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X Y Z |
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| Activities of Daily Living (ADLs) |
The basic activities and functions performed on a daily basis
that are usually done without assistance. The six ADLs are:
1.
Eating
2.
Dressing
3.
Bathing
4.
Toileting
5.
Transferring
6.
Continence |
|
Accumulation Period
|
The
pre-determined amount of time that must pass before the
benefits are to go into effect for the claimant.
|
|
Accreditation
|
A formal
recognition by an impartial and independent organization,
which confirms that a particular insurance company is
upholding the standards of the industry. |
|
Actuary
|
This person
is professionally trained in the specifics of pensions,
insurance and related areas. They determine how much money
must be contributed to an insurance or pension fund in order
to be sufficient for the future. |
|
Additional
Insured |
An insured
person specifically stated in an insurance policy
|
|
Adjustable
Life Insurance
|
A type of
insurance that allows the holder to change the terms of the
insurance, raise or lower the face value of the policy,
increase or decrease the premiums and/or the time period of
the policy |
|
Adult Day
Care |
A daily
program made up of social and health-related services
provided daily outside the home in a group setting to
support weak, elderly, or other adults with impairment
|
|
Advantage
List |
List of
health service providers that agree to give particular
insurance company policyholders a preset discount
|
|
Age Limits
|
Stated
minimum and maximum ages below and above that the insurance
company will not accept policy applications |
|
Agent
|
A licensed
insurance company representative who sells, negotiates
insurance policies, and provides service to the policy
holders |
|
Alien
Insurer |
An insurance
company located in another country |
|
Allocated
Benefits |
Benefits that
have a stated maximum amount payable for specific services
itemized in the contract |
|
Alzheimer's Care Center
|
A treatment
center that specializes in providing care for those with
Alzheimer's Disease with more of the care geared towards
supervision of the patient in a safe and controlled
environment |
|
Alzheimer's Disease
|
A
degenerative disease of the brain which attacks nerve cells
in the cortex of the brain thereby impairing a person's
abilities to think and function |
|
Amendment
|
A formal
written document signed by both the insurance company and
the policyholder, which changes the terms of the insurance
policy |
|
Application
|
A signed
statement of facts filled out by the person applying for the
insurance policy, which is then used by the insurance
company to decide whether or not to issue a policy. The
application then becomes part of the policy |
|
Assessment
|
Determination
of the person's level of physical ability or mental
capability, and the type and extent of services available
and needed |
|
Assignment
|
The legal
transfer of one person's insurance policy to another person
|
|
Assisted
Living Facility
|
A facility
which provides 24 hour around the clock care to resident
patients in need of assistance with any number of the
Activities of Daily Living (ADLs).
|
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|
Baby
Boomer |
A person born
between the years of 1945 and 1964. |
|
Bad Faith
|
A charge
against the insurance company that they have not acted in a
way that is consistent to the way a reasonable policyholder
would have expected. |
|
Beneficiary
|
The person
designated or provided for by an insurance policy's terms to
receive any benefits provided by the policy or plan upon the
death of the insured |
|
Benefit
Period |
The amount of
time an insurance company will make payments to the
individual to pay for care, etc after the deductible has
been satisfied. |
|
Benefit
Triggers |
Specific
situations that start payment of benefits |
|
Benefits
|
Money paid by
the insurance company to the claimant. |
|
Benefit
Limits |
An amount
that represents the daily benefit times the maximum number
of days you can receive for all benefits combined under the
policy |
|
Benefit
Options |
Each
carrier's insurance type generally has a set list of
available benefits. Each benefit comes with a price
|
|
Binder
|
A written or
oral contract that temporarily places an insurance policy in
effect when it is not possible to issue a new policy or
endorse the existing policy immediately. The binder must
meet all the terms of the policy issued |
|
Binding
Receipt |
A receipt
given for a premium payment with the application for the
insurance. If the policy is approved, this receipt binds the
company to make the policy effective from the date of the
receipt |
|
Board and
Care Homes |
Provides
seniors with a room, meals, and assistance with ADL's and
some supervision for their safety. These homes are generally
not certified by Medicaid, but are licensed and approved by
the State |
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Cancellation
|
Done either
by the insurer or insured, this discontinues the policy
before its normal expiration date |
