Disability Insurance Quotes & Rates from Brokers: Glossary


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Disability Insurance Quotes & Rates from Brokers: Glossary
When your researching information on disability insurance quotes and policies, some of the terminology may not be familiar to you. Use this glossary of terms to help you understand disability insurance terminology.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Click on the desired letter to see the glossary terms that start with chosen letter.

Accelerated Benefits	Benefits available prior to death, to help pay the costs of long-term care or terminal illness. Life insurance riders which allow the policy's death benefits to offset expenses incurred in a convalescent or nursing home facility.
Access	Availability of medical care. Determined by availability of transportation, location, type of medical services in the area, etc.
Accident Insurance	Insurance against loss by accidental bodily injury to the insured.
Accidental Death and Dismemberment	Policy or provision in a Disability Income policy that pays a specified amount or a multiple of the weekly disability benefit should the insured die, lose his sight, or lose two limbs as the result of an accident. Lesser amount is payable for the loss of one eye, arm, leg, hand, or foot.
Accidental Death Benefit	Extra benefit that, in general, equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident. A provision added to a life insurance policy for payment of an additional benefit if death is caused by an accident. Sometimes called "double indemnity."
Accidental Death Insurance	Form of insurance providing payment if the death of the insured results from an accident. Often combined with Dismemberment Insurance in a form called Accidental Death and Dismemberment.
Accrete	Medicare term meaning the process of adding new members to a health plan.
Actively-At-Work	Depending upon the policy, if an employee is not actively at work on the day the policy goes into effect, coverage does not begin until the employee returns to work.
Activities of Daily Living	Activities performed by individuals without assistance in the course of day to day living that include mobility, dressing, personal hygiene and eating.
Activities of Daily Living Standards	Standards assessing the ability of an individual to live independently, measuring the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. Standards are often discussed as a measurement or definition of eligibility for long term care.
Actual Charge	Actual amount charged by a physician for medical services.
Acute Care	Medically necessary, skilled care provided by nursing and medical personnel to restore a person to good health.
Additional Drug Benefit List	Prescription drugs listed as commonly prescribed for patients' long-term use. Subject to review and revision by the health plan involved. Also referred to as drug maintenance list.
Additional Monthly Benefit	Riders added to disability income policies to providing additional benefits for the first year of a claim while the insured is waiting for commencement of Social Security benefits.
Adjusted Average Per Capita Cost	Estimated average cost of Medicare benefits established on county basis. Factors include age, sex, Medicaid, institutional status, disability, and end stage renal disease status. Determines Medicare benefits payments to cost contractors.
Adjusted Community Rating	Community rating adjusted by factors that are specific to a particular group. Also referred to as factored rating.
Admits	Number of admissions to a hospital (includes outpatient and inpatient facilities).
Adult Day Care	Group program for functionally impaired adults. Meets health, social and functional needs in a setting other than adult's home.
Aftercare	Patient services, customized to the individual, required after hospitalization or rehabilitation.
Age Change	For insurance purposes, date that a person's age changes. In majority of Life Insurance contracts, defined as the date midway between the insured's natural birth dates. For Health Insurance purposes, the age of the previous birth date is frequently used for rate determinations. Based upon the rating structure of the particular insurer, on the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date.
Age/Sex Factor	A measurement is used in underwriting; comparing the age and sex risk of medical costs of one group in relation to another. Higher than average risk of medical costs due to that factor is indicated by age/sex factor above 1.00. Conversely, a factor below 1.00 indicates lower than average risk.
Agent	An authorized representative of an insurance company who sells and services insurance contracts.
Annuity	A contract between a private individual and a life insurance company. The individual pays a sum of money that is invested and in return the insurance company makes periodic payments to the individual as specified in the contract. Annuities are primarily used as a vehicle for retirement income.

Base Capitulation	Total amount covering cost of health care per person, minus mental health or substance abuse services, pharmacy, and administrative charges.
Basic Hospital Expense Insurance	Benefits provided by hospital coverage for room and board and miscellaneous hospital expenses for specified number of days during hospital confinement.
Beneficiary	The person or entity, such as a trust fund, named in a life insurance policy as the recipient of policy proceeds in the event of the policyholder's death.
Benefit Levels	Maximum amount a person is entitled to receive for particular services as described in the contract with insurer or health plan.
Benefit Package	Description of services offered by insurer or health plan to those covered under the terms of health insurance contract.
