previously been convicted of two or more felonies. |
| Superintendent Responsibilities | Power to prescribe, withdraw or amend insurance regulations that are not inconsistent with New York Insurance Laws, the Superintendent also has the power to: Govern all duties assigned to the members of the staff of the Department of Financial Services; Prescribe forms and create regulations; Interpreting the provisions of the New York Insurance Code; Governing the procedures to be followed in the procedures of the Department. |
| Independent Adjuster | Acts on behalf of an insurer |
| Public Adjuster | Acts on behalf of an insured |
| Licensing Requirements | 1) 18 years of age 2) Fingerprinting 3) No license will be issued to a convicted felon or to an individual who has been involved in an offense involving fraudulent or dishonest practices, 4) Affidavits from 5 reputable citizens who have known the applicant for at least five years 5) pass the state licensing exam, 6) maintain a $1,000 surety bond |
| Controlled business | Business an agent sells on himself, his family or employees and an agent that sells only this will have their license revoked or suspended |
| Affiliate | Any company that controls, is controlled by, or is under common control with another company |
| Clear and conspicuous | A notice is reasonably understandable and designed to call attention to the nature and significance of the information in the notice |
| Collect | To obtain information that the licensee organizes or can retrieve by the name of an individual or by identifying number, symbol or other identifying particular assigned to the individual, irrespective of the source of the underlying information. |
| Company | A corporation, limited liability company, business trust, general or limited partnership, association, sole proprietorship or similar organization |
| Consumer | An individual who, in this State, seeks to obtain, obtains or has obtained an insurance product or service, directly or through a legal representative, from a licensee that is to be used primarily for personal, family, or household purposes, and about whom the licensee has nonpublic personal information. |
| Control | Ownership |
| Customer | A consumer who has a customer relationship with a licensee |
| Customer relationship | A continuing relationship between a consumer and a licensee under which the licensee provides one or more insurance products or services in this State to the consumer that are to be used primarily for personal, family, or household purposes. |
| Financial institution | Any institution the business of which is engaging in activities that are financial in nature or incidental to such financial activities as described in the Bank Holding Company Act of 1956 (12 U.S.C. 1843(k)). |
| Financial product or service | Any product or service that a financial holding company could offer by engaging in an activity that is financial in nature or incidental to such a financial activity under the Bank Holding Company Act of 1956. Financial service includes a financial institution's evaluation or brokerage of information that the financial institution collects in connection with a request or an application from a consumer for a financial product or service. |
| Health care | Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, services, procedures, tests or counseling that relates to the physical, mental or behavioral condition of an individual; or affects the structure or function of the human body or any part of the human body, including the banking of blood, sperm, organs, or any other tissue; or prescribing, dispensing, or furnishing to an individual drugs or biologicals, or medical devices or health care equipment and supplies |
| Health care provider | A physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law, or a health care facility |
| Health information | Any information or data except age or gender, whether oral or recorded in any form, created by or derived from a health care provider or consumer relating to: the past, present or future physical, mental or behavioral health or condition of any individual or a member of the individual's family; the provision of health care to any individual; or payment for the provision of health care to any individual |
| Insurance product or service | Any product or service that is offered by a licensee pursuant to the Insurance Laws of this state. Insurance service includes a licensee's evaluation, brokerage or distribution of information that the licensee collects in connection with a request or an application from a consumer for an insurance product or service. |
| Licensee | A person licensed, or required to be licensed, or authorized, or required to be authorized, or registered, or required to be registered pursuant to the Insurance Law of this State; a health maintenance organization holding, or required to hold, a certificate of authority, or an unauthorized insurer in regard to the excess line business conducted pursuant to state law; but shall not include a registered service contract provider, charitable annuity society, or a licensed viatical settlement company or viatical settlement broker. |
| Nonaffiliated third party | Any person except: A licensee's affiliate; or a person employed jointly by a licensee and any company that is not the licensee's affiliate |
| Nonpublic personal information | nonpublic personal financial information and nonpublic personal health information. |