|
Caregiver
|
The
individual who cares for someone with a disability or
illness. The primary caregiver is usually a spouse, child or
other relative. |
|
Care
Coordinator
|
An individual
employed by the insurance company to handle all matters,
financial and otherwise, regarding the welfare of the
claimant for cost effective purposes. This includes, but is
not limited to, selecting physicians, specialists, care
centers, hospitals, etc. as well as coordinating time
periods of care |
|
Care Line
|
An
informational service that provides information on where to
go for care |
|
Care
Manager |
A trained
professional who is able to work with you and your family
and your doctors to assess your situation and determine the
appropriate Plan of Care. They will also help with finding
the available care resources |
|
Care Plan
|
This is a
written plan formulated by a health care professional after
an assessment has been done on the individual with a chronic
illness or disability. The plan provides a detailed outline
of the person's needs and what health services are required
to meet those needs |
|
Case
Coordinator Nurse
|
This is your
contact person to discuss claims and benefits |
|
Cede
|
To transfer
all or part of the written risk to an insurer or to a
reinsurer |
|
Certificate of Insurance
|
A statement
given to the policyholder stating the insurance benefits and
terms |
|
Chronically Ill
|
A condition
that is verified by a physician that the renders the
individual unable to perform at least two of the Activities
of Daily Living (ADL's) for at least 90 days which requires
the individual to have Substantial Supervision to protect
themselves from threats to health and safety |
|
Claim
|
A submitted
request to the insurance company by the claimant to receive
payment and/or reimbursement for expenses incurred due to
disability, illness, etc. which are covered under said
policy |
|
Claims
Adjuster |
This is the
person who settles the claim, either an agent, company
adjuster, independent adjuster, adjustment bureau, or public
adjuster |
|
Cognitive
Impairment |
Loss of
rational comprehensive thought processes due to a
degenerative disease or disorder |
|
Commission
|
A part of the premium that is paid
to the policyholder's agent or broker for their services in
the insurance policy process |
|
Commissioner
|
A state officer who handles the
state's insurance laws and regulations |
|
Congregate Housing Facilities
|
Similar to a dormitory setting,
individuals have their own private rooms, but often share
meals. Care is generally minor supervision to provide
safety with emergency medical assistance always available
|
|
Contract of Adhesion
|
A contract written by one party
and signed or denied by another with no chance of change to
the terms stated within the contract |
|
Compulsory
Insurance |
Any form of insurance that is
required under the law |
|
Concealment
|
Intentionally withholding
information on an insurance application to hide facts from
the insurance company |
| Conservation |
An attempt made by the insurance
company to prevent of the lapse of a policy |
|
Consideration
|
Acceptance by
the insurance company of the payment of the premium and the
statement made by the prospective policyholder in the
application |
|
Contingent
Beneficiary |
The person who will receive the benefits of a policy or plan if
the main beneficiary dies while the insured is living |
|
Contract |
A binding agreement between two or more parties stating
specific terms and agreements. A contract of insurance is a
written document known as a policy |
|
Contract
Holder |
The person, group, or entity, which the contact is issued |
|
Contract Law |
The part of civil law that interprets written contracts between
parties and resolves any disagreements |
|
Coverage |
The amount of protection provided under the contract of
insurance |
|
Covered
Nursing Care Facility (Confined) Benefits |
Policies that provided benefits for all levels of care will pay
for benefits in a nursing home that is licensed in the state
in which the claim is being made |
|
Custodial
Care |
Non-medical care in which the patient receives help with their
ADL's. Providers of this care do not need to be
professionally trained nurses or therapist. |
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|
Daily
Benefit Period
|
The length of time which your daily benefits cover |
|
Daily
Benefit Rate
|
The rate predetermined by your policy provider to cover your
daily benefits |
| Declination |
The refusal
of an insurer to issue a policy based on the review of the
application for insurance and other relevant factors
|
|
Deductible
|
An
out-of-pocket amount of money that the insured must pay
before the insurance company assumes financial
responsibility for the claimant's expenses |
|
Demutualized
|
When shares of the company's stock are sold individually rather
than part of a large portfolio consisting of several
individual stocks, i.e. mutual fund |
|
Deposit
Premium |
This is the initial premium paid by the prospective
policyholder when the insurance application is filled out.