Benefit Period	Period during which Medicare beneficiary is eligible for Part A benefits. Benefit period is 90 days, beginning the day of patient's admission to hospital and ending when individual has not been hospitalized for a period of 60 consecutive days.
Billed Claims	Amounts submitted by health care provider for services provided to a covered individual.
Birthday Rule	A method determining which parent's medical coverage is primary for dependent children: parent whose birthday falls earliest in the year is considered to have primary plan.
Blanket Insurance	Health Insurance contract covering all of a class of persons not individually identified in the contract.
Blanket Medical Expense	Policy or provision in Health Insurance contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except for possibly a maximum aggregate benefit under the policy. Frequently written with an initial deductible amount.
Board Certified	Physician or other professional who has passed an examination certifying him as a specialist in a particular medical area.
Board Eligible	Professional person or physician eligible to take a specialty examination.
Business Overhead Expense	Disability income policy indemnifying the business for specified overhead expenses incurred should the business owner become totally disabled.
Calendar Year	January 1 through December 31 of the same year. Under major medical plans, many deductible amount provisions are on based a calendar year. Benefits under basic hospital surgical and medical plans are based on an amount per calendar year.
Capitulation	A rate paid to health care provider, usually monthly. The provider agrees to deliver health services as agreed upon to covered person.
Carrier	Commercial insurer contracted by the Department of Health and Human Services to process payment of Part B claims.
Carrier Replacement	A situation where one carrier replaces another carrier or carriers.
Carry Over Provision	For major medical policies, an insured who has submitted no claims during the year can apply any medical expenses incurred in the last three months of the year toward the next calendar year's deductible.
Case Management	Assessment of a person's long term care needs and followed by appropriate recommendations for care, monitoring and follow-up as applies to extent and quality of services to be provided.
Case Manager	Person, usually experienced professional, who coordinates services necessary for case management approach.
Case Mix	Number of cases requiring different hospital resources.
Cash Value	The amount available in cash when surrendering a permanent life insurance policy before it becomes payable upon death or maturity.
Catastrophic Disability	The total, permanent and irrevocable loss of speech, hearing in both ears, the sight of both eyes or the use of both legs, both arms, or one leg and one arm, due solely to a sickness or injury.
Certificate of Authority	State issued licensing the operation of an HMO (Health Maintenance Organization).
Certificate of Need	Government issued certification that the proposed facility meets the needs of those for whom it is intended. The need may involve constructing a new health facility, offering new or different health services, or acquiring new medical equipment.
Chemical Dependency Services	Services required for treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.
Closed Access	Situation in which covered the insured must select a sole primary care physician. This physician is the only one to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper.
COB	Coordination of Benefits. See Non-duplication of Benefits.
COBRA	See Consolidated Omnibus Budget Reconciliation Act of 1986.
Cognitive Impairment	Deficiency in ability to think, perceive, reason or remember. Results in loss of ability to attend to one's daily living needs.
Coinsurance Clause	Provision stating that insured and insurer will share all losses covered by the policy in a previously agreed upon proportion, i.e., 80-20 means the insurer would pay 80% and the insured would pay 20% of all losses. See also Percentage Participation.
Competitive Medical Plan	Refers to permission given by the federal government allowing an organization to write a Medicare risk contract.
Composite Rate	One rate covering all members of the group regardless of their family status.
Comprehensive Major Medical	Insurance plan that has a low deductible, high maximum benefits, and a coinsurance feature. A combination of basic coverage and major medical coverage that has replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.
Conditionally Renewable	Contract providing the insured may renew it to a stated date or an advanced age, that is subject to the right of the insurer to decline renewal only under conditions as previously stated in the contract.
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986	Legislation providing a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may continue up to 36 months in other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.
Continuation	Terminated employees are allowed to continue their group health insurance coverage under certain conditions.
Contract Year	The period running from effective date to expiration date of contract.
Coordination of Benefits	Group policy provision that determines the primary carrier in situations when insured is covered by multiple policies. Prevents insured from receiving claims or an overpayment.
Co-pay	Arrangement where covered person pays a specified amount for specified services and health care provider pays remainder. Covered person usually pays his or her share when service is rendered. Unlike coinsurance which is a percentage, co-payment is a dollar amount.
CO-pay Provision	Often used with major medical policies. CO-pay provision states percentage of a claim the company will pay and percentage the insured will pay. Example, an 80% CO-pay provision the insurer pays 80% of claims and the insured pays 20%.
