Insuring Clause

• General statement that identifies the basic agreement between the company and insured and states what kind of loss is covered.

Probationary Period

• Time after the payment that before the insured can start to use the benefits.
  

Elimination Period

• Waiting time to get the benefit after reporting a illness. Or accident.
• The longer is the elimination the lower is the premium or cost of coverage.

Waiver of Premium

• In the event of total and permanent disability premiums will be waived.
• Usually regulated by 3 to 6 months of disability. During this waiting period the insured needs to pay the premiums that will be retroactive to him.
• Usually expires when achieving the age of 65 without paying premiuns.

Pre Existing Conditions

• Are excluded to be covered in the plans due to the affordable care act.
  Can be covered by covered by Medicare supplement policies and long term care insurance.

Coinsurance

• typically 80% the insurance company pays but others as 90/10, 75/25 and 50/50.
• Control overutilization.
• Stop-loss limit - amount more than the stipulated for a year, the insurance company have to pay 100% of the utilization.
  

Copayment - Set dollar amount that the insured needs to pay everyt time he uses a medical service.

Deductibles

• Anual Deductible independent of the number of time they use it.
• Individual deductible for member of the familyor family deductible.
• Per occurrence or flat deductible.
• Common accident provision - only one deductible is applied when family members suffer the same accident.
• Integrateed Deductible - for regular policy and supplement.
• Carry - over provision - when you didn’t used the hole deductible for an year, the amount will be add to your new “limite”
• Considered as a copay in the total amount to pay for service.

Eligible Expenses

• Medical expenses covered and specified in the policy.

Pre - authorization and Prior Approval Requirements

• Some policies required that the insured inform the medical procedure or hospital stays in advance.

Usual, Reasonable and Customary URC Charges

• Benefit schedule states what is covered and how much. Other have this provision that means the insurance company will pay the average for procedure at that area.

Exclusions and Limitations

• War, military duty, self inflicted, dental, cosmetic, eye refractions and care in government facilities.
  Suspended when living abroador serving the military.
• Mental , emotional and substance abuse disorders - limit of visits and copay per year.

Impairment Rider

• coverage excluded in case of pre existing condition. Even for a back problem.
  
  

Guaranteed Insurability

• Future increase and guaranteed purchase also called.
• Can also have the in the contract a limit amount to ad disability coverage without evidence of insurability and only attained by age.

Rights of Rewewability

• Must be in the face page stated that is renewable but the insurer reserves the right to not do it???
• Non cancellable - guaranteed until 65 - then after Medicare coverage but not increasing the premiuns.
• Cancellable - not common and even ilegal in many states. Company cannot do that during a claim process.
• Guaranteed Renewable - increase the policy premium on the anniversary date on a class basis, not individual.