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Glossary
We are constantly improving the glossary, mostly based on your input. If you need help with a particular word and cannot find it in the glossary, please let us know, or check our Questions & Answers page.
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
A
Accidental Death & Dismemberment: A lump sum payment if the insured dies as a result of an accident or loses eyesight, hearing, or appendages (i.e. arms, legs, feet and hands.)
Administrator: The individual or company responsible for administering the group insurance contract including the accounting and enrollment.
Adverse Selection: Persons with poorer-than-average health (or health expectations) tend to apply for greater insurance coverage than do persons in average or better health.
Age Reduction: A reduction in the amount of insurance when a person reaches a certain age.
Aggregate: When referring to a family deductible or out-of-pocket maximum, aggregate implies that the family charges may total up to the maximum, as long as one member meets the individual amount.
Allowable Expense: Any claims that meet the criteria of the insurance policy which you are covered by.
Anti-selection: The selection of coverage beneficial to the employee but not beneficial to the plan itself.
Association Group Plans: Health plans designed for members of an association.
B
Basic Life Coverage: The base life insurance plan. If desired, additional life coverages can be added to Basic Life to increase the coverage.
Beneficiary: The person designated by the insured to receive Group Life and/or Accidental Death Benefits upon the death of the insured.
Benefit: The amount payable by the insurance company to the holder, assignee or beneficiary of the insurance policy when a loss covered by the policy occurs.
C
Carrier: The insurer who agrees to underwrite the group contract and provide certain types of coverage and service.
Child, Handicapped: Specific provision in contract for the continuing coverage of dependent child regardless of age, if handicapped and unable to provide for themselves.
Claim: A demand by the insured person to the insurer for the payment of benefits.
Claimant: A plan beneficiary exercising his/her right to receive benefits.
Coordination of Benefits: A policy which will determine how benefits will be calculated if the claimant is insured under more than one group contract insuring the same event.
Notice and Proof of Claim: The policy will specify time limits for giving notice, and then proof of claim. It also specifies the manner in which the proof of loss must be submitted.
Claims Paid: Checks paid out to claimants by the insurance company. The checks are considered Paid Claims if they either are dated within the policy year or are cleared by the banks within the policy year.
Class: A categorical listing of insurance coverage which an individual is placed into to determine eligible coverage under the policy.
COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 is the federal health care continuation law. COBRA requires companies with 20 or more employees to offer continued health care coverage to employees and qualified beneficiaries of employees at the participant's expense if employer-provided health coverage is terminated due to a qualifying event.
Coinsurance: The insured and the insurer share the cost of the claim within a specified ratio. For example, if the insurer pays 80%, the insured pays 20% of the claim expense.
Common-Law Marriage: A person of the opposite sex who has been cohabiting and residing with you for a continuous period of at least one year, and has been publicly represented by you as your spouse.
Consultant: A person or firm specializing in the design, sale and service of employee benefit plans.
Contingent Beneficiary: The person legally entitled to an insurance policy if the primary beneficiary dies before or at the same time as the insured.
Contributory: A portion of the premium paid by the employee is required.
Contributory Plan: A plan which requires employees to pay part of the cost for the benefit plan.
Conversion: The individual has the right to convert group insurance coverage to an individual plan without presenting evidence of insurability if converted within 31 days of termination.
Copayment: A specified dollar amount of eligible expenses which the member is required to pay for a specific covered service and which will be deducted from the provider's reasonable charge before the determination of benefits payable under the program is made.
Coverage: A classification of benefits provided under a group policy or the amount of insurance or benefits stated in the group policy for which an insured is eligible.
Covered Person: Any person entitled to benefits under a group coverage.
D
Deductible: An amount of expenses that must be paid by the insured before any benefits become payable.
Dependent: The employee's spouse or children.
Dependent Life: Life Insurance issued for the spouse and children with the employee as the beneficiary.
E
Effective Date: The date a policy becomes effective. If the hour is not specified, the effective time is 12:01 a.m. on the appropriate date.
Eligible Employees: Employees who have met the requirements under the group policy for insurance.
