A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | A Absolute Liability: This provides financial protection for innocent victims of a wrongdoer, even if the wrongdoer has violated the terms of the insurance policy. A common example is a pedestrian injured by an insured vehicle owned and operated by a driver whose license is suspended. The insurer would be under strict (or absolute) obligation to pay the pedestrian's damages. The insurer would not, however, be obliged to pay for damage to the car. The policyholder would have to reimburse the insurer for its payment to the pedestrian. Accidental Death, Disease & Dismemberment (ADD&D): ADD&D pays a benefit for accidental death. It also pays a benefit for loss of or loss of use of limbs, loss of speech, loss of hearing or loss of sight as the direct result of an accidental cause or a specified Critical Disease. Accidental Death & Dismemberment (AD&D): AD&D pays a benefit for death, loss of or loss of use of limbs, loss of speech, loss of hearing or loss of sight as the direct result of an accidental cause. Accident Benefits: This coverage provides compensation, regardless of fault, if you, your passengers, or pedestrians suffer injury or death in an automobile collision. Accident benefits coverage is compulsory in all provinces except Newfoundland and Labrador. Actively at Work: The plan member is working at the plan sponsor's place of business and is performing all of the normal duties of his/her own occupation on a full pay status on a regular and continuous basis for the number of hours regularly scheduled. Actual Cash Value: The market value of the property, taking into account things such as cost of replacement less any depreciation and obsolescence. In determining depreciation, the condition of the property immediately before the damage occurred, the resale value and normal life expectancy are considered. Actual Cash Value or Current Value: A method used to determine the value of an item. It is calculated as follows: ACV = The cost to replace the item - depreciation. Actuary: A person trained in mathematics and insurance who conducts statistical studies and determines policy rates, reserves and dividends. Actuaries also have responsibility for company solvency. Adjudication: The act of reviewing claims information and making a determination as to whether the claimant meets the policy requirements to receive benefits. Additional Living Expenses (ALE): If your home is unfit to live in as a result of a covered loss, or you are required to leave while repairs are being made, we will pay any necessary additional living expenses you incur to maintain your usual standard of living. Your Claims Service Advisor will help to make the necessary arrangements. Administration Fee: If you pay for your policy via pre-authorized payments through your bank account, an administration fee may be applied for this service. Administrative Services Only (ASO): An arrangement in which a plan sponsor contracts with a third party, such as an insurer, to provide services such as claims adjudication and processing. Age Limits: Stipulated minimum and maximum ages below and above which the company will not accept applications or may not renew policies. Agent: An individual licensed to sell insurance, who places business exclusively with one insurance company (e.g. The Co-operators). The agent is paid a commission by the insurer. This commission is part of the premium paid to the insurer by the policyholder. The agent is the policyholder's representative. Aggregate Stop-Loss: This is an arrangement where the total claims in excess of a predetermined percentage of annual premium over a fixed period of time are the responsibility of the insurer and are not charged to the experience of the plan. The insurer will charge a stop-loss or pooling charge to assume this risk. Allocated Loss (or Claim) Adjustment Expenses (ALAE): Expenses of loss adjustment that can be charged specifically to a claim. Examples would be certain legal, medical and other fees. Allowable Expense - See Eligible Expense All Source Compensation: Group disability plans take into account benefits received from all sources as a result of disability and adjust the group disability benefit so that total disability benefits from all sources do not exceed a certain percentage (e.g. 85%) of the income earned prior to becoming disabled. The purpose is to ensure there exists financial incentive for the plan member to return to work. Amendment: An addition, deletion or change to the group policy. Amount of Insurance: The maximum amount that could be paid in the event of loss with respect to specific policy coverage/section. Annuity: A contract that provides an income for a specified period of time, such as a number of years or for life. Antiselection: The tendency of an individual to select insurance based on his or her health status or expected medical care needs. Any Occupation Definition of Disability: For the purposes of long and/or short term disability benefits, disability or total disability may be defined as the inability to perform the duties of 'any occupation' for which the individual is trained or may reasonably become trained. This definition may apply from the initial date of disability or the plan may change from an 'own occupation' definition to 'any occupation' after the individual has been disabled for a period of time (commonly two years). Appraisal: Refers to a document completed by a reputable person with some expertise and knowledge of the item, on which a value is placed on the item (e.g., jewellery appraisal completed by a licensed gemologist; watercraft appraisal completed by a marine surveyor). Appraisers: Our Staff Appraisers assess damages caused to your vehicle as a result of an accident. For example, after an auto accident, our Claims Service Advisor assigns an Appraiser to view the damages and determine if the vehicle is reparable. If it is reparable, our Appraiser and the auto body shop will agree on a price to complete the repairs. If the vehicle is a total loss, our Appraiser will negotiate a cash settlement directly with you.
Assets: The items on the balance sheet which show the book value of property owned. Assignment of Benefits: The transfer of benefits, via a signature, from a plan member to a provider. For example, it is common practice to 'assign' dental benefits directly to the dentist. Average Premium: The average dollar amount of premium billed/received. Calculated by dividing Gross Written Premium by the average number of policies in force. Back to Top B Base Rate/Premium: The basic or fundamental rate/premium charged to every risk of a specific group. Basic Dental Services: Basic dental services will generally include the following services: Diagnostic - exams and x-rays Preventative - teeth cleaning and fluoride application Oral surgery - extraction of teeth Restorations - fillings and stainless steel crowns Prosthetic repair and reline - some carriers will include repair and
relining of dentures under
Basic services and some will include under Major services Beneficiary: A person designated by the plan member to receive benefits payable from group life insurance, accidental death insurance, optional accidental death insurance and optional life insurance if the plan member dies. The plan member may designate a different beneficiary for optional life than group life and accidental death benefits. The plan member may change this beneficiary at any time. Under a group policy the plan member is assumed to be the beneficiary for all other benefits not listed above.
Beneficiary, Contingent: An alternate beneficiary designated by the plan member to receive the benefits only if the primary beneficiary is not living. The plan member may change the contingent beneficiary at any time. Beneficiary, Irrevocable: A beneficiary who may only be changed with the written consent of the beneficiary. Beneficiary, Revocable: A beneficiary who may be changed at any time by the insured person, without the written consent of the beneficiary. Benefits: The covered services available to group benefit plan members and their eligible dependents. Benefit Plan: A list of specific benefits provided. Best Doctors®: A service that provides employees and their families with access to technologies and medical opinions of world-class medical specialists when seriously ill or injured. Best Doctors offers three progressive services: InterConsultation™, FindBestDoc™, and FindBestCare®. Billed Group: A policyholder for whom the insurer maintains plan member records, calculates required premium and produces a billing statement (usually monthly). Binder: A temporary agreement with a new insured, granting certain coverages, pending the issuance of the insurance policy. Bodily Injury: This coverage provides up to $200,000