AMF Group Insurance key terms

The single contract issued to a group policyholder that covers all eligible members; individual participants receive certificates that summarize, but do not replace, its terms.

A document given to each covered member describing the benefits, exclusions, and limits provided under the master policy; it is evidence of coverage, not the contract itself.

The employer, association, union, or trustee that contracts with the insurer for coverage of a defined group of people and typically shares or pays the premium.

The interval between a person joining the group and becoming eligible for coverage, often expressed as days of service or full-time status.

A condition that an employee must be performing normal job duties on the day coverage would begin; absence due to illness or leave can delay the effective date.

A minimum percentage or number of eligible group members who must enroll before the insurer will issue or continue the group contract.

The tendency of people with higher health or mortality risk to seek or retain coverage more than lower-risk members, which group underwriting controls through eligibility and participation rules.

A pricing method that sets premium largely on the group's own past claims and expense history, often with retention of a margin and possible refund of favorable experience.

A pricing approach using pooled industry or insurer-wide rates by age, sex, occupation, or class rather than the specific group's own claims history.

A pricing method charging the same rate to all members of a defined geographic area or class regardless of individual health status, age, or claims experience.

A return of part of the premium when actual claims and expenses are lower than the amount retained under an experience-rated or retrospective arrangement.

The portion of premium an insurer keeps for expenses, risk charges, taxes, and profit before any experience refund or dividend is calculated.

An eligible person who enrolls after the initial eligibility period without a qualifying event; insurers may require evidence of insurability or delay benefits.

Health or medical information an insurer requires before approving coverage or an increased benefit amount, typically used for late enrollees or amounts above a guarantee issue limit.

The benefit amount an insurer will approve without medical underwriting for eligible group members, with amounts above that limit subject to evidence of insurability.

The process of evaluating a group's risk as a whole using factors such as industry, size, demographics, participation, and prior claims to set terms and premium.

Rules that determine which of two or more group health plans pays first and how remaining expenses are shared, preventing duplicate payment beyond actual cost.

The plan that pays first under coordination of benefits rules; the secondary plan then considers the remaining allowable expense.

A statement showing services billed, amounts allowed, the insurer's payment, and the member's remaining responsibility such as deductible, coinsurance, or copay.

The percentage share of covered expenses the member pays after the deductible, with the plan paying the remaining percentage up to any out-of-pocket maximum.

The most a member pays in a benefit period for covered in-network expenses through deductibles, coinsurance, and copays before the plan pays the full allowed amount.

A provision that restricts or delays benefits for a condition treated during a defined look-back period before coverage began, subject to applicable legal limits.

Prior health coverage that can reduce or eliminate a pre-existing condition exclusion period when the member moves between group plans without a significant break.

Life coverage provided to a group for a stated period, usually one year, paying a death benefit if the member dies while the policy is in force; it builds no cash value.

The member's written choice of who receives the death benefit, which generally overrides a will and should be updated after major life events.

The right of a covered member whose group coverage ends to convert to an individual policy without new evidence of insurability, within a stated time and at individual rates.

An option allowing a member to continue group coverage after leaving the group by paying the premium directly, often with limits on amount and duration.

Coverage paying an additional benefit for death by accidental means and scheduled amounts for loss of limbs, sight, or other specified functions from an accident.

Income replacement for a limited period, commonly weeks to months, for a member unable to work due to a non-occupational illness or injury.

Income replacement that begins after short-term benefits end and may continue for years or to retirement age, often with a reduced benefit after a defined period.

The waiting period after disability begins before benefits become payable, functioning like a deductible measured in time.

A disability standard that considers a member disabled if unable to perform the material duties of their own occupation, typically applied in the early benefit period.

A stricter disability standard that applies later in the benefit period and considers a member disabled only if unable to perform any occupation for which reasonably suited.

A plan design letting members choose among benefit options or allocate employer credits, often funded through pre-tax salary reduction arrangements.

A tax-advantaged employer arrangement permitting employees to pay certain premiums or expenses with pre-tax salary reductions, subject to nondiscrimination and election rules.

A benefit arrangement offering employees a menu of choices among cash and qualified benefits, frequently structured under Section 125 to gain favorable tax treatment.

A federal right for certain participants to continue group health coverage after a qualifying event by paying the full premium plus a permitted administrative charge.

A life or employment change such as termination, divorce, or loss of dependent status that can trigger continuation rights or a special enrollment opportunity.

A window outside the annual open enrollment when a member may add or change coverage because of a qualifying event, generally requiring enrollment within a set number of days.

The obligation of a plan administrator and others handling plan assets to act solely in participants' interest, prudently, and in accordance with plan documents.

The federal law setting minimum standards for private employer benefit plans covering reporting, disclosure, fiduciary conduct, and participant claim procedures.

The ethical requirement to recommend coverage that fits a client's needs, financial situation, and objectives rather than the producer's compensation or convenience.

A documented review of a client's income, obligations, existing coverage, and goals used to justify the type and amount of group benefits recommended.

The act of surrendering, lapsing, or reducing existing coverage to buy new coverage; it requires disclosure and a comparison showing whether the change benefits the client.