Employee Benefit Program: A program through which various benefits are offered to employees by their employer to cover such contingencies as medical expenses, disability income, retirement and death; usually paid for wholly or in part by the employer. Such benefits frequently are referred to as "fringe benefits" because they are separate from wages and salaries.
Evidence of Insurability: Proof presented through written statements on an application form, and/or through a medical examination, that an individual is eligible for a certain type of insurance coverage.
Experience: The past history of claims for a classification of insurance. The experience affects the rates/premiums the insurance company charges for insurance coverage.
EOB: Once a claim has been processed, the subscriber will receive an Explanation Of Benefits statement. The following information is detailed on the EOB: actual charges, allowed charges, deductible and coinsurance amounts, total benefits payable and the subscriber responsibility.
F
Family: Two spouses who are legally married or living common-law, or one or two adults (legally married or living common-law) and their dependent children.
G
Group Insurance: Insurance issued, usually without medical examination, on a group of people under a master contract. It is usually issued to an employer for the benefit of employees. The individual members of the group hold certificates as evidence of their insurance.
GICR: The Group Insurance Change Report is a monthly report that accompanies each billing statement. This form is used to report all changes submitted for the month and sent with the monthly premium payment.
Group Life: Insurance covering a group of employees under one life insurance policy.
Guaranteed Issue: Minimum amount of benefit that will be provided without the need for evidence of insurability.
H
HIPAA: The Health Insurance Portability and Accountability Act of 1996 applies to all groups with 2 or more employees. The main purpose of HIPAA is to make health insurance more accessible and portable for those participating in individual and group plans.
HMO: A Health Maintenance Organization is a managed care plan where the member uses a Primary Care Physician from a network of providers to coordinate care. Coverage is provided only for care received in the network.
I
Insured: The member who is covered by the policy.
Insurer: The insurance carrier who agrees to underwrite the group contract and provide certain types of coverage and service.
Indemnity Plan: Plan which restores or reimburses one to the extent of their loss.
J
K
L
LTD: Long Term Disability insurance provides income protection in the event of time lost due to sickness or accident of long term nature. Generally monthly payments commence after a specified waiting period and continue while the employee remains disabled usually up to a specified age.
M
Maximum Benefit: The maximum amount any one individual may receive under an insurance contract.
Medicare: The programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.
N
Noncontributory: A plan where the Employer pays the entire cost.
O
Open Enrollment: The enrollment period where employees can change their benefit elections. If employees waive coverage at the time of original enrollment, they can elect benefits at this time.
Out-of-Country Expenses: Expenses incurred by an insured or insured dependent for emergency services and treatment of bodily injury or disease while travelling outside the United States.
Out-of-Network: Services received from a non-participating provider. Out-of-Network expenses are covered differently under different types of plans.
Out-of-Pocket Expenses: Those medical expenses which an insured is required to pay because they are not covered under the group contract.
Out-of-Pocket Maximum: The maximum amount of coinsurance an insured is required to pay before the plan will pay 100% .
P
Participating Provider: A doctor who participates in the approved plan and accepts the usual customary and reasonable charges as payment in full.
Participating Unit: An ISEBA member school, which participates in any of the employee benefit programs offered through ISEBA.
Payroll Deduction: The amount taken from the employee's earnings with his/her consent, as contribution toward the cost of the group insurance plan.
Period of Disability: The period during which an employee is prevented from performing the usual duties of his/her occupation or employment or during which a dependent is prevented from performing the normal activities of a healthy person of the same age or sex. More than one cause (accident or sickness) may be present during or contribute to a single period of disability.
Permanent and Total Disability: A disability that will presumably last for the insured's lifetime and prevents engagement in any occupation for which the insured is reasonably fitted.
Planholder: Iowa Schools Employee Benefits Association and shall include any affiliate or subsidiary of the Planholder participating in the plan.
POS: A Point-Of-Service plan is a managed care plan which utilizes primary care physicians to coordinate care. Coverage is available outside of the network at higher out-of-pocket costs.
Pooling: The combination of all premiums, claims, expenses for certain size cases, types of coverage or excess classes in order to spread the risk.
Pre-Existing Condition: Any physical and/or mental condition or conditions that existed prior to the effective date of coverage under a contract.
