Traumatic Brain Injury
Glossary of Insurance Terms
Accident - An event causing loss, which takes place without being expected. In most cases the accident can be characterized with regard to time and place of occurrence. The public commonly associates this term with an event that was unavoidable. Therefore, when referring to injuries caused by motor vehicles, the preferred term is motor vehicle "crash" rather than motor vehicle accident. Virtually all crashes are preventable.
Adjuster - A person who handles claims. This term is becoming obsolete because its connotation is often negative and misunderstood. See Claims Service Representative.
Administrative Services Only Plan - An arrangement under which an insurance carrier or an independent organization will, for a fee, handle the administration of claims, benefits, and other administrative functions of a self-insured group.
Aggregate Indemnity - The maximum dollar amount that may be collected for any disability, or period of disability, under the policy.
Benefits - The amount payable by the insurance company to a claimant, assignee, or beneficiary under each coverage.
Blanket Medical Expense - A provision which entitles the insured person to collect up to a maximum established in the policy for all hospital and medical expenses incurred, without any limitation on individual types of medical expenses.
Carrier - The insurance company or the one who agrees to pay the losses. The carrier may be organized as a company (either stock, mutual, or reciprocal), or as an Association of Underwriters.
Case Reserve - The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
Claim - A request for payment of reparation for a loss covered by an insurance contract.
Claimant - One who seeks a claim.
Claims Service Representative - A person who investigates losses and settles claims for an insurance carrier or the insured. A term preferred to adjuster.
Coinsurance - A policy provision frequently found in major medical insurance, by which both the insured person and the insurer share the covered losses under a policy in a specified ratio.
Comprehensive Major Medical Insurance - A policy designed to give the protection offered by both a basic and a major medical health insurance policy. It is characterized by a low deductible amount, a coinsurance feature, and high maximum benefits.
Contributory - A group insurance plan issued to an employer under which both the employer and employee contribute to the cost of the plan; 75% of the eligible employees must be insured.
Deductible - The amount of covered charges incurred by the protected person which must be assumed or paid by the insured before benefits by the insurance company become payable.
Disability - The state of being disabled from earning full wages at the work at which the employee was last employed.
Disability Income Insurance - A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
Dismemberment - Loss of a body member(s), or use thereof, or loss of sight due to injury.
Double Indemnity - A policy provision usually associated with death, which doubles payment of a designated benefit when certain kinds of accidents occur.
Duplication of Benefits - Overlapping or identical coverage of the same insured under two or more health plans, usually the result of contracts between different insurance companies, service organizations, or prepayment plans; also known as multiple coverage.
Elimination Period - A period of time between the period of disability and the start of disability income insurance benefits, during which no benefits are payable. See Waiting Period.
Evidence of Insurability - Any statement of proof of a person's physical condition and/or other factual information affecting his/her acceptance for insurance.
Exclusions - Specific conditions or circumstances listed in the policy for which the policy will not provide benefit payments.
Health Insurance - Protection which provides payment of benefits for covered sickness or injury. Included under this heading are various types of insurance such as accident insurance, disability income insurance, medical expense insurance, and accidental death and dismemberment insurance.
Impairment - The inability or lessened ability to function in the performance of work duties because of injury or illness from a work-related accident or disease.
Injury - Harm to a worker subject to treatment and/or compensable under workers' compensation.
Insured - The person, organization or other entity who purchases insurance.
Insurer - The insurance company or any other organization which assumes the risk and provides the policy to the insured.
Lapse - Termination of a policy upon the policyholder's failure to pay the premium within the time required.
Medicaid - State programs of public assistance to persons regardless of age whose income and resources are insufficient to pay for health care. Provided under Title XIX of the Federal Social Security Act of 1966.
Medicare - The hospital insurance system and the supplementary medical insurance for disabled or aged persons created by the 1965 amendments to the Social Security Act.
Morbidity - The incidence and severity of sicknesses and accidents in a well-defined class or classes of people.
Non-disabling injury - An injury which may require medical care, but does not result in loss of working time or income.
Occupational Disease - Any disease or specified diseases that are common to or a result of a particular occupation or specific work environment.
Occupational Hazard - Occupations that expose the insured to greater than normal physical dangers by the very nature of the work in which the insured is engaged, and the varying periods of absence from the occupation, due to the disability, that can be expected.
Occurrence - Any incident or happening involving possible loss to a policyholder.
Partial Disability - The result of an illness or injury which prevents an insured from performing one or more of the functions of his/her regular job.
Policy - The legal document issued by the company to the policyholder which outlines the conditions and terms of the insurance.
Policyholder - One who owns an insurance policy.
Pre-Existing Condition - A physical and/or mental condition of an insured which first manifested itself prior to the issuance of the individual policy or which existed prior to issuance and for which treatment was received.
Premium - The periodic payment required to keep a policy in force.
Rehabilitation - Restoration of a totally disabled person to a meaningful occupation. A provision in some long-term disability policies that provides for continuation of benefits or other financial assistance while a totally disabled insured is retraining or attempting to resume productive employment.
Residual Disability Benefit - A provision in an insurance policy that provides benefits in proportion to a reduction of earnings as a result of disability, as opposed to the inability to work full-time.
Rider - A document which amends the policy or certificate. It may increase or decrease benefits, waive the conditions of coverage, or in any other way amend the original contract.
Self-Administration - The procedure where an employer maintains all records regarding the employees covered under a group insurance plan.
Self-Insurer - An employer who can meet the state legal and financial requirements to assume all risks and pay for the losses, although the employer may contract with an insurance carrier or others to provide certain essential services.
Third-Party Administration - Administration of a group insurance plan by some person or firm other than the insurer or the policyholder.
Tort Liability - The legal requirement that a person responsible, or at fault, shall pay for the damages and injuries caused.
Total Disability - An illness or injury that prevents an insured person from continuously performing every duty pertaining to his/her occupation or engaging in any other type of work.
Underwriter - The term generally is used for either: a) a company that receives the premiums and accepts responsibility for the fulfillment of the insurance policy contract; b) the company employee who decides whether or not the insurance company should assume a particular risk; or c) the agent who sells the policy.
Uninsurable Risk - One not acceptable for insurance due to excessive risk.
Waiting Period - The length of time an employee must wait from the date of employment or application for coverage, to the date that the insurance policy is effective.
Waiver - An agreement attached to a policy that exempts from coverage certain disabilities or injuries which are normally covered by the policy.
Workers' Compensation - The social insurance system for industrial and work injury regulated primarily among separate states, but regulated in certain specified occupations by the federal government.
Workers' Compensation Commission - One of many terms identifying the state public body which administers the workers' compensation laws, holds hearings on contested cases, promotes industrial safety, rehabilitation, etc. It is often located within the state labor department. The national organization is the International Association of Industrial Accident Boards and Commissions.