Corridor Deductible	Major Medical deductible providing for a deductible, or "corridor," after full payment of basic hospital and medical expenses to a stated amount. If further expenses are incurred, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and deductible is portion paid by the insured.
Cost of Living Benefit	Optional disability benefit where monthly benefit is increased annually once insured is on claim for 12 months.
Cost Sharing	Covered persons pay a portion of the health costs such as deductibles, coinsurance, or CO-payment amounts.
Covered Expenses	Health care expenses incurred by covered person that qualify for reimbursement under a policy contract.
Covered Person	Person who pays premiums to the contract for benefits provided and also meets eligibility requirements.
Custodial Care	Care primarily for meeting personal needs such as assistance in bathing, dressing, eating or taking medicine. Can be provided by someone without professional medical.
Date of Service	The date health service was provided.
Death Benefit	The amount paid to the beneficiary or beneficiaries of a life insurance policy if an insured dies.
Death Spiral	Potentially destructive cycle that occurs in an indemnity plan as a result of increased HMO penetration. Process occurs if indemnity plan rates continuously increase because healthier and younger employees choose HMOs, leaving less healthy individuals in experience-rated indemnity plans. Employer contribution strategies and HMO pricing techniques add to the problem.
Deductible Carryover Credit	During the last three months of calendar year, charges incurred for services can be applied the deductible for the following calendar year. Credits may be applied whether or not the prior calendar year's deductible is met.
Deferred Compensation Administrator	A company providing services under deferred compensation plan. Services include administration of self-insured plans, salary surveys, compensation planning, retirement planning, etc.
Delete	The process of taking an individual off Medicare coverage.
Dental Insurance	A Health Insurance contract that provides payment for specified dental services.
Dependent Coverage	Insurance coverage on the head of a family which is extended to his or her dependents, including only the lawful spouse and unmarried children who are not yet employed on a full-time basis. "Children" may be step, foster, and adopted, as well as natural. Certain age restrictions on children usually apply.
Designated Mental Health Provider	Organization hired by health plan to provide mental health and substance abuse services.
Diagnosis	Disease identification.
Diagnosis Related Groups	Classification of inpatient hospital services. Used as method of determining financing to reimburse providers for services performed.
Disability	A condition due to sickness or injury that curtails a person's ability to carry on normal pursuits. A disability may be partial or total, and temporary or permanent as verified by a doctor.
Disability Benefits Law	State law requiring employer to provide disability benefits to covered employees for non-occupational injuries. This is in contrast to Workers Compensation, which pays for occupational injuries. Laws are currently in effect in New York, New Jersey, Rhode Island, California, and Hawaii.
Disability Income Insurance	Form of health insurance providing periodic payments to replace income, actual or presumed loss, when sickness of injury results in the insured being unable to work. Provides periodic pay-outs when an insured is unable to work due to illness or injury as verified by a doctor.
Discharge Planning	Determination of the extent of patient's medical needs after discharge from a hospital or other inpatient treatment.
Dismemberment	Loss of, or loss of use of, specified members of the body resulting from accidental bodily injury.
Dismemberment Benefit	Benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment and Multiple Indemnity.
Dividend	In life insurance, an amount of money returned to the holder of a policy. The money is a partial refund of the premium paid. Dividends are received when interest and expenses were more favorable than expected at the time the premiums were set.
Dread Disease Policy	Coverage, usually with a high maximum limit, for all of medical expenses as a result of diseases specified in the contract. Diseases covered are multiple sclerosis, poliomyelitis, spinal meningitis, diphtheria, and tetanus. Cancer is may be covered or added with some companies by a rider.
Drug Formulary	Schedule of prescription drugs approved for use that will be covered by the plan. These are then dispensed through participating pharmacies.
Drug Price Review	Determination of drug price maximums. It involves determining wholesale drug prices based on the American Druggist Blue Book.
Drug Utilization Review	Evaluation or review of the use of drugs in order to determine appropriateness of drug therapy.
Dual Choice	Federal requirement for employers having 25 or more employees and within the service area of a federally qualified HMO, paying at least minimum wage and offering a health plan to their employees, must offer HMO coverage as well as an indemnity plan.
Duplicate Coverage Inquiry	Request to determine whether or not other coverage exists. For use in applying the coordination of benefits provisions when two or more insurance companies are involved.