PPO: A Preferred-Provider-Organization plan is a managed care plan which utilizes network providers to contain costs. Coverage is available out-of-network at higher out-of-pocket costs.
Premium: The amount paid to the insurer for the insurance protection.
PCP: The Primary Care Physician chosen for immediate care. He/she coordinates care and refers to a specialist, when necessary, for the highest payment of benefits.
Primary Payer: The plan that pays first when you have coverage through two benefit plans.
Provision: A part of a group insurance contract that explains or describes a feature, benefit, condition, requirement, etc., of the insurance protection afforded by the contract.
Q
Qualifying Status Change: An enrollment change required due to a qualifying event.
Qualifying Event: An occurance entitling a person to change existing coverage or to elect continuation outside of open enrollment, such as marriage, birth, etc. Wish to view a list of qualify-events.
R
Reasonable and Customary: This term refers to limiting benefit payments to fees which are reasonable and representative for the service rendered, under the circumstances rendered, by the physician rendered.
Reasonable Occupation: An occupation for which you are suited or for which you can become suited with education, training or experience.
Recurring Disability: A case where if a second disability occurs related to the first disability within a specified period of time, the second disability will be a continuation of the first disability claim.
Rehabilitation: Refers to a provision in many long-term disability (LTD) plans that enables the insured claimant to receive at least partial benefits while undergoing retraining and seeking new employment.
Rehabilitative Employment: Any occupation or work for compensation or profit approved by the Insurer and undertaken by the insured while unable to work on a full-time basis usually in conjunction with a LTD plan.
Renewal Date: The date when the insurance policy is to be reviewed for experience and the rates are adjusted.
Retention: The portion of the premium retained by the insurance company to cover expenses and provide profits.
Retirement: Permanent withdrawal from the labor force.
S
Secondary payer: The plan that pays second when you have coverage through two benefit plans (yours and your spouse's plan). This is known as co-ordination of benefits where you can be reimbursed up to 100% (but not more) when you submit your claim to both benefit plans.
STD: Short-Term Disability benefit provided to employees who are absent from work due to illness or disability. Short Term Disability (also known as Weekly Indemnity or Sick Leave) usually has a maximum amount of time the benefit will last.
Sickness: Illness not arising from accident or injury. Usually the sickness causing disability must be contracted by the insured while the policy is in effect. Some policies require that the sickness need only manifest itself while the policy is in effect.
Single: An unmarried person with no dependent children.
Social Security: A federal program of old age and related benefits covering most workers in the country.
Spouse: The person to whom you are lawfully married; or a person of the opposite sex who has been cohabiting and residing with you for a continuous period of at least one year, and has been publicly represented by you as your spouse.
Subject to Insurability: A statement of proof of a person's physical condition, occupation or other factor affecting his or her acceptance for insurance is required.
Subrogation: The acquiring by the insurer of the insured's rights against third parties for the indemnification of a loss to the extent that the insurer pays the loss.
T
Term Life Insurance: Life insurance plan that terminates when employment ceases. Conversion policies are available.
Termination: An employee who terminates employment with the employer or withdraws from a group plan offered by the employer.
Total Disability: Inability to perform all of the duties of one's regular occupation or the duties of any occupation for which the individual may become fitted due to education, training or experience.
Twenty-Four Hour Coverage: Insurance providing benefits for an accident or sickness incurred either on the job or off the job.
U
Underwriting: The process by which an insurance company determines whether or not it will accept an application for insurance.
V
Voluntary: Chosen by one's own consent. Often refers to lack of minimum enrollment requirements.
W
Waiting Period: A period of time that must pass in order for an individual to become eligible for benefits under a group insurance policy.
Waiver: An agreement attached to a policy which exempts from coverage certain disabilities normally covered by the policy.
Waiver of Premium: A provision that under certain conditions a person's insurance will be kept in full force by the insured without further payment or premiums. It is used most often in the event of permanent and total disability.
Worker's Compensation Act: A statute imposing liability on employers to pay benefits and furnish care to employees injured and to pay benefits to dependents of employees killed, in the course of and because of their employment.
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Last updated: Friday, December 09, 2005 Page:
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