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Exclusions found in Basic and Major Medical
-Injuries due to war or military conflict
-Elective cosmetic surgery
-Routine Dental Care
-Eye Exams & Glasses Treatment in a Veterans Hospital or other Gov Facility
-Workers Compensation Accidents
-Claims Occurring Outside the U.S.
-Intentionally Self-Inflicted Injury
Limited Coverage
Specified Coverage policies, or Limited Coverage, are insurance policies that
limit coverage to one illness or one limiting group of coverage.
Dread Dieses (Limited Risk)
Policies provide a variety of benefits for a specific disease such as a cancer
policy or a heart disease policy. Benefits are usually paid as a scheduled
amount of indemnity for
specified events or medical procedures, such as hospital confinement or
chemotherapy.
,Critical Illness Plans
-Pays a lump sum to the insured upon the diagnosis (& survival) of a critical
illness. The insured must survive the illness for a certain time period (Ex 30 days).
Hospital Indemnity
-Provides a specific amount on a daily, weekly or monthly basis while the insured
is
confined to a hospital. The benefit payments are sent directly to the insured and
can be used for any purpose.
Travel Insurance
Covers most kinds of travel accidents, but only for a specified period of time.
Workers Compensation
A benefit required by the state and benefits will vary to some degree from state
to state.
This coverage is made available through government programs, private
insurers, or by self-insuring. To be eligible the employee must work in an
occupation covered by Workers Compensation insurance, and have had an
accident or sickness that is work related.
Disability Income Insurance
-Designed to replace income lost due to a disability or illness of the insured wage
earner. It never pays for the medical expenses; it only replaces lost income and
must be paid no less frequently than monthly. Its to avoid Economic Death.
-Can be group of individual policy
,Malingering
Making the loss last longer than it has to.
DI Position Schedule
Used in employer sponsored group plans because it bases the benefit on the
position held in the company.
DI Flat Dollar Amount
In the event the insured becomes disabled the policy might pay a flat $1,000 per
month, regardless of any other income benefits.
DI Taxation
. If an individual buys Disability Insurance with his/her after-tax dollars, the
benefits will be tax-free. On the other hand, when employers pay for Group
Disability Income benefits, the benefits are taxable to the employee.
Morbidity Tables
-Based on the law of large numbers.
-Predict how many people are going to be disabled in a given year and the
severity the disability.
-Tables are important to an insurer because some insureds become more
disabled than others.
, Total Disability
The inability to perform the duties of one's own occupation for which a person
is suited by reason of education, training or experience.
Partial Disability
May be related to loss of Time, Function or Compensation. Partial disability is
defined as the inability to perform one or more of the regular duties of one's
own occupation or the inability to work on a full time basis, which results in a
decrease in income.
Permanent Total Disability
The most severe of the classes. The insured will never work again. Examples might
be paralysis or coma.
Temporary Total Disability
Insured is rendered unable to work for a period of time, but recovery can be
anticipated. Maternity leave or traction for a bad back are examples.
Permanent Partial Disability
refers to a type of injury, which is permanent, but the insured can still work. A
loss of a finger is an example of this type of injury
Temporary Partial Disability
The least severe of the classifications and usually refers to a disability which
lasts a very short period of time. A sprained ankle which takes seven or eight
days to recover would be an example