Lapin Law Offices offers the following general definitions of commonly used words and phrases in insurance policies, statutes, and by insurance agents and claim adjusters. Some words and phrases may have a different definition depending on the situation or if specifically defined in a particular insurance policy.
Actual Cash Value: Cost of replacing damaged or destroyed property with comparable new property, minus depreciation and obsolescence.
Aggregate Limit: The amount of coverage that an insured has under an insurance policy for a specified period of time regardless of how many separate claims are made.
Coinsurance: is the sharing of an insurance risk. It usually occurs when a claim could be very large that a single insurance company would not want to underwrite the entire risk. The underwriter is liable up to the agreed upon limit and the co-insurer’s becomes liable for amounts above that limit.
Conditions: You and your insurance company’s responsibilities under the policy. For example, you have the duty to pay your premiums on time and promptly notify the insurance company about an accident. Your insurance company has the duty to pay your accident-related medical expenses under your Medical Payment coverage.
Consolidated Omnibus Budget Reconciliation Act (COBRA): Under certain circumstances providers workers and their families who lose their health insurance benefits from their employer to continue receiving benefits for a limited period of time.
Coordination of Benefits (COB): Provision within insurance policies to determine which policies pays first. One plan is considered “primary” while additional plans are “secondary”, “tertiary” and so on. You are not entitled to any monies from the secondary or other policies until the primary policy is exhausted. In motor vehicle accidents, the insurance policy insuring the vehicle is primary while a person’s personal automobile insurance policy, if different, is secondary. In health insurance plans involving spouses, the employee’s insurance policy with their employer is primary while their spouse’s policy would be secondary.
Copayment: A preset, flat amount a person pays for medical treatment.
Coverage: Sets forth the specific circumstances in which you are entitled to receive benefits or benefits would be paid on your benefit.
Deductible: The amount of money you must pay before you can collect any money from your insurance company.
Employee Retirement Income Security Act (ERISA): Federal laws that provide standards, guidelines and rules regulating voluntarily established pension and health insurance plans.
Exclusions: Sets for the circumstances in which you or your car are not covered in an accident.
Explanation of Benefits (EOB): A document sent by an insurance company to an insured indicated the amount an insured was charged for medical services, the amount paid by the insurance company to the medical provider or if payments were not made and the reasons for the amount of payment or denial.
Guaranty Association: A non-profit organization, created by state statute, that assumes responsibility for.
Health Insurance Portability and Accountability Act (HIPAA): A federal act passed in 1996 that contains two major provisions. Title I relates to continuing insurance coverage for workers when they change or lose their job. Title II, relate to standards for health care providers and information. HIPAA is most widely known for its protection of health information.
Health Maintenance Organization (HMO): A prepaid group health insurance plan that contracts with physicians, hospitals and clinics for medical treatment. Insured’s must use contracted medical providers to receive benefits under an HMO plan.
Health Savings Account (HSA): A special bank account that allows you or your employer to contribute pre-tax money to be used for qualified medical expenses. To be eligible for a HSA you must be covered under a qualified high-deductible health insurance policy. Money paid into a HSA can be carried over to subsequent years. Penalties are imposed if the money is used for non-medical purposes.
Insolvency: Having more debts than assets or being unable to pay debts as they come due as they become due in the usual course of business. Insolvency does not mean the same as bankrupt. Bankruptcy is a judicial determination of insolvency. Insolvency does not necessarily lead to bankruptcy, but all bankrupt debtors are considered insolvent.
Pre-Existing Condition: A medical, either physical, mental, or psychology, condition that had been diagnosed or had existed prior to the issuance of the insurance policy. An insurance company may impose waiting periods before pre-existing conditions become covered or may not cover the pre-existing condition at all. In some instances, the waiting period may be eliminated or reduced if you were covered by a health insurance policy prior to the issuance of the new policy without any lapse in coverage. For example, if you covered by Acme Insurance then switch to Smith Insurance, and there is no period of time in which you were not insured, there may not be a waiting period for a pre-existing condition.
Premium: The total cost of the insurance policy that is determined by the types and limits of your coverages and deductibles.
Primary and Secondary Coverage: In most situations, the insurance policy for the vehicle being driven has the primary coverage. That means, it pays first. Secondary coverage is other coverage which could include your own coverage if you are a passenger in someone else’s vehicle. Secondary coverage is not paid until primary coverage is exhausted.
Qualified High-Deductible Health Plan: An insurance policy, usually with lower premiums, the covers medical expenses only after the insured has paid the deductible amount. To be eligible for a HAS the insurance plan must have a minimum deductible for an individual of $1,100 and $2,200 for a family.
Reinsurance: Insurance that an insurance company purchases to insure itself against large claims.
Replacement Cost: The amount to replace a damaged item without deducting for depreciation. The amount recoverable is limited by the amount set forth in the declarations page of the policy.
Reserve: An amount “set aside” by an insurance company to pay a claim. It is the job of an insurance adjuster to set the reserve. This is usually the maximum amount an insurer will pay in a settlement.
Split/ Dual Coverage Limits: Split/ Dual coverage limits set forth a per person and per accident maximum payment for any single accident. An example would be $25,000/$50,000. This means that the most any one person damaged in an accident can recover is $25,000 and the most the insurance company will pay out for an accident is $50,000 regardless of the number of people or property damaged.
Subrogation and Reimbursement: Subrogation is the right of a person or entity to assume the legal rights of another to enforce their rights. It can exist either by law or by contract. Most commonly, it arises in injury cases where an insurance company (automobile, health, disability) or governmental entity has paid your medical expenses and the injuries are due to another’s conduct. Generally speaking, it is a right to be reimbursed for any amounts paid on your behalf that another person is responsible for. For example, if you are injured in a car accident and your car insurance company pays $5,000 for your medical expenses they have the right to be reimbursed $5,000 from the party causing the accident.
Underwriting: An analysis of the risks of a potential insured used to set premiums or reject applicants.