georgia life and health insurance

Accident

An unplanned unforseen event which occurs suddenly at an unspecified place

Accident insurance

A type of insurance that protects the insured against loss due to an accidental bodily injury

Accidental bodily injury

Unplanned unforseen traumatic injury to the body

Accidental Death and Dismemberment

An insurance policy which pays a specified number or specified multiple of the insurer's benefit if the insured dies, loses his/her sight, or loses two limbs due to an accident.

Acquired Immunodeficiency Symdrome

An infectious and incurable disease caused by the human immunodeficiency virus (hiv)

Activities of daily living

Activities individuals must do every day such as moving about, getting dressed, eating, bathing, etc.

Actual charge

The amount a physician or supplier actually bills for a particular service or supply.

Adhesion

A contract offered on a "take it or leave it" basis by an insured, in which the insured's only option is to accept or reject the contract. Any ambiguities in the contract will be settled in favor of the imsured.

Admitted (Authorized) Insurer

An insurance company authorized and licensed to transact business in a particular state.

Adult Day Care

A program for impaired adults that attempts to meet their health, social, and functional needs in a setting away from their homes.

Adverse Selection

The tendency of risks witha higher probability of loss to purchase and maintain insurance more often than the risks who present lower probability

Agent

An individual who is licensed to sell, negotiate, or effect insurance contracts on behalf of an insurer.

Aleatory

A contract in which participating parties exchange unequal amounts. Insurance contracts are aleatory in that the amount the insured will pay in premiums is unequal to the amount the insurer will pay in the event of a loss.

Alien Insurer

An insurance company that is incorporated outside the United States.

Alzheimer's Disease

A disease that causes the victim to become dysfunctional due to degeneration of brain cells and severe memory loss.

Ancillary

Additional, miscellaneous services provided by a hospital, such as x-rays, anesthesia, and lab work, but not hospital room and board expenses.

Apparent Authority

The appearance or the assumption of authority based on the actions, words, or deeds of the principal or because of circumstances the principal created.

Approved Amount

The amount Medicare determines to be reasonable for a service that is covered under part B of Medicare.

Assignment

A claim to a provider or medical supplier to receive payments directly from Medicare.

Attained Age

The age of the insured at a determined date.

Attending Physician Statement (APS)

A statement usually obtained from the applicant's doctor.

Avoidance

A method of dealing with risk (e.g. if a person wanted to avoid the risk of being killed in an airplane crash, he/she might choose never to fly in a plane).

Basic Hospital Expense Insurance

Coverage that provides benefits for room, board and miscellaneous hospital expenses for a certain number of days during a hospital stay.

Basic Medical Expense Insurance

Coverage for doctor visits, x-rays, lab tests, and emergency room visits; benefits, however, are limited to specified dollar amounts.

Beneficiary

The person who receives the proceeds from the policy when the insured dies.

Benefit Period

The length of time over which the insurance benefits will be paid for each illness, disability, or hospital stay

Birthday Rule

The method of determining primary coverage for a dependent child, under which the plan of the parent whose birthday occurs first in the calendar year is designated as primary.

Boycott

An unfair trade practice in which one person refuses to do business with another until he or she agrees to certain comditioms.

Blanket Medical Insurance

A policy that provides benefits for all medical costs, including doctor visits, hospitalization, and drugs.

Buyers Guide

A booklet that describes insurance policies and concepts, and provides general information to help an applicant make an informed decision.

Cafeteria Plan

A selection of health care benefits from which an employee may choose the ones that he/she needs.

Capital Amount

A percentage of the principal amount of a policy paid to the insured if he/she suffered the loss of an appendage.

Carriers

Organizations that process claims and pay benefits in an insurance policy

Cease and Desist Order

A demand of a person to stop committing an action that is in violation of a provision.

Certificate Authority

A document that authorizes a company to start conducting business and specifies the kind(s) of insurance a company can transact. It is illegal for an insurance company to transact insurance without this certificate.

Certificate of Insurance

A written document that indicates that an insurance policy has been issued, and that states both the amounts and types of insurance provided.

Claim

A request for payment of the benefits provided by an insurance contract.

Coercion

An unfair trade practice in which an insurer uses physical or mental force to persuade an applicant to buy insurance.

Coinsurance

An agreement between an insurer and insured in which both parties are expected to pay a certain portion of the potential loss and other expenses.

Coinsurance clause

A provision that states that the insurer and the insured will share the losses covered by the policy in a proportion agreed upon in advance.

Commissioner

The chief executive and administrative officer of the insurance department

Comprehensive policy

A plan that provides a package of health care services, including preventive care, routine physicals, immunization, outpatient services and hospitalization.

Comprehensive Major Medical

A combination of basic coverage and major medical coverage that features low deductibles, high maximum benefits, and coinsurance.

Concealment

The withholding of known facts which, if material, can void a contract.

Conditional Contract

A type of an agreement in which both parties must perform certain duties and follow rules of conduct to make the contract enforceable.

Consideration

The binding force in a contract that requires something of value to be exchanged for the transfer of risk. The consideration on the part of the insured is the representations made in the application and the payment of premium; the consideration on the part of the insurer is the promise to pay in the event of loss.

Consideration Clause

A part of the insurance contract that states that both parties must give something of value for the transfer of risk, and specifies the conditions of the exchange.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985

The law that provides for the continuation of group health care benefits for the insured for up to 18 months if he/she terminates employment or is no longer eligible, and for the insured's dependents for up to 36 months in case of loss of eligibility due to deaththe of the insured, divorce, or attainment of limiting age.

