CLA Combo Health & Disability Sec 11

THE MAXIMUM AMOUNT PAYABLE IN ONE SUM IN TH EVENT OF ACCIDENTAL DISMEMBERMENT

ONCE THE INSURED HAS MET THEIR DEDUCTIBLE, THE INSURED AND INSURER SHARE IN AN AGREED PROPORTION OF COVERED EXPENSES. MAJOR MEDICAL AND PPO's' AND POS HAVE THIS

IN LEGAL TERMS, CONSIDERATION IS AN EXCHANGE OF SOMETHING OF VALUE ON WHICH A CONTRACT IS BASED

THIS IS THE AMOUNT THE INSURED MUST PAY OF COVERED EXPENSES BEFORE THE INSURER WILL PAY

A LIMITED HEALTH POLICY THAT PROVIDES COVERAGE ONLY FOR A CERTAIN SPECIFIED DISEASE SUCH AS CANCER

A TYPE OF DEDUCTIBLE FOUND IN DISABILITY INCOME POLICIES WHICH REFERS TO THE PERIOD OF TIME THAT MUST EXPIRE AFTER THE ONSET OF AN ACCIDENT OR ILLNESS BEFORE BENEFITS ARE PAYABLE UNDER THE POLICY

THE PERIOD OF TIME AFTER A PREMIUM IS DUE IN WHICH A PAYMENT MAY STILL BE MADE WITHOUT A LAPSE IN COVERAGE

THE CLAUSE IN A POLICY THAT SPECIFIED IN BRIEF THE CONTRACT'S INTENT (PROMISE). IT IS USUALLY THE INITIAL (FIRST) POLICY CLAUSE

THE PROBABILITY OR FREQUENCY OF ACCIDENT OR SICKNESS WITHIN A GIVEN GROUP OF PEOPLE

THIS POLICY PROVISION STATES THAT ONLY ILLNESS AND INJURY THAT HAPPEN OFF THE JOB ARE COVERED

THIS POLICY PROVISION STATES THAT ILLNESS AND INURY THAT OCCURS BOTH ON AND OFF THE JOB ARE COVEREED

A CONDITION IN WHICH (1) MORE INSURANCE IS IN FORCE ON THE INSURED OR THE RISK THAN THE POTENTIAL OF LOSS OR (2) SO MUCH INSURANCE IS IN FORCE AS TO CONSTITUTE A MORAL OR MORALE HASZARD.

AN ILLNESS OR MEDICAL CONDITION THAT EXISTED PRIOR TO THE POLICY'S EFFECTIVE DATE; USUALLY EXCLDED FROM COVERAGE FRO A PERIOD OF TIME

THE AMOUNT THAT IS PAYABLE AS A DEATH BENEFIT IF DEATH IS DUE TO AN ACCIDENT IN A DIABILITY POLICY. THE BENEFIT SETTLES LUMP SUM.

IS BASICALLY A ONETIME WAIT THAT BEGINS AFTER THE EFFECTIVE DATE OF THE COVERAGE

AN ILLNESS THAT FIRST MANIFESTS ITSELF WHILE THE POLICY IS IN FORCE

A MAXIMUM DOLLAR AMOUNT THAT MUST BE SHARED ON A COINSURANCE BASIS TO LIMIT INSURED'S OUT OF POCKET EXPENSE. ONCE THIS LIMIT HAS BEEN MET DTHE INSURER PAYS 100% OF THE COVERED EXPENSES FOR THE REMAINDER OF THE YEAR

THE PERIOD OF TIME AN EMPLOYEE MUST WAIT BEFORE THEY ARE ELIGIBLE TO ENROLL IN THE GROUP PLAN

THE INSURER WAIVES PREMIUM PAYMENTS AFTER THE INSURED HAS BEEN TOTALLY DISABLED (AS DEFINED IN THE POLICY) FOR A SPECIFIED PERIOD OF TIME USUALLY THREE OR SIX MONTHS

A FLAT DOLLAR AMOUNT (COULD BE PERCENTAGE) OF THE COST OF CARE PAID BY THE INSURED BEFORE SERVICE IS RENDERED

A MODEL OF HMO AND PPO ORGANIZATIONS THAT USES THE INSURED'S PRIMARY CARE PHYSICIAN (THE GATEKEEPER) AS THE INITIAL CONTACT FOR THE PATIENT'S MEDICAL ARE AND FOR REFERRALS