This is generally equal to the first month's premium and is
applied towards the first month's actual premium |
| Discount Rate |
This rate is used to calculate the value of dollars paid or
received in future years to current dollars. For example, a
dollar today may only be worth 50 cents ten years from now. |
| Doctrine of Reasonable Expectations |
A legal document that states policies must be written in such a
way that a reasonable person who is not trained in the law
may interpret them |
| Domestic Insurer |
An insurance company that is operates in the state in which
they are incorporated |
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| Effective Date |
The date on which the insurance policy begins |
| Eldercare Locator |
A national hotline service that refers people to local services
if you or someone you know needs long term care. The number
is 1-800-677-1116 |
| Elimination Days |
A period of time between the initial need for care and the
beginning of the payments from the insurance company. |
| Elimination Period |
The number of days that you have to pay benefits before your
coverage begins to pay for benefits |
| Evidence of Insurability |
Statements or proof or a person's physical condition affecting
the acceptance for insurance |
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| Fair Premium |
The premium level that is just high enough to cover an
insurer's expected costs and give insurance company owners a
just return on their invested capital |
| Favorable Tax Treatment |
Benefits are received free from tax. Also, your premium and
long-term care expenses may be deductible from your Federal
Income Taxes, within reason. Please contact your tax
advisor for more information. |
| Financial
Counseling Programs |
Help seniors with managing their finances, bills, and
completing Medicaid, Medicare or insurance forms |
| Financial Soundness |
Related to stability, it is important to compare the financial
ratings and asset of insurance carriers |
| Foreign Insurer |
When the insurer is not located in the state in which they are
incorporated |
| Free-Look Period |
Once you buy a policy, most states allow you up 30 days to
return your policy. Make sure to get written proof of this
option when you receive your policy |
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| Gatekeeper |
Decided when a patient should be referred to a specialist or
when particular tests should be given |
| Geriatrics Manager |
A person who assesses the needs of elderly people in terms of
what services they need, often arranges for these services
and keeps in touch with the person. The geriatrics manager
is often hired by the person's immediate family to keep them
informed of the person's status when they cannot be there
themselves. |
| Gross Premium |
The premium paid by the policyholder |
| Guaranteed Rate Policy |
Written agreement stating premium rate will not increase over
time |
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| High Risk Individuals |
People who have a pre-existing health condition that have a
greater than average probability of future medical expense |
| HIPAA (The Health Insurance Portability and Accountability
Act of 1996) |
This act became a law on January 1, 1997. The act states the
requirements that a long term care policy must follow in
order that the premiums paid may be deducted as medical
expenses and benefits not paid be considered as taxable
income |
| Home Care Providers |
A person who provides home health care or hospice services and
who meets the following criteria
- Under the
Medicare Program, has an agreement to be a provider of
home health care services
- Is licensed
by their state as a home health care agency or hospice
if licensing is required in the state in which they are
practicing
- Is a licensed
therapist, a registered nurse (R.N), a licensed
practical nurse( L.P.N), or a licensed vocational nurse
(L.V.N.) providing services under the guidelines of
their license
|
|
Home Care
Services |
Household services done by someone else because you are unable
to do them yourself. These include nursing services,
personal hygiene, house chores, errands, and preparation of
meals, laundry and small house maintenance. |
|
Home
Delivered Meals
|
"Meals on Wheels", provide meals to those who cannot cook for
themselves |
|
Home
Health Aid |
Licensed individual that performs daily care for those
in need of assistance in their homes. Generally these
people provide help with basic daily activities such as
bathing, eating, and dressing |
|
Homemaker
Service |
Generally in combination with a Home Health Aide, this person
will cook, clean, run errands, etc. |
|
Hospice
Care Services
|
Out patient services provided by a licensed hospice provider to
help ease the pain of terminally ill patients in their last
stages of their terminal disease. They also provide support
to the primary care giver and the family. |
|
House
Claims Department
|
Department that processes and reviews all claims |
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|
Immediate
Family |
The person's spouse, children, parents, siblings, grandchildren
or in-laws |
|
Incurred
Services |
Received services from providers |
| Indemnity |
Compensation to the claimant for disability or illness suffered
- security against loss. |
|
Independent Agent
|
A business person that represents two or more insurance
companies in sales and service and who is paid on a
commission basis |
|
Independent Caregiver
|
A person who provides home health care services or hospice care
who:
- Is licensed
to provide the care they are giving and are working
independently from a home health care agency. They must
be licensed in the state they are working in.
