BAY AREA INSURANCE TERMS
GLOSSARY
A-B
Annualized
Premium: The total
amount of premiums paid
within 12 policy months. For
example, if the monthly
premium is $10, the
annualized premium is $120
($10 x 12 months).
Assignment:
The transfer of ownership
rights in a life insurance
policy or other type of
contract from one party to
another, or the document
that causes the transfer of
ownership rights to go into
effect.
Benefit Period:
The maximum number of days
for which benefits can be
paid for any one or
successive periods of
confinement or disability.
C
Cafeteria
Plan/Flex Plan —
Participating:
A benefit plan maintained by
an employer for its
employees, under which all
participants have the
opportunity to select
benefits that are suitable
for their lifestyles, and
for which premiums can be
deducted from their
paychecks on a pre-tax
basis.
Cafeteria
Plan/Flex Plan —
Nonparticipating: A
benefit plan maintained by
an employer for its
employees, under which all
participants have the
opportunity to select
benefits that are suitable
for their lifestyles, and
for which premiums can be
deducted from their
paychecks on an after-tax
basis.
Canceled:
Policy terminated by
request.
Claim:
Written proof of financial
loss.
Claims History:
History of claims previously
processed.
Compliance (or
Conformity With State and
Federal Statutes):
To abide by the statutory
requirements established at
the federal, state, and
industry levels.
Continuous
Coverage: Occurs
when a person is deleted
from a policy and issued a
new policy under one of the
following conditions: policy
upgrade, divorce of a
husband and wife who hold a
family policy, dependent
child has reached the age
limit or marries, a husband
and wife decide they want
separate policies.
Conversion:
The process of exchanging
benefits for the purpose of
increasing or decreasing
coverage.
Copayment:
The fixed amount and/or
percentage amount you pay
for covered services after
meeting any applicable plan
deductible.
Copayment/coinsurance
maximum: The limit
on the amount you pay for
certain covered services
during a calendar year. Once
the maximum is reached Blue
Shield will pay 100% of the
allowable amount for all
applicable covered services,
up to specified maximums for
the rest of the calendar
year. Certain PPO plan
covered services, such as
office visits, generally do
not count towards these
maximums, and continue to be
your responsibility.
Coinsurance
(applies to plans
underwritten by Blue Shield
Life): The percentage of the
allowable amount or billed
charges that you pay for
covered services after
meeting any applicable plan
deductible.
D
Decline:
An applicant is denied
coverage with Aflac for
specified reasons.
Deductible:
The initial amount you pay
in a calendar year for
particular covered services
before Blue Shield pays.
Denial:
The process of reviewing a
claim and deciding that, due
to the terms of the policy
contract, no benefits are
due for the claim.
Dental Hygienist:
A legally qualified person,
other than a member of your
immediate family, who is
licensed by the state to
treat the type of condition
for which a claim is made.
Dentist:
A legally qualified person,
other than a member of your
immediate family, who is
licensed by the state to
treat the type of condition
for which a claim is made.
Dependent
Children: Please
see your policy for
specific definition.
Direct Billing:
A mode of premium payment in
which policies are billed on
an individual basis to the
policyholder at home.
DOD:
Date of death.
Downgrade:
Change in coverage to a plan
with lower premiums/benefits
than that of the original
plan.
Due Date:
Date to which premiums have
been paid.
E-F
Each Subsequent
Year: Every
12-month period after the
policy year.
Effective Date:
Date the policy goes into
effect.
Effective Date
Family: Date family
coverage was added to the
policy.
Elimination
Period: Please see
your policy for a specific
definition.
Employer
Statement: Part of
the Aflac claim form that is
to be completed by the
employer.
Endorsement:
An endorsement adds or
deletes a person or benefit
to/from an existing policy.
The endorsement is mailed to
the policyholder to attach
to the original policy.
Entire Contract
Clause: A provision
in an insurance contract
stating that the entire
agreement between the
insured and the insurer is
contained in the contract,
including the application
(if it is attached),
declarations, insuring
agreements, exclusions,
conditions, and
endorsements.
Excessive
Coverage: A
policyholder is covered by
two or more like policies
which, when combined,
provide more coverage than
Aflac guidelines allow.
Exclusion:
An exclusion refers to a
person(s) or a condition(s)
not covered by the policy
due to policy provisions or
underwriting requirements.
First Policy
Year: The period of
time that begins on the
effective date of coverage
as shown in the Policy
Schedule and ends 365 days
from the effective date.
Flex One ®
: The
trademarked name of Aflac's
Section 125 Cafeteria Plan
(see Cafeteria Plan above
for more detail).
G-K
Grace Period:
A period of time beyond the
due date for premium payment
(usually 31 days) during
which time a policyholder
may still remit the premium
payment without losing
coverage.
Group Number:
A five-digit identification
code assigned by Aflac for
group billing.
Guaranteed-Issue:
Insurance coverage for which
there is usually no
individual underwriting. All
eligible members of a
particular group of proposed
insureds who apply for the
policy and who meet certain
conditions are automatically
issued a policy.
HMO: HMO
stands for Health
Maintenance Organization. An
HMO provides comprehensive
health care by network
physicians to enrolled
individuals and families in
a particular geographic
area. It is financed by
fixed periodic payments
determined in advance. In an
HMO, you need to access care
through a designated
Personal Physician.
Husband and Wife
Only: Coverage for
the insured and the spouse
only.
Immediate Family:
Anyone related to the
insured in the following
manner: spouse, brother, or
sister (includes stepbrother
and stepsister); children
(includes stepchildren);
parents (includes
stepparents); grandchildren;
father- or mother-in-law;
and spouses of any of these,
as applicable.
Inactive:
Term used to describe a
policy that is lapsed,
terminated, or canceled.
Indemnity:
Term used to describe a
benefit that pays a specific
dollar amount rather than
the actual charges or a
percentage of the charges.
Individual:
Coverage for only the
insured person listed in the
Policy Schedule.
Initial Start
Date: The actual
date the account was
established.
Insured:
Primary person covered under
the policy.
Insurer:
The party to an insurance
arrangement who undertakes
payment for losses, provides
benefits, or renders
services.
Issue Date:
The effective date of the
policy.
Issue State:
State in which the policy
was issued.
L-O
L&Es:
Limitations and exclusions
regarding policy provisions
and benefits.
Line of Business:
Refers to various types of
policies sold by Aflac (for
example, cancer, intensive
care, accident).
Minimum Salary
Requirements:
Salary required to qualify
for the total amount of
coverage provided by the
policy.
Non-preferred
providers (applies
to PPO plans): Providers who
have not contracted with
Blue Shield (or Blue Shield
Life as applicable) to be
part of our preferred
provider network.
Non-preferred providers
often charge members more
than Blue Shield allowable
amounts. You are responsible
for the difference between
the amount the non-preferred
provider bills and any
amount that Blue Shield
pays. Some PPO plan
benefits, such as certain
preventive care and office
visits, are not covered when
accessed from these
providers.
Occurrence Date:
Initial date of loss for a
specified claim.
One-Parent
Family: Please see
your policy for a specific
definition.
Original
Effective Date: The
effective date of the policy
as stated in the Policy
Schedule.
P
Paid-to Date:
The day, month, and year
through which a policy is
paid.
Participating
Employee: Status of
an employee who chooses to
participate in an account's
Section 125 Cafeteria Plan.
Pending:
A claim that cannot be
processed completely until
additional information
requested by the
claims specialist is
received.
Personal
physicians (applies
to HMO plans): Providers who
have contracted with Blue
Shield to provide primary
care to HMO members and to
refer, authorize, supervise
and coordinate the provision
of all care to members.
Physician
Statement: The part
of the claim form that is to
be completed by the
physician.
Plan Effective
Date: Beginning
date of coverage for a
current plan.
Plan Code:
Six-digit code used to
identify the type of policy
payable under the plan.
Policyholder:
Person listed as the owner
of the policy and who is
responsible for premium
payment.
PPO: PPO
stands for Preferred
Provider Organization. Blue
Shield PPO plan members
receive full coverage by
using doctors and hospitals
within the PPO network, or
they can pay more to have
the freedom to go outside of
the network for care. In our
PPO plans, contracted
doctors and hospitals are
called preferred providers.
Preferred
providers (applies
to PPO plans): Providers who
have contracted with Blue
Shield to be part of our
preferred provider network.
Preferred providers render
covered services to PPO plan
members at contracted rates
(allowable amount). Except
for applicable deductibles,
copayments, coinsurance and
amounts above the plan's
benefit maximums, they will
accept Blue Shield's payment
as payment in full. Members
under a Blue Shield Life
plan access Blue Shield Life
Preferred Providers.
Premium:
The amount of money required
at specified intervals to
keep a policy contract in
force.
Pre-existing
condition: An
illness, injury or condition
for which medical advice,
diagnosis, care or treatment
was recommended or received
from a licensed health
practitioner during the six
months prior to the plan
effective date.
Pre-tax:
Premiums that are deducted
from the employee's paycheck
before taxes are calculated
and deducted.
Preventive care:
Primary preventive medical
services provided by a
physician for the early
detection of disease when no
symptoms are present.
Primary
Policyholder: The
person to whom the policy
was issued.
Proof of Loss:
Written proof that is
required to be furnished to
the insurer about a loss to
help determine the extent of
insurer liability.
Provider:
A facility, licensed as
such, that provides health
services for an individual.
Q-T
Reinstatement:
The act of putting a lapsed
policy back in force.
Reinstatement
Date: Date the
lapsed or terminated policy
was put back in force.
Replacement
Policy: A policy
that has replaced a similar
product from another
company.
Rider: A
supplementary section or
page that is attached to and
made a part of the insurance
contract to modify or add to
the coverage the contract
provides.
Supplemental
Insurance:
Insurance policies designed
to supplement other basic
coverage.
Term:
Period of time the policy is
in force.
Terminated:
A term used to describe a
policy or account that is no
longer active.
Termination Date:
The actual date the coverage
ceased.
Transit One®:
Name of Aflac's Section 132
transportation expense
program.
Two-Parent
Family: Please see
your policy for a specific
definition.
U-Z
Unearned Premium:
The portion of the written
premium that can be applied
to the unexpired or unused
part of the period for which
the premium has been paid or
refunded to the insured. For
example, in the case of an
annual premium, at the end
of the first month of the
premium period, 11/12 of the
premium is unearned.
Waiting Period: Please
see your policy for a
specific definition.
Waivered
condition: A
condition that is excluded
from coverage for charges
and expenses incurred six
months from the effective
date of coverage. A waivered
condition only applies to a
condition for which medical
advice, diagnosis, care or
treatment (including
prescription drugs) was
recommended or received from
a licensed health
practitioner during the six
months immediately preceding
the effective date of
coverage.
Waiver of
Premium: The
provision of the policy that
relieves payment
responsibility for the
policyholder as defined in
the policy.
Note:
Some definitions included
here are from
Insweb.com.
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