IC-38 Insurance Agent Exam - Health key terms

A contract in which an insurer agrees to pay specified medical costs or a fixed benefit in exchange for premiums paid by or for the insured person.

The person or entity that owns the health insurance contract, pays the premium, and holds the right to cancel or change the policy.

The individual whose health, medical expenses, or disability is covered under the policy; this may differ from the person who owns the contract.

The person named to receive policy proceeds, such as an accidental death benefit, when the insured dies while the coverage is in force.

The amount the policyholder pays, usually monthly, quarterly, or annually, to keep the health insurance coverage in force.

The amount of covered medical expense the insured must pay out of pocket each period before the insurer begins paying its share of claims.

The percentage split of covered costs shared between insurer and insured after the deductible is met, for example 80% paid by the insurer and 20% by the insured.

A fixed dollar amount the insured pays for a specific service, such as a doctor visit or prescription, at the time the service is received.

The cap on the covered costs an insured pays in a period through deductibles, coinsurance, and copayments; after reaching it, the insurer pays covered expenses in full.

A health condition, illness, or injury for which the insured received diagnosis or treatment before the effective date of the new coverage.

The insurer's process of evaluating an applicant's health history, age, and risk factors to decide whether to issue coverage and at what premium.

A physical exam, lab test, or health questionnaire the insurer may require during underwriting to verify an applicant's health status before issuing coverage.

A specific condition, treatment, or circumstance listed in the policy that the insurer will not cover, such as cosmetic surgery or self-inflicted injury.

A stated length of time after the policy effective date during which benefits for a particular condition or service are not yet payable.

The number of days of disability or hospitalization that must pass before benefits begin, functioning like a time deductible for income or hospital benefits.

The maximum length of time for which policy benefits are payable for a covered illness, disability, or hospital stay, such as two years or to age 65.

An optional provision added to a health policy that expands, limits, or modifies coverage, often for an additional premium.

A set number of days after a premium due date during which the policy remains in force and the insured may still pay without losing coverage.

The termination of coverage that occurs when a required premium is not paid within the grace period or other policy conditions are not met.

The process of restoring a lapsed health policy, usually by paying overdue premiums plus interest and providing evidence of insurability, subject to policy terms.

The clause stating the insurer's right, or lack of right, to cancel or refuse renewal of the policy at the end of a coverage term.

A policy feature under which the insured has the right to renew coverage without proving insurability, although the insurer may raise premiums for an entire class of policyholders.

A policy the insurer cannot cancel and must renew at the same premium and with the same benefits, as long as the insured pays premiums on time.

A traditional health plan that reimburses the insured for a set portion of covered medical expenses after the deductible, without requiring a network of providers.

A delivery system that controls cost and quality through provider networks, care coordination, and review of services, commonly seen in HMO and PPO plans.

A managed care plan in which members generally must use network providers and obtain care through a primary care physician who coordinates referrals.

A managed care plan that contracts with a network of providers offering discounted rates, while still allowing members to use out-of-network providers at higher cost.

The physician in many managed care plans who provides routine care, coordinates treatment, and authorizes referrals to specialists.

The group of hospitals, physicians, and other providers that have contracted with an insurer to deliver covered services at negotiated rates.

Authorization from a primary care physician allowing a patient to see a specialist or receive specialized services under a managed care plan.

The insurer's process of evaluating whether requested or delivered medical services are medically necessary, appropriate, and covered under the policy.

A request submitted to the insurer, with supporting documentation, for payment of benefits for covered medical services or losses.

Documentation, such as medical records or bills, that the insured must submit to support a claim and show the amount and cause of the loss.

Coverage that replaces a portion of earned income when the insured becomes unable to work because of illness or injury.

A disabling condition, defined by the policy, that prevents the insured from performing the substantial duties of their own occupation or any occupation.

A partial disability in which the insured can still work but earns less because of the impairment, often triggering reduced benefits under the policy.

A benefit, often added by rider, that pays an additional amount to the beneficiary when the insured dies from an accidental injury.

A false or misleading statement made by an applicant or insured on an application or claim, which may affect the validity of coverage or the payment of benefits.

The highest dollar amount or number of days the insurer will pay under a policy or for a particular covered service.