Policy once the application has been signed, the medical examination completed, and the settlement for the premium tendered.
Amounts paid to providers based on plan.
Paid Claims Loss Ratio
Calculated as paid claims divided by total premiums.
Definition varies by policy. A condition as a result of injury or sickness when the insured cannot perform all of the duties of his occupation but a portion of them.
Partial Hospitalization Services
Additional services provided to mental health or substance abuse patients providing outpatient treatment as an alternative or follow-up to inpatient treatment.
Employee or former employee eligible to receive benefits from an employee benefit plan or whose beneficiaries may be eligible to receive benefits from the plan.
Number of employees enrolled compared to total eligible for coverage. Often, a minimum participation percentage is required.
Provision in contract stating that the insurer shares losses in an agreed proportion with the insured. Example: An 80-20 participation where the insurer pays 80% and the insured pays the 20% of covered losses. Many times erroneously referred to as coinsurance.
Permanent and Total Disability
Total disability from which the insured does not recover.
Permanent Partial Disability
Condition where the injured party's earning capacity has impaired for life, but he can work at reduced efficiency.
Permanent Total Disability
Condition where the injured party is unable to work at any gainful employment for balance of his lifetime.
Trained medical person providing rehabilitative services and therapy to help restore bodily functions (walking, speech, the use of limbs, etc.).
Place of Service
Where the actual services are performed. It may be home, hospital, office, clinic, etc.
Plan allows choice of receiving services from a participating or from nonparticipating provider.
Pool (Risk Pool)
Separate account including entries for income and expenses. Used when a number of groups are combined for the purposes of combining their premium and paying their losses.
Licensed individual providing custodial type care (help in walking, bathing, feeding, etc.). They do not administer medication or perform other medically related services.
Cost containment feature of group medical policies. The insured must contact the insurer prior to hospitalization and receive admision authorization.
Prior to admission as an inpatient in a hospital, specific criteria are used to determine whether the inpatient care is necessary.
Physical condition existing prior to the effective date of a policy. In many policies not covered until after a stated period of time has elapsed.
Preferred Provider Organization (PPO)
Organization consisting of hospitals and physicans providing, for a set fee, services to insurance company clients. These are preferred providers and insured selects from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal copayment for each office visit or hospital stay.