| Nonpublic personal financial information | Personally identifiable financial information; and any list, description or other grouping of consumers (and publicly available information pertaining to them) that is derived using any personally identifiable financial information other than publicly available information |
| Nonpublic personal health information | Health information: that identifies an individual who is the subject of the information; or with respect to which there is a reasonable basis to believe that the information could be used to identify an individual |
| Opt Out | A direction by a consumer that the licensee not disclose nonpublic personal financial information about the consumer to a nonaffiliated third party |
| Personally identifiable financial information | Any information: A consumer provides to a licensee to obtain an insurance product or service from the licensee; About a consumer resulting from a transaction involving an insurance product or service between a licensee and a consumer; or A licensee otherwise obtains about a consumer in connection with providing an insurance product or service to that consumer |
| Publicly available information | Any information that a licensee has a reasonable basis to believe is lawfully made available to the general public from: Federal, state, or local government records; Widely distributed media; or Disclosures to the general public that are required to be made by Federal, state or local law |
| Anterior | Front (head) of an individual |
| Anteroposterior | From head end to opposite end of body |
| Appendage | A structure that extends (and can move separately) from the main body |
| Contralateral | On the opposite side |
| Deep | Further away from the surface |
| Distal | The tip of an appendage |
| Dorsal | Back (spine) of an individual |
| Dorsoventral | From spinal column (back) to abdomen (front). |
| Intermediate | Between two other structures |
| Ipsilateral | On the same side |
| Lateral | A directional term used as a modifier for both the left and right sides of the body |
| Median | Point in the center of the body |
| Mediolateral | From center of the body to one side or the other. |
| Parietal | Pertaining to the wall of a body cavity |
| Posterior | Tail of an individual |
| Proximal | Describes where an appendage joins the body |
| Proximodistal | From the tip of an appendage to where it joins the body |
| Superficial | Near the outer surface |
| Ventral | Abdomen of an individual |
| Visceral | Associated with organs within the body’s cavities |
| Abduction | A motion that pulls a structure or part away from the midline of the body |
| Adduction | A motion that pulls a structure or part towards the midline of the body. |
| Circumduction | The circular movement of a body part, such as a ball-and-socket joint or the eye. |
| Dorsiflexion | Flexion of the entire foot, as if taking one’s foot off an automobile pedal. |
| Extension | A straightening movement that increases the angle between body parts |
| External (or Lateral) Rotation | A rotation of the shoulder or hip that would turn the toes or the flexed forearm outwards. |
| Flexion | Bending movement that decreases the angle between two parts |
| Internal (or Medial) Rotation | A rotation of the shoulder or hip that would point the toes or the flexed forearm inwards. |
| Opposition | A motion involving a grasping motion of the thumb and fingers |
| Plantar flexion | Flexion of the entire foot, as if pressing an automobile pedal. Occurs at ankle |
| Pronation | A rotation of the forearm that moves the palm to a facing down position |
| Protrusion | The anterior movement of an object. This term is often applied to the jaw |
| Protraction | Anterior movement of the arms at the shoulders |
| Reposition | To release an object by spreading the fingers and thumb |
| Retraction | Posterior movement of the arms at the shoulders |
| Retrusion | Opposite of protrusion, moving a part posteriorly |
| Rotation | A motion that occurs when a part turns on its axis. The head rotates on the neck |
| Supination | A rotation of the forearm that moves the palm to a facing up position |
| Laboratory Tests | Tests performed in a medical laboratory including blood test and urine tests. |
| Radiography (X-ray) | The making of film records (radiographs) of internal structures of the body by passage of x-rays or gamma rays through the body to act on specially sensitized film. |
| Magnetic Resonance Imaging (MRI) | A test that provides pictures of organs and structures inside the body by using a magnetic field and pulses of radio wave energy |
| Computerized Tomography | A special radiographic technique that uses a computer to assimilate multiple x-ray images into two dimensional cross-sectional images. This can reveal many soft tissue structures not shown by conventional radiography |
| Electromyography (EMG) | A test which measures muscle response to nerve stimulation |
| Nerve Condition Studies | Measure how well individual nerves can transmit electrical signals |
| Myelography | A diagnostic procedure where a radiopaque contrast dye is injected into |
| Arthroscopy | The introduction of a thin fiber optic scope into a joint space to allow direct visualization of internal structures |
| Electrocardiogram (EKG) | The recording of the electrical activity of the heart on a moving strip of paper |
| Electroencephalography (EEG) | The recording of the electric currents developed in the brain, by means of electrodes applied to the scalp, to the surface of the brain or placed within the substance of the brain |