Duplication of Benefits	Identical or overlapping coverage exists between two or more insurance companies or service organizations.
Elective Benefits	Lump sum payments that the insured may choose in lieu of periodic payments for certain injuries.
Eligibility Date	Date a person becomes eligible for benefits.
Eligibility Period	(1) Period of time during which potential members of a Group program may enroll without providing evidence of insurability. (2) Period of time under Major Medical policy during which reimbursable expenses may be accrued.
Eligibility Requirements	Requirements imposed for coverage eligibility, usually in a group insurance or pension plan.
Eligible Dependent	Dependent of insured person eligible for coverage according to the requirements in the contract.
Eligible Employee	Employee who is eligible based on the requirements detailed in the group contract.
Eligible Expenses	Expenses, defined in the plan, that are eligible for coverage. May involve specified health services fees or "customary and reasonable charges."
Eligible Person	Similar to eligible employee, however the contract may cover people who are not employees of a specified employer. An example might be members of an association, union, etc.
Elimination Period	The number of days of disability that must go by during a period of disability before benefits become available. Sometimes designates the probationary period, but most often states the waiting period in a Health Insurance policy.
Emergency	Injury or disease that happens suddenly and requires treatment within 24 hours.
Emergency Accident Benefit	Group medical benefit reimbursing the insured for expenses incurred for emergency treatment of accidents.
Employee Benefit Program	Benefits offered to an employee by his employer at his place of work, covering contingencies such as medical expenses, disability, retirement, and death, paid for wholly or in part by the employer. These benefits are usually insured.
Employee Certificate of Insurance	Employee's evidence of participation in a group insurance plan; a brief summary of plan benefits. The employee is provided with a certificate of insurance in lieu of the actual insurance policy.
Employee Contribution	Employee's share of premium costs.
Employer Contribution	Portion of the cost of a health insurance plan that is paid by the employer.
Enrollee	Eligible individual enrolled in a health plan; does not include eligible dependent.
Enrolling Unit	Organization (such as employer) that contracts for participation in a health insurance plan.
Enrollment	Total number of enrollees in a health plan. May also be used to refer to the process of enrolling people in a health plan.
Enrollment Period	Amount of time an employee has to sign up for contributory health plan.
Evidence of Insurability	Statement of information needed for underwriting of an insurance policy.
Evidence of Insurance	Medical exams or test required by an insurer before an applicant can purchase an individual life insurance policy.
Exclusive Provider Organization	Preferred provider organization where individual members use specific preferred providers rather than having a choice of preferred providers. EPOs are characterized by a primary physician who monitors care and makes referrals to a network of providers.
Expected Claims	Estimated claims for a person or group for a contract year based on actuarial statistics.
Expected Morbidity	Expected incidence of sickness or injury within a group during a period of time as shown on a morbidity table.
Experimental or Unproved Procedures	Health care services, supplies, procedures, therapies, or devices that the health plan determines to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.
Explanation of Benefits	Statement sent to participant listing services, amounts paid by the plan, and total amount billed to the patient.
Extended Care Facility	Facility, such as a nursing home, which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care are defined as: skilled, intermediate, custodial, or any combination.
Extended Coverage	Provision in Health policies, usually Group, to allow the insured to receive benefits for specified losses sustained after the termination of coverage, such as maternity expense benefits incurred for a pregnancy in progress at the time of the termination.
Face Amount	The amount stated on the face of a life insurance policy to be paid in the case of death or policy maturity. It does not include dividends or additional amounts payable under accidental death or other special provisions.
Family Dependent	Person entitled to coverage because they are: 1) Enrollee's spouse, or 2) Single dependent child of either the enrollee or the enrollee's spouse (including stepchildren or legally adopted children), and 3) Resident of the enrollee's home.
Family Expense Policy	Policy insuring medical expenses of all members of a family.
Fee Maximum	Maximum amount available to a provider for health care services specified in a contract.
Fee Schedule	List of maximum fees for providers on a fee-for-service basis.
Fee-for-Service Equivalency	Difference between amount a provider receives from a reimbursement system such as capitulation (a flat charge per month, for instance) compared to fee-for-service reimbursement.
Fee-for-Service Reimbursement	Health care system where physicians and providers receive payment based on billed charge for each service provided.
Field Underwriting	Initial screening "in the field" of prospective buyers of health insurance, performed by sales personnel. Also may include quoting of premium rates.
Flat Maternity Benefit	Stated benefit in a policy that is paid for maternity confinement, regardless of the actual cost of the confinement.
Flexible Benefit Plan	Program where employees tailor their benefits to meet their specific needs.
Franchise Insurance	Plan for covering groups of persons with individual policies having uniform provisions, although policies may differ in benefits. Each person is issued an individual contract with individual underwriting. Usually applied to groups too small to qualify for true group coverage, and solicitation usually takes place among an employer's work force with his consent.
Frequency	Number of times a particular service is provided over a given time period.
Funding Level	Dollar amount required to purchase a particular program. Measured by the premium rate for an insured program, or amount assessed for expected claim loss and related fees under self-funded program.
Funding Methods	Agreed means by which an employer pays for health coverage.
Gatekeeper Model	Under this model of HMO and PPO organizations, primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. Also known as closed access or closed panel.
General Agent	Individual appointed by Health insurer to administer its business in a territory. Responsible for building his own agency and service force. Compensated on commission basis, although possibly has some additional expense allowances.
General LTC Rider	LTC (Long Term Care) rider attached to a life insurance policy but is independent of the life policy. The life insurance benefits are not reduced by any LTC benefits paid.
Generic Drug	Drug that is exactly the same as a brand name drug and is allowed to be produced after the brand name drug's patent has expired. Also known as "generic equivalent."
Grace Period	A period (usually 30 or 31 days) following each insurance premium due date during which an overdue premium may be paid. All provisions of the policy remain in force throughout this period.
Grievance Procedure	Procedure allowing member of a health plan or provider of benefits to express complaints and seek remedies.
Group	Coverage of a number of individuals under one contract. Commonly the group is employees of the same employer.
Group Certificate	Document provided to each member of a group plan. It details benefits provided under the group contract issued to the employer or other insured.
Group Contract	Contract of insurance made with an employer or other entity covering a group of persons identified by their relationship to the entity buying the contract. Generally used to cover employees of a common employer, members of a trade association or trusteeship, members of a welfare or employee benefit association, members of a labor union, or members of a professional or other association not formed only for the purpose of obtaining insurance.
Group Disability Insurance	Coverage provided for a group for loss of compensation due to accident or sickness.
Group Model HMO	Health plan where designated group of physicians is reimbursed for services provided at a negotiated rate. HMO also contracts with hospitals for the care of patients of physicians who belong to the group.
Health Benefits Package	Coverage offered by a health plan.
Health History	Form used by underwriters to evaluate groups or individuals to determine the risk.
Health Insurance	Insurance against loss by sickness or bodily injury.
Health Maintenance Organization	A prepaid medical service plan providing services to plan members. Providers contract with the HMO to provide medical services to members. Contracted providers must be used. Emphasis is on preventive medicine.
Health Plan	Any kind of plan covering health care services such as HMOs, insured plans, preferred provider organizations, etc.
Health Services	Benefits covered under a health contract.
Home Health Agency	Certified facility approved by health plan to provide services.
Home Health Care	Care received at home in the form of part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or chore workers.
Hospice	Organization providing primarily pain relief, symptom management and supportive services for the terminally ill and their families.
Hospital Affiliation	Contract with one or more hospitals agreeing to provide benefits to members of a specific health plan.
Hospital Alliances	Group of hospitals working together sharing common services and thereby reducing health costs. They are better able to compete with other alliances or chains.
Hospital Benefits	Benefits payable for hospital room and board, and miscellaneous charges as a result of hospitalization.
Hospital Income Insurance	Form of insurance providing stated weekly or monthly payment during hospitalization of insured regardless of expenses incurred and whether or not other insurance is in force.
Hospital Indemnity	Coverage pays based on daily, weekly, or monthly limits regardless of the amount of actual hospital expenses.
Hospitalization Expense Policy	Policy covering daily hospital room and board charges and miscellaneous hospital expenses (such as X-ray, etc.). Often covers emergency treatment charges and may also include a surgical benefit.
Hospitalization Insurance	Form of insurance providing reimbursement within contractual limits for hospital and specific related expenses arising from hospitalization caused by injury or sickness.
Identification Card	Card given to each person covered under the plan which identifying them as eligible for benefits.
In-Area Services	Services provided within the "authorized" service area as specified in the plan.
Individual Contract	Contract with an individual covering that individual and perhaps specified members of his family.
In-Force Business	Life or Health Insurance for which premiums are being paid or have been fully paid. Total premium volume of an insurer's portfolio of business.
Initial Eligibility Period	During this time period, prospective members can apply for coverage without providing evidence of insurability.
Injury	In a disability insurance policy, an accidental bodily injury which occurs while the policy is in force.
Inside Limits	Limits placed on hospital expense benefits modifying benefits from the overall maximums stated in the policy. When applied to room and board, limits not only maximum amount payable, but also the number of days the benefit will be paid.
Insurance In Force	Annual premium payable on current contracts of insurance.
Insured	The person on whose life or disability an insurance policy is issued.
Intentional Injury	Injury resulting from an act, the doer of which intended to inflict injury.
Intermediate Care	Level of care associated with skilled nursing facility providing nursing care under the supervision of physicians or a registered nurse.
Intermediate Care Facility	Facility licensed by the state providing nursing care to persons who do not require the degree of care provided by a hospital or skilled nursing facility.
Intermediate Report	Claim report on the condition of a continuing disability.
Invalidity	Sickness.
Lapsed Policy	An insurance policy terminated at the end of the grace period because premiums were not paid.
Large Claim Pooling	System designed to stabilize the premium fluctuation in small groups. Large claims are charged to a pool with contributions from many small groups who belong and share in the pool. The smaller the group of groups, the lower the pooling level. Conversely, larger groups will have a larger pooling level.
Legend Drug	Drug with the following stated on its label "caution: federal law prohibits dispensing without a prescription."
Length of Stay (LOS)	Total number of days participant stays in care facility such as a hospital.
Long-Term Care (LTC)	Care provided for persons with chronic diseases or disabilities. Includes a range of health and social services provided under the supervision of medical professionals.
Long-term Care Facility	State licensed facility providing skilled nursing services, intermediate care and custodial care.
Long-term Care Insurance	An insurance that covers nursing care and assisted living expenses if a chronic illness or disability leaves an insured unable to care for themselves.
Long-term Disability Income Insurance	Long-term Disability Income Insurance is designed to provide benefits for a long duration such as 2 years, 5 years, or in some cases up to age 65. The elimination period for this policy is usually 90 or more days.
Long-term Disability Insurance	Policy providing coverage for longer than a short term, usually until the insured reaches age 65.
Loss of Income Insurance	Insurance paying loss of income benefits.
Loss-Of-Income Benefits	Benefits paid as remuneration for inability to work due to disability resulting from accidental bodily injury or sickness.
Major Hospitalization Policy	Same as Major Medical Insurance, except applies to expenses incurred only when insured is hospitalized. See also Major Medical Insurance.
Major Medical Insurance	Health Insurance providing benefits up to a high limit for most types of medical expenses incurred, subject to a substantial deductible. Contracts may contain limits on specific types of charges, like room and board, and a percentage participation clause (coinsurance clause). Policies usually pay covered expenses whether an individual is in or out of the hospital.
Managed Care	System of health care with the goal being a system delivering quality, cost effective health care through monitoring and recommending utilization of services, and cost of services.
Managed Health Care Plan	Plan involving financing, managing, and delivery of health care services. Typically, involves a group of providers sharing the financial risk of the plan or who having incentive to deliver cost effective, but quality, service.
Mandated Benefits	State or federally required benefits.
Mandated Providers	Medical care providers whose services must be included by state or federal law.
Manual Rates	Rates based on average claims data for large number of groups. Rates are adjusted for specific groups based on a particular group's characteristics, such as the type of industry, changes in benefits from the standard, etc.
Maximum Allowable Costs List	List of prescriptions where reimbursement is based on cost of comparable generic product.
Maximum Disability Policy	Non-cancelable Disability Income Insurance limiting insurer's liability for any one claim but not the aggregate amount of all claims. For any one claim there is a maximum amount payable, but there could be any number of separate claims for different disabilities.
Maximum Out-of-pocket Costs	Largest amount insured will pay considering co-payments, coinsurance, deductibles, etc.
Medical Expense Insurance	Health Insurance providing benefits for medical, surgical, and hospital expenses. Include coverage under the names Hospital-Surgical Expense Insurance and Medical Care Insurance.
Medical Loss Ratio	Total health benefits divided by total premium.
Medical Supplies	Items essential in treating a patient's illness or injury.
Medically Necessary	Service or treatment deemed absolutely necessary in treating a patient and the omission of such could adversely affect the patient's condition.
Member	Person covered under a health plan (enrollee or eligible dependent).
Member Certificate	Term for certificate of coverage.
Member Month	Monthly total number of participants who are members.
Members Per Year	Number of member months divided by 12.
Mental Health Services and Supplies	Required for treatment of mental illness, which include substance abuse and alcoholism.
Minimum Premium	Cost plus arrangement with the employer paying the insurer only a portion of the premium which to be used for administration costs. Remainder is placed in a "bank account" and then used by the insurer to pay claims.
Miscellaneous Expenses	Expenses, usually hospital charges other than daily room and board. Examples: X-rays, drugs, and lab fees. Total amount of these charges to be reimbursed is limited in most basic hospitalization policies.
Morbidity	Relative incidence of disease.
Morbidity Rate	Ratio of incidence of sickness to number of well persons in given group of people over defined period of time.
Morbidity Table	Table exhibiting incidence of sickness at specified ages in the same fashion that mortality table shows the incidence of death at specified ages.
Multi-disciplinary	Treatment involving care provided by a range of specialists.
Multiple Option Plan	Employees optionally choose from an HMO to a PPO to a major medical plan.
Non-cancelable	Health Insurance contract where the insured has a right to continue in force by payment of premiums, as set forth in the contract, for a substantial period of time, also as specified in the contract. The insurer has no right to make any change in any provision of the contract, during that period of time. It is recommended that the term "non-cancelable" not be permitted to be used to designate any form that is not renewable to at least age 50 or for at least five years if issued after age 44.
Non-disabling Injury	Injury not qualifying the insured for total or partial disability benefits.
Non-duplication of Benefits	Provision in some policies specifying benefits will not be paid for amounts reimbursed by others. Often called coordination of benefits (COB).
Non-Occupational Policy	Policy or provision of a policy excluding accidents that occur on the job, when such employment is covered by workers compensation.
Non-participating Provider	Provider who has not signed a contract with a health plan. Medical or health care provider who is not certified to participate in the Medicare program.
Non-participating Provider Indemnity Benefits	Services provided by nonparticipating providers are reimbursed under an indemnity basis.
Nurse Fees	Provision calling for reimbursement for fees of nurses other than those employed by the hospital.
Nursing Home	Licensed facility providing general nursing care to the chronically ill or those unable to take care of necessary daily living needs. Also known as Long Term Care facility.
Occupational Disease	Impairment of health which has been caused by continued exposure to conditions inherent in a person's occupation or a disease caused by employment or resulting from the nature of employment.
Office Visit	Health care services provided in the physician's office.
Open Access	Also called open panel, allows participant to see another participating service provider without a referral.
Open Enrollment Period	Period during which members elect to be included under an alternate plan, usually without providing evidence of insurability.
Optionally Renewable	Contract in which an insurer reserves the unrestricted right to terminate coverage at any anniversary or at any premium due date.
Out-of-pocket Costs	Amounts insured must pay out of their own pocket, including such things as coinsurance, deductibles, etc.
Out-of-pocket Limit	Maximum coinsurance insured is required to pay, after which the insurer will pay 100% of covered expenses up to policy limit.
Outpatient	One who is not a bed patient in the hospital in which they are receiving treatment.
Over-the-counter Drugs	Drug that can be purchased without a prescription.
Paid Business	Policy once the application has been signed, the medical examination completed, and the settlement for the premium tendered.
Paid Claims	Amounts paid to providers based on plan.
Paid Claims Loss Ratio	Calculated as paid claims divided by total premiums.
Partial Disability	Definition varies by policy. A condition as a result of injury or sickness when the insured cannot perform all of the duties of his occupation but a portion of them.
Partial Hospitalization Services	Additional services provided to mental health or substance abuse patients providing outpatient treatment as an alternative or follow-up to inpatient treatment.
Participant	Employee or former employee eligible to receive benefits from an employee benefit plan or whose beneficiaries may be eligible to receive benefits from the plan.
Participation	Number of employees enrolled compared to total eligible for coverage. Often, a minimum participation percentage is required.
Percentage Participation	Provision in contract stating that the insurer shares losses in an agreed proportion with the insured. Example: An 80-20 participation where the insurer pays 80% and the insured pays the 20% of covered losses. Many times erroneously referred to as coinsurance.
Permanent and Total Disability	Total disability from which the insured does not recover.
Permanent Life Insurance	A type of life insurance that includes both a death benefit and a cash value component.
Permanent Partial Disability