SS-Georgia Accident & Sickness Insurance – Exam Review

83 vocabulary flashcards summarizing key terms, provisions, and Georgia-specific regulations for the Accident & Sickness Insurance exam.

Disability policy that reimburses a business for ongoing operating expenses when a key person or owner becomes disabled.

Business Overhead Expense Policy

Policy that funds a buy–sell agreement by providing cash to purchase a disabled owner’s share of the business.

Business Disability Buyout Policy

Coverage that pays a lump-sum benefit for accidental death or the loss of sight, limb, or specified body functions.

Accidental Death and Dismemberment (AD&D)

First-dollar health policy with low limits and no deductible, covering hospital, medical, and often surgical expenses.

Basic Medical Expense Policy

Comprehensive health plan with broad benefits, high maximum limits, coinsurance, and a deductible.

Major Medical Policy

Managed-care plan emphasizing preventive care; members use network providers and typically require primary-care gatekeepers.

Health Maintenance Organization (HMO)

Network plan that offers greater choice of providers and pays reduced benefits for out-of-network services.

Preferred Provider Organization (PPO)

Hybrid of HMO and PPO that allows members to go outside the network at higher cost while still encouraging use of a primary doctor.

Point of Service (POS) Plan

Employer-established cafeteria-plan account that lets employees pay qualified medical expenses with pre-tax dollars.

Flexible Spending Account (FSA)

Medical plan with a large deductible that qualifies the participant to fund a Health Savings Account for tax advantages.

High Deductible Health Plan (HDHP)

Tax-advantaged account owned by an individual and paired with an HDHP to pay current or future medical expenses.

Health Savings Account (HSA)

Employer-funded account that reimburses workers for qualified medical expenses; unused amounts may roll forward.

Health Reimbursement Arrangement (HRA)

Private insurance that pays Medicare deductibles, coinsurance, and certain gaps in Parts A and B coverage.

Medicare Supplement (Medigap) Policy

Federal law allowing employees and dependents to continue employer group coverage after qualifying events such as job loss.

COBRA

Group insurance arrangement in which employees pay part of the premium, generally requiring at least 75% employee participation.

Contributory Group Health Plan

Basic self-care tasks (e.g., bathing, dressing) used to determine eligibility for Long-Term Care benefits when 2 or more cannot be performed.

Activities of Daily Living (ADLs)

Supplemental policy that pays a fixed dollar benefit per day of hospitalization, regardless of actual expenses.

Hospital Indemnity Plan

Limited-benefit plan (e.g., cancer or critical illness insurance) that pays for a named disease or condition only.

Specified Disease Policy

Temporary health coverage designed to fill gaps in insurance, usually lasting a few months up to a year.

Short-Term Medical Policy

States that the policy, application, and any riders constitute the complete agreement between insurer and insured.

Entire Contract Provision

Incontestability clause that prevents the insurer from voiding the policy for misstatements after a set period (typically 2 years).

Time Limit on Certain Defenses

Allows the insured extra time after the premium due date (e.g., 31 days) to pay without the policy lapsing.

Grace Period Provision

Gives the policyholder the right to restore lapsed coverage after non-payment, subject to conditions and possible waiting period.

Reinstatement Provision

Requires the insured to inform the insurer of a loss within a specified time (often 20 days) to start the claims process.

Notice of Claim Provision

Obligates the insurer to supply claim forms within a set time; if not, a written statement by the insured is acceptable.

Claim Forms Provision

Mandates that written evidence of loss be submitted (often within 90 days) for claim consideration.

Proof of Loss Provision

Explains how and to whom benefits are paid—medical benefits typically go directly to providers.

Payment of Claims Provision

Grants the insurer the right to examine the insured or request an autopsy, where permitted by law, at the insurer’s expense.

Physical Exam and Autopsy Provision

Sets a waiting period (e.g., 60 days after proof of loss) before the insured can sue and limits the time for legal action.

Legal Actions Provision

Allows the insurer to adjust benefits to what premiums would have purchased at the correct age rather than void coverage.

Misstatement of Age Provision

Permits benefit or premium adjustment if the insured changes to a more or less hazardous job, preventing overinsurance.

Change of Occupation Provision

Denies liability for losses occurring while the insured is committing or attempting an illegal act or engaged in illegal business.

Illegal Occupation Provision

Suspends future premium payments when the insured is totally disabled for a specified period, keeping the policy in force.

Waiver of Premium Rider

Lets the insured purchase additional coverage at stated intervals without evidence of insurability.

Guaranteed Insurability Rider

Hospital Insurance covering inpatient hospital, skilled nursing facility, home health, and hospice services.

Medicare Part A

Medical Insurance covering doctor visits, outpatient services, preventive care, and medical supplies.

Medicare Part B

Private plan alternative combining Parts A and B benefits, often with additional services, under Medicare rules.

Medicare Part C (Medicare Advantage)

Voluntary prescription drug coverage provided through private plans approved by Medicare.

