3/14/25, 12:07 PM Life & Health Insurance Exam Prep / Comprehensive Study Guide – Expert Strategies, Review of Key Quizzes, and Practice Que…
Life & Health Insurance Exam Prep / Comprehensive
Study Guide – Expert Strategies, Review of Key Quizzes, and Practice
Questions for Guaranteed Success Complete exam for study
Terms in this set (157)
-Pay doctors and hospitals directly according to the
# of days of coverage that is provided in the contract
Service Based Contracts for each event and are prepayment plans. Once a claim
is settled, the insured will receive an Explanation of
Benefit (EOB), which is a written confirmation that the
claim was paid. Blue Cross and Blue Shield, Health
Service Corporations and Medicare coverage are all
provided on a Service Basis.
-Secondary benefits (inside benefits) because they occur inside
the hospital for
Miscellaneous Expense charges related to the stay. X-rays, prescriptions, MRI's,
Benefits anesthesia and lab fees are usually separate fees
incurred during a stay. Miscellaneous Expense Benefits
have
separate limits, referred to as Inside Limits. The are
expressed usually as a multiple of the daily amount
(UCR)
A schedule of procedures lists the amount allowable for each
procedure. If a
Surgical Expense surgical procedure is not found in the schedule, it will
still be payable. The amount payable for a procedure
not listed is based on its relative value to a procedure
of similar difficulty. There are usually no deductibles.
Is simply a price list. Each procedure is listed and a
Surgical Schedule
dollar amount assigned and if a procedure is not listed
in the schedule it is still paid.
qu… 1/26
,3/14/25, 12:07 PM Life & Health Insurance Exam Prep / Comprehensive Study Guide – Expert Strategies, Review of Key Quizzes, and Practice Que…
scientific method of paying different benefits based on
the region of the country an insured lives. It is based
Relative Value
on assigning a value to each procedure and using a
conversion factor. A schedule of assigned points for
each procedure must be included in the policy.
Pays for visits to the doctor (office hospital) plus post
operation care. There may be a per-visit benefit, or the
Physicians Medical Expense coverage is based on UCR.
-May or may not be a deductible . This policy is usually
written as an indemnity plan and has first dollar
coverage (no deductible).
-usually written as an indemnity plan and has first dollar coverage
-Cover "catastrophic" or huge loss. A Catastrophic loss
is defined as whenever Basic coverage runs out and
not a specific dollar amount.
Major Medical Expense -High Maximum Limits ($2,000,000)
-Deductibles (per person or per family ea yr))
-Co- insurance (Usually 80/20%)
-Stop Loss
-Miscellaneous Expense Benefits - x-rays, MRI, lab tests, etc.
- Once the deductible is met the insured and the
Coinsurance insurance company share in the expenses in what is
called coinsurance. It is written as 80/20, 70/30, etc.
Also called percentage participation requirement.
-Portion of medical expenses that are paid by the
insured each year before benefits start. The higher the
deductible the lower the annual premium will be.
Flat Deductible
-If a medical incident occurs in the last three months of
any plan year and the annual deductible has met the
yearly requirement then the medical treatment for that
incident only would be covered in the new plan year.
Thus a "carryover" into the next year of the paid
deductible has occurred.
Per Cause Deductible A separate deductible for each separate illness or accident.
Max amount the insured is required to pay out of
pocket: After the stop loss amount is reached by the
Stop Loss
insured, in a calendar year, the company will pay 100%
of the
qu… 2/26
, 3/14/25, 12:07 PM Life & Health Insurance Exam Prep / Comprehensive Study Guide – Expert Strategies, Review of Key Quizzes, and Practice Que…
remaining covered expenses.
-calculated by adding both deductibles and coinsurance
amounts.
Comprehensive major medical Major Medical and Basic Medical are written together.
Occurs in the middle of the hospital stay, and bridges
Corridor deductible
the gap from the basic to the major medical plan.
-To Prevent avoid adverse selection.
-A is a medical condition for which an insured sought
medical attention, treatment, or advice for symptoms
Pre-Existing Condition
or for which should have sought medical
advice/treatment in the previous 6 months.
-For individual policies, the exclusion can not exceed 24
months, for group policies 12 months, and for late
enrollees in group plans, 18 months.
-Injuries due to war or military conflict
-Elective cosmetic surgery
-Routine Dental Care
Exclusions found in Basic
-Eye Exams & Glasses Treatment in a Veterans Hospital or other
and Major Medical Gov Facility
-Workers Compensation Accidents
-Claims Occurring Outside the U.S.
-Intentionally Self-Inflicted Injury
Specified Coverage policies, or Limited Coverage, are
Limited Coverage
insurance policies that limit coverage to one illness or
one limiting group of coverage.
Policies provide a variety of benefits for a specific disease
such as a cancer policy or a heart disease policy. Benefits
Dread Dieses (Limited Risk)
are usually paid as a scheduled amount of indemnity for
specified events or medical procedures, such as
hospital confinement or
chemotherapy.
-Pays a lump sum to the insured upon the diagnosis (&
Critical Illness Plans
survival) of a critical illness. The insured must survive
the illness for a certain time period (Ex 30 days).
