Claim: Request made by the insured for the insurer to remit payment due to a loss incurred and covered by the policy agreement. In most cases, an adjuster will inspect the damage to your home and offer you a certain amount of money for repairs, depending on the terms and limits of your home policy. The first check you receive from your insurance company is usually an advance of the full settlement amount, not the final payment. Insurance company: An insurance company must have a license from the Department of Insurance to sell health insurance.
The insurer issues policies that describe coverage. An insurance policy is a contract between the insured and the insurance company. You pay premiums to an insurance company. Then, they pay some or all of your medical provider's bills when you need treatment.
Managed care plans (sometimes called health maintenance organizations or HMOs) also offer medical coverage, receive different treatment in California, and are not considered safe. National Association of Insurance Commissioners (NAIC): organization governed by insurance commissioners from all 50 states. The insurance responsible for paying your claim first, before it pays for secondary insurance (for patients who are covered by more than one insurance). Underwriting: the process of selecting insurance risks and classifying them according to their degree of insurability so that insurance companies can assign appropriate rates.
Adjuster: A person who works for the insurance company to determine if the insurance company is responsible for the claim and then pays benefits if they are due. Medicare Supplement Insurance: Sometimes called Medi-GAP, these are insurance policies that you can take out to pay for things that Medicare doesn't cover. For people who are covered by more than one insurance plan, the secondary policy may cover expenses after the main insurance has paid its share of the health care bill. Coverage: The scope of protection provided by an insurance contract that includes any of the benefits listed in an insurance policy.
Broker: person authorized by the State to sell insurance coverage with several health plans or insurers. Experience Rating: A way to adjust the workers' compensation insurance premium for a specific risk, comparing the losses of an insured party with the average losses of employers in a similar sector. The NAIC provides data and analysis to promote uniform insurance regulation, monitors the financial health of insurance, and develops model laws for state legislatures to enact. It also allows the insured and the doctor to know what procedures the insurance company will cover and at what price.
There are questions that an injured employee can send to the insurance company and questions that an insurance company can send to the injured employee. Independent Medical Review (IMR): A process in which expert medical professionals, who have no relationship with their health insurance company or health plan, review specific medical decisions made by the insurance company. Texas workers' compensation insurance companies must report claim data, medical data, and proof of insurance coverage to the DWC through EDI. National Compensation Insurance Council (NCCI): an association of insurers that sell workers' compensation coverage and that operate as a rating organization.
Agent: In the insurance industry, an insurance company appoints an agent to sell insurance policies.