Medicare Part D

Joint federal-state program offering health coverage, including long-term care, to eligible low-income individuals and families.

Medicaid

Federal income benefits payable if a disability is expected to last at least 12 months or result in death and prevents substantial work.

Social Security Disability Benefits

Pays a partial benefit when the insured returns to work but earns less income due to a disability.

Residual Disability Benefit

Ownership privileges such as naming beneficiaries, receiving dividends, and assigning or canceling the policy.

Policyowner Rights

Person (e.g., spouse, child up to specified age or full-time student) eligible for coverage under an insured’s health plan.

Qualified Dependent

First in line to receive policy proceeds upon the insured’s death.

Primary Beneficiary

Provision that determines the order of payment when an individual is covered by multiple health plans to avoid overpayment.

Coordination of Benefits (COB)

Health or disability insurance that includes injuries or illnesses that occur while working on the job.

Occupational Coverage

Insurance that covers only off-the-job injuries and illnesses, excluding workplace incidents.

Non-Occupational Coverage

Initial risk evaluation performed by the producer during solicitation, including completing the application and collecting premium.

Field Underwriting

If an error is made, the agent must have the applicant initial the change rather than altering or white-outing the form.

Application Error Correction

Federal regulation safeguarding individuals’ protected health information and limiting its disclosure.

HIPAA Privacy Rule

Non-profit organization that stores coded health data to help member insurers detect fraud and adverse selection.

Medical Information Bureau (MIB)

If no premium is received with the application, coverage is not in effect and the agent must collect payment upon delivery.

Collecting Initial Premium

Receipt stating coverage begins once premium is paid and the applicant meets all underwriting conditions.

Conditional Receipt

Agent’s duty to hand over the policy, explain benefits, riders, ratings, and obtain any outstanding signatures or premium.

Policy Delivery

Element of a legal contract; the insurer’s promise to pay and the insured’s statements plus premium constitute consideration.

Consideration

Contract element requiring the agreement’s objectives and performance to be lawful.

Legal Purpose

Contract requirement that both insurer and insured have legal capacity and authority to enter into the agreement.

Competent Parties

Elected official who enforces and regulates insurance laws in Georgia, serving a four-year term.

Georgia Commissioner of Insurance

In Georgia, the Insurance Commissioner is elected for a 4-year term.

Commissioner’s Term Length

Power of the Commissioner to inspect the books and records of all licensed insurers and producers.

Examination Authority

The Commissioner may impose fines, revoke licenses, or seek imprisonment for violations of insurance law.

Penalties for Violations (Georgia)

Insurance company formed under the laws of Georgia.

Domestic Insurer

Insurance company incorporated under the laws of a country other than the United States.

Alien Insurer

State license that authorizes an insurer to transact insurance within Georgia.

Certificate of Authority

Licensed individual authorized to solicit, negotiate, and transact insurance on behalf of an insurer.

Insurance Agent (Producer)

Any actions such as solicitation, negotiation, sale, or collecting premiums related to an insurance contract.

Transacting Insurance

Policies written chiefly on an agent’s own life, close relatives, or business associates; limited by law.

Controlled Business

Offering any inducement not stated in the policy (such as part of the commission) to persuade a sale.

Rebating

Making or circulating false or malicious statements about another insurer or its financial condition.

Defamation

Illegally inducing a policyholder to lapse or replace a policy through misrepresentation of terms.

Twisting

Unethical practice of replacing existing coverage within the same insurer for the producer’s benefit and not the client’s.

Churning

Charging different rates or issuing terms based on race, religion, or other prohibited factors.

Unfair Discrimination

Providing false or misleading information about a policy’s benefits, advantages, or terms.

Misrepresentation

Duty of an agent to properly handle and account for premiums and other funds belonging to clients and insurers.

Fiduciary Responsibility

Illegally mixing personal funds with client or premium funds held in trust.

Commingling

State-mandated entity that protects policyowners if a licensed insurer becomes insolvent, up to statutory limits.

Georgia Life and Health Insurance Guaranty Association

Georgia license required to provide insurance advice for a fee.

Insurance Counselor License

Requirement that individual accident and sickness policies provide at least a 30-day period for full premium refund upon cancellation.

Georgia Accident & Sickness Policy Free-Look

State rules governing group accident and sickness insurance policies issued in Georgia.

Georgia Regulation 100-2-10 through 12

Georgia rule mandating that Medigap policies clearly state they are not affiliated with or endorsed by Medicare.

Medicare Supplement Disclosure Requirement

Georgia prohibits Medigap policies from duplicating Medicare coverage and limits preexisting condition exclusions.

Medicare Supplement Preexisting Condition Rule

Georgia requirement that LTC policies provide a 30-day period for the insured to receive a full premium refund if canceled.

Long-Term Care 30-Day Free Look

State-federal initiative allowing LTC policyholders to protect an equivalent amount of personal assets if they later apply for Medicaid.

Georgia LTC Partnership Program