A SYSTEM THAT IMPOSES CONTROLS ON THE USE OF HEALTH CARE SERVICES. COMMON MANAGED CARE PLANS ARE HMO, PPO, AND EPO

AN ORGANIZATION THAT PROVIDES HEALTH COVERAGE BY CONTRACTING WITH PROVIERS TO PROVIDE MEDICAL SERVICES TO SUBSCRIBERS WHO PAY IN ADVANCE THROUGH PREMIUMS. COMMON PROVIDERS BLUE CROSS, BLUE SHIELD, AND HMO'S

IN MAJOR MEDICAL PROLICIES, ALLOWING AN INSURED WHO HAS SUBMITTED NO CLAIMS DURING THE YEAR TO APPLY ANY MEDICAL EXPENSES INCURRED IN THE LAST THREE MONTHS OF THE YEAR TOWARD THE NEW CALENDAR YEAR'S DEDUCTIBLE.

A FAMILY DEDUCTIBLE CAN BE ONE LARGE DEDUCTIBLE THAT THE ENTIRE FAMILY'S COVERED MEDICAL EXPENSES APPLY TO

THIS PROVISION STATES THAT IF THE INSURED DID NOT HAVE ENOUGH IN COVERED MEDICAL EXPENSES TO MEET THEIR OWN DEDUCTIBLE THEY COULD TAKE THE MEDICAL EXPENSES INCURRED IN THE LAST 3 MONTHS OF THE YEAR AND CARRY THEM INTO THE NEXT YEAR

THE DEDUCTIBLE THAT MUST BE PAID ONCE THE BASIC PLAN BENEFITS HAVE BEEN EXHAUSTED BEFORE THE SUPPLEMENTAL MAJOR MEDICAL BEGINS COVERING EXPENSES

IN LONG TERM CARE IF THE INSURED CAN GO 180 DAYS WITHOUT NEEDING SERVICES THE AMOUNT OF BENEFITS THAT HAD BEEN PAID OUT WILL BE RESTORED TO THE POLICY AS THOUGH THERE HAD BEEN NO CLAIM

AN OUTSIDE FIRM THAT PROVIDES ADMINISTRATIVE SERVICES SUCH AS PROCESSING ELIGIBILITY AND CLAIMS FOR A SELF-FUNDED PLAN

THIS MEANS THAT THE EMPLOYEE AND EMPLOYER SHARE IN THE PREMIUM COSTS. THIS PLAN REQUIRES 75% OF THE ELIGIBLE EMPLOYEES TO BE ENROLLED.

ALL GROUP POLICIES MUST OFFER THIS WHEN THE GROUP COVERAGE IS TERMINATED TO AN INDIVIDUAL POLICY. THE COVERED MEMBER/EMPLOYEE MUST CONVERT WITHIN 31 DAYS OF BEING TERMINATED FROM THE PLAN THEN NO PROOF OF INSURABILITY WILL BE REQUIRED

IN GROUP INSURANCE PLANS, WHEN A POLICY IS TERMINATED, THIS WILL PROVIDE BENEFITS FOR UP TO 12 MONTHS OF ANY TOTALLY DIABLED EMPLYEE OR DEPENDENT, WHEN CLAIMED PRIOR TO TERMINATION.

SOMETIMES REFERRED TO AS THE MASTER CONTRACT. IT IS ISSUED TO THE EMPLOYER UNDER A GROUP PLAN.

ANY GROUP FORMED FOR A REASON OTHER THAN TO OBTAIN INSURANCE

EMPLOYEE BENEFIT PLAN UNDER WHICH THE EMPLOYER BEARS THE FULL COST OF EMPLOYEE'S BENEFITS. THIS PLAN REQUIRES 100% OF ELIGIBLE EMPLOYEES TO BE ENROLLED.

A SELF-INSURED GROUP QUALIFIES FOR STOP-LOSS COVERAGE AFTER THE CLAIMS EXCEED A SPECIFIC LIMIT FOR A SET PERIOD OF TIME