Consumer report

A written and/or oral statement regarding a consumer's credit, character, reputation, or habits collected by a reporting agency from employment records, credit reports, and other public sources.

Contract

An agreement between two or more parties that enforceable by law

Contributory

A group insurance plan that requires the employees to pay part of the premuim

Coordination of Benefits

A provision that helps determine the primary provider in situations where an insured is covered by more than one policy, thus avoiding claims overpayments.

Copayment

An arrangement in which an insured must pay a specified amount for services "up front" and the provider pays the remainder of the cost.

Custodial Care

Care that is rendered to help an insured complete his/her activities of daily living.

Death benefit

The amount payable upon the death of the person whose life is insured.

Deductible

The portion of loss that is to be paid by the insured before any claim may be paid by the insurer.

Defamation

An unfair trade practice in which one agent or insurer makes an injurious statement about another with the intent of harming the person's or company's reputation.

Director

The chief executive and administrative officer of the Insurance Department.

Disability

A physical or mental impairment, either congenital or resulting from an injury or sickness.

disability income insurance

Health insurance that provides periodic payments to replace an insured's income when he/she is injured or ill.

Disclosure

An act of identifying the name of the producer, representative or firm, limited insurance representative, or temporary insurance producer on any policy solicitation.

Domestic Insurer

An insurance company that is incorporated in the state.

Domicile of insurer

Insurer's location of incorporation and the legal ability to write business in a state.

Dread (Specified) Disease Policy

A policy with a high maximum limit that covers certain diseases named in the contract (such as polio and meningitis).

Dual Choice

A federal requirement that employers who have 25 or more employees, who are within the service area of a qualified HMO, who pay minimum wage, and offer a health plan, must offer HMO coverage as well as an indemnity plan.

Eligibility Period

The period of time in which an employee may enroll in a group health care plan without having to provide evidence of insurability.

Elimination Period

A waiting period that is imposed on the insured from the onset of disability until benefit payments begin.

Emergency

An injury or disease which occurs suddenly and requires treatment within 24 hours.

Endodontics

An area of dentistry that deals with diagnosis, prevention and treatment of the dental pulp within natural teeth at the root canal.

Enrollment period

The amount of time an employee has to sign up for a contributory group health plan.

Estoppel

A legal impediment to denying a fact or restoring a right that has been previously waived.

excess charge

The difference between the Medicare approved amount for a service or supply and the actual charge.

Expiration

The date specified in the policy as the date of termination

Explanation of Benefits (EOB)

A statement that outlines what services were rendered, how much the insurer paid, and how much the insured was billed.

Explanation of Medicare Benefits

A statement sent to a Medicare patient indicating how the Medicare claim will be settled.

Exposure

A unit of measure used to determine rates charged for insurance coverage.

Express Authority

The authority granted to an agent by means of the agent's written contract.

Extended Care Facility

A facility which is licensed by the state to provide 24 hour nursing care.

Extension of Benefits

A provision that allows coverage to continue beyond the policy's expiration date for employees who are not actively at work due to disability or who have dependents hospitalized on that date. This coverage continues only until the employee returns to work or the dependent leaves the hospital.

Fair Credit Reporting Act

A federal law that established procedures that consumer-reporting agencies must follow in order to ensure that records are confidential, accurate, relevant and properly used.

Fiduciary

An agent/broker who handles insurer's funds in a trust capacity.

Flexible Spending Account (FSA)

A salary reduction cafeteria plan that uses employee funds to provide various types of health care benefits.

Foreign Insurer

An insurance company that is incorporated in another state.

Fraternal Benefit Societies

Life or health insurance companies formed to provide insurance for members of an affiliated lodge, religious organization, or fraternal organization with a representative form of government.

Fraud

The intentional misrepresentation or deciet with the intent to induce a person to part with something of value.

Free Look

A period of time, usually required by law, during which a policyowner may inspect a newly issued individual life or health insurance policy for a stated number of days and surrender it in exchange for a full refund of premium if not satisfied for any reason.

Gatekeeper Model

A model of HMO and PPO organizations that uses the insured's primary care physician (the gatekeeper) as the initial contact for the patient for medical care and for referrals.

Grace Period

Period of time after the premium due date in which premiums may still be paid and the policy and its riders remain in force.

Group Disability Insurance

A type of insurance that covers a group of individuals against loss of pay due to accident or sickness.

Group Health Insurance

Health coverage provided to members of a group.

Hazard

A circumstance that increases the likelihood of a loss.

Hazard, Moral

The effect of a person's reputation, character, living habits, etc. on his/her insurability.

Hazard, Morale

The effect a person's indifference concerning loss has on the risk to be insured.

Hazard, Physical

A type of hazard that arises from the physical characteristics of an individual, such as a physical disability due to either current circumstance or a condition present at birth.

Health Insurance

Protection against loss due to sickness or bodily injury.

Health Maintenance Organization (HMO)

A prepaid medical service plan in which specified medical service providers contract with the HMO to provide services. The focus of the HMO is preventive medicine.

Health Reimbursement Account (HRAs)

Plans that allow employers to set aside funds for reimbursing employees for qualified medical expenses.

Health Savings Account (HSAs)

Plans designed to help individuals save for qualified health expenses.

Home Health Agency

An entity certified by the insured's health plan that provides health care services under contract.

Home Health Care

Type of care in which part-time nursing or home health aide services, speech therapy, physical or occupational therapy services are given in the home of the insured.