- Is chosen by
You and has been qualified under the Independent
Caregiver Certification Benefit
- Is not a
member of your immediate family living with you
|
| Informal Caregiver |
Usually a spouse or relative, an informal caregiver is an
unpaid individual who takes on the responsibility of
providing care for the individual in question. |
| Inflation Rate |
The rate, which the cost of long-term care is expected to
increase in the future. Generally this rate is 1-2% higher
than the overall U.S inflation rate. |
| Inflation Protection with the Automatic Increase Benefit
Rider AIB |
A rider that helps you to keep up with the potential cost of
your care due to inflation. The rider increases your maximum
daily benefit either on a simple or compound basis,
depending on the rider you choose. |
| Instrumental Activities of Daily Living (IADLs) |
Determines the physical and mental impairment while performing
activities such as shopping, telephone use, housekeeping,
laundry, taking medications, and managing finances |
| Insurance |
A system of exchange under contract where payments over a
period of time (premiums) entitle individuals compensation
by an organization (insurance company) in the event of loss
due to pre-specified conditions. |
| Insurance Carrier |
Insurance provider |
| Insurance Commissioner |
The top insurance regulation official in the state |
| Insurance Policy |
A legal contract issued by the insurance company to secure
coverage for claimant |
| Insurance Premium |
The pre-specified amount an individual pays to guarantee
coverage for a policy |
| Insured |
A person covered under an insurance policy, including any
persons named as receiving protection under the policy |
| Insurer |
The insurance company that agrees to pay losses of benefits.
Also, the insurer can be any company whose primary business
is selling insurance to the public |
| Insuring Agreement |
The part of the insurance policy that specifies the promises of
the insurer |
| Insuring Clause |
A statement that specifies the type of loss covered by the
policy and the parties involved in the insurance contract |
| Intermediate Nursing Care |
This care is provided to those who do not need care on a
24-hour basis. A skilled care person on a non-continuous
basis provides the nursing care. |
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| Lapse |
The ending of the insurance policy due to the non-payment of a
premium |
| Lapsed Policy |
A policy, which has discontinued due to the non-payment of
premiums |
| Level Premium |
A premium that remains the same throughout the life of the
policy |
| Licensed Health Care Provider |
A doctor, or health care professional, who certifies every 12
months that you are continuously ill and in need of support. |
| Life Expectancy |
The average number of years of life remaining for a group of
persons given age according to a particular mortality table |
| Living Will |
A written document, which states the wishes of an individual in
advance concerning the use of life saving devices and
procedures in the event that the person is terminally ill or
has suffered an injury and is no longer competent |
| Long Term Care |
Care given in the form of medical and support services to
persons who have lost some or all of their capacity to
function due to an illness or disability. These services
are generally provided away from the primary health care
facility and are of a long time frame. |
| Long Term Care Insurance |
The insurance which pays for a succession of care giving
services for the elderly or chronically ill. This care may
be provided in a facility (nursing home, mental hospital,
etc.) or in the individual's home with a nurse or aide. |
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| Maintenance or Personal Care Services |
Any care where he main reason for which the care is provided is
to assist those in need of care resulting from a chronic
illness or disability |
| Married Couples Discount |
A plan that offers a reduced rate to those couples that apply
for coverage and are approved |
| Maximum Lifetime Benefit |
The total amount Your carrier will pay you in Your lifetime for
all benefit provided under your policy. |
| Medicaid |
Public assistance funded through the state to individuals
unable to pay for health care. Medicaid can be accessed
only when all prior assets and funds are depleted. |
| Medical Help System |
A communication system set up in your home that is used to
contact medical personnel in the case of an emergency |
| Medicare |
A Government program, administered by the Social Security
Administration, which provides financial assistance to
individuals over the age of 65 for hospital and medical
expenses. Medicare does not cover long-term care expenses. |
| Medigap |
Private health insurance that is used to pay costs not covered
by Medicare, such as deductibles and co-insurance |
| Mode of Premium Payment |
The schedule of payment of premiums, monthly, quarterly,
semiannually, or annually |
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| National Association of Insurance Commissioners (NAIC) |
A national organization made up of state officials who are in
charge of regulating insurance.
They have considerable influence and strive to promote
national uniformity in insurance regulations. |
| Named Insured |
The first person in whose name the insurance policy is issued |
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| Payment of Claim |
Timely payment, generally monthly after services have been
given to patient and the filed claim is proven valid |
| Peril |
The cause of a loss, insured against in a policy |
| Plan of Care |
A program of care and/or treatment that is set up with your
licensed physician and approved in writing before the start
of care |
| Policy |
A written legal contract of insurance issued by the insurance
company to the policyholder, which outlines the terms of the
insurance |
| Policy Holder |
Individual that has a written and signed agreement with their
insurance provider |
| Policy Language |
Clarity of policy explanation |
| Policy Lapse |
Length of time the since policy has been active (???) |
| Policy Term |
The length of time the insurance policy provides coverage |
| Premium |
The annual payment from the individual to the insurance policy
to keep the policy active. |
| Premium Rates |
Rates that determine amount of the premium. It is important to
research the history of rate increases for each perspective
carrier. |
| Premium Stability |
The amount of risk involved in maintaining current premium
rate. The lower the chance of the rate fluctuating, the
lower the risk and the higher the premium stability |
| Premium Taxes |
A state controlled tax this is placed on premiums charged by
insurance agencies operating within a state, generally these
taxes are two to three percent of the total premium |
| Proof of Loss |
Documents , such as bills that show the break down of money
spent on services provided |
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| Quote |
A proposed estimation of the needs of the assessed individual
to determine an appropriate policy |
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| Rate |
The pricing factor that the insurance company bases their
insurance buyer's premium |
| Rated Policy |
Also known as an "Extra-Risk" policy, this policy is issued at
a higher than stated premium rate due to extra risk in the
policy holder, such as impaired health or a dangerous
occupation |
| Ratemaking |
The process by which insurance companies determine the risks
and the pricing for the classes of insurance |
| Reimbursement |
Payment back to the claimant for expenses incurred out of
pocket which are inherently covered by the policy. |
| Renewal |
The continuance of the coverage of a policy that is beyond the
original length of time set in the original policy based on
the acceptance of the new policy's premium |
| Respite Care |
Care provided through a long-term care facility to temporarily
relieve the informal caregiver's burden of responsibility. |
| Rider |
Written contract agreement between insurer and insured which
changes the policy or certificate |
| Risk |
The chance of loss |
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| |
A schedule of benefit coverage that is given to each covered
person under the policy that states the premium amounts, the
payment mode, and a summary of benefits and limitations |
| Senescence |
The process of growing old |
| Senior Centers |
Provide an assortment of social and recreational services.
Many provide programs offering low cost or free meals. |
| Senior Citizen Policies |
Insurance policies for those over the age of 65. In many cases
these policies are in combination with coverage provided by
the government under the Medicare Program |
| Senior Transportation Services |
Help seniors with their shopping, medical appointments and
other appointments. |
| Severe Cognitive Impairment |
A loss or breakdown of the mental capability that is similar to
Alzheimer's Disease and similar forms of dementia. It is
measured by clinical evidence and standard tests that
provide valid information regarding the patient's impairment
which includes (1) memory both short-term and long-term, (2)
orientation to people, places, or time, and (3) deductive or
abstract reasoning. |
| Skilled Nursing Care |
This is the highest level of care provided by a Registered
Nurse (R.N) or a Licensed Practical Nurse (L.P.N) 24 hours a
day. It is prescribed by a physician for the most severely
impaired person who cannot perform their own personal needs. |
| Spousal Discount |
Set discount if policy holder is married |
| Stability of Carrier |
Strength of the insurance carrier based on their profitability
and market share |
| Substantial Supervision |
This is continuous supervision that is proved to those who have
Severe Cognitive Impairment, which threatens their health
and safety |
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| Tax Qualified (TQ) Policies |
Beginning January 1, 1997, long-term policies meeting certain
requirements qualify for favorable tax treatment. Buyers of
these plans may deduct the premiums if they itemize their
deductions on their Federal Tax return. Premiums are treated
as medical or health insurance expenses and must be equal to
more then 7.5% of adjusted gross income. Also, benefits
received from a Tax Qualified Plan (TQ Plan) are not taxable
up to $175.00 a day |
| "The Lion's Share of the Business" |
In relation to market share, how much of the industry the
company generates and controls, companies that have a large
market share are established and stable, with confidence in
their future. Low market share companies are much less
stable and often provide incentives such as low rates to
attract more customers. |
| Transition Expense |
Expense incurred during the time you are waiting for Home
Health Care |
| Transition Expense Allowance |
Set amount of funds paid during the waiting period, which may
be used for in home equipment |
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| Underwriting Process |
Steps through which an insurance application is reviewed by a
licensed insurance counselor to become approved for
insurance |
| Unique Features |
Benefits, options, and advantages that are particular to an
insurance carrier |
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| Validity of Claim |
Judgment passes on claim from house claims department, which
verifies that the claim is accurate and truthful |
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| Waiting Period |
Period of time lost while waiting for Home Health Care |
| Waiver |
An agreement attached to the policy that exempts from coverage
specific disabilities and injuries that normally would be
covered under the policy |
|
Written
Premiums |
The total amount of premiums due in a year for all policies
issued by an insurance company |