-Provides a specific amount on a daily, weekly or
Hospital Indemnity monthly basis while the insured is confined to a
hospital. The benefit payments are sent directly to the
qu… 3/26
Life & Health Insurance Exam Prep / Comprehensive
Study Guide – Expert Strategies, Review of Key Quizzes, and Practice
Questions for Guaranteed Success Complete exam for study
Terms in this set (157)
-Pay doctors and hospitals directly according to the
# of days of coverage that is provided in the contract
Service Based Contracts for each event and are prepayment plans. Once a claim
is settled, the insured will receive an Explanation of
Benefit (EOB), which is a written confirmation that the
claim was paid. Blue Cross and Blue Shield, Health
Service Corporations and Medicare coverage are all
provided on a Service Basis.
-Secondary benefits (inside benefits) because they occur inside
the hospital for
Miscellaneous Expense charges related to the stay. X-rays, prescriptions, MRI's,
Benefits anesthesia and lab fees are usually separate fees
incurred during a stay. Miscellaneous Expense Benefits
have
separate limits, referred to as Inside Limits. The are
expressed usually as a multiple of the daily amount
(UCR)
A schedule of procedures lists the amount allowable for each
procedure. If a
Surgical Expense surgical procedure is not found in the schedule, it will
still be payable. The amount payable for a procedure
not listed is based on its relative value to a procedure
of similar difficulty. There are usually no deductibles.
Is simply a price list. Each procedure is listed and a
Surgical Schedule
dollar amount assigned and if a procedure is not listed
in the schedule it is still paid.
qu… 1/26
,3/14/25, 12:07 PM Life & Health Insurance Exam Prep / Comprehensive Study Guide – Expert Strategies, Review of Key Quizzes, and Practice Que…
scientific method of paying different benefits based on
the region of the country an insured lives. It is based
Relative Value
on assigning a value to each procedure and using a
conversion factor. A schedule of assigned points for
each procedure must be included in the policy.
Pays for visits to the doctor (office hospital) plus post
operation care. There may be a per-visit benefit, or the
Physicians Medical Expense coverage is based on UCR.
-May or may not be a deductible . This policy is usually
written as an indemnity plan and has first dollar
coverage (no deductible).
-usually written as an indemnity plan and has first dollar coverage
-Cover "catastrophic" or huge loss. A Catastrophic loss
is defined as whenever Basic coverage runs out and
not a specific dollar amount.
Major Medical Expense -High Maximum Limits ($2,000,000)
-Deductibles (per person or per family ea yr))
-Co- insurance (Usually 80/20%)
-Stop Loss
-Miscellaneous Expense Benefits - x-rays, MRI, lab tests, etc.
- Once the deductible is met the insured and the
Coinsurance insurance company share in the expenses in what is
called coinsurance. It is written as 80/20, 70/30, etc.
Also called percentage participation requirement.
-Portion of medical expenses that are paid by the
insured each year before benefits start. The higher the
deductible the lower the annual premium will be.
Flat Deductible
-If a medical incident occurs in the last three months of
any plan year and the annual deductible has met the
yearly requirement then the medical treatment for that
incident only would be covered in the new plan year.
Thus a "carryover" into the next year of the paid
deductible has occurred.
Per Cause Deductible A separate deductible for each separate illness or accident.
Max amount the insured is required to pay out of
pocket: After the stop loss amount is reached by the
Stop Loss
insured, in a calendar year, the company will pay 100%
of the
qu… 2/26
, 3/14/25, 12:07 PM Life & Health Insurance Exam Prep / Comprehensive Study Guide – Expert Strategies, Review of Key Quizzes, and Practice Que…
remaining covered expenses.
-calculated by adding both deductibles and coinsurance
amounts.
Comprehensive major medical Major Medical and Basic Medical are written together.
Occurs in the middle of the hospital stay, and bridges
Corridor deductible
the gap from the basic to the major medical plan.
-To Prevent avoid adverse selection.
-A is a medical condition for which an insured sought
medical attention, treatment, or advice for symptoms
Pre-Existing Condition
or for which should have sought medical
advice/treatment in the previous 6 months.
-For individual policies, the exclusion can not exceed 24
months, for group policies 12 months, and for late
enrollees in group plans, 18 months.
-Injuries due to war or military conflict
-Elective cosmetic surgery
-Routine Dental Care
Exclusions found in Basic
-Eye Exams & Glasses Treatment in a Veterans Hospital or other
and Major Medical Gov Facility
-Workers Compensation Accidents
-Claims Occurring Outside the U.S.
-Intentionally Self-Inflicted Injury
Specified Coverage policies, or Limited Coverage, are
Limited Coverage
insurance policies that limit coverage to one illness or
one limiting group of coverage.
Policies provide a variety of benefits for a specific disease
such as a cancer policy or a heart disease policy. Benefits
Dread Dieses (Limited Risk)
are usually paid as a scheduled amount of indemnity for
specified events or medical procedures, such as
hospital confinement or
chemotherapy.
-Pays a lump sum to the insured upon the diagnosis (&
Critical Illness Plans
survival) of a critical illness. The insured must survive
the illness for a certain time period (Ex 30 days).
-Provides a specific amount on a daily, weekly or
Hospital Indemnity monthly basis while the insured is confined to a
hospital. The benefit payments are sent directly to the
qu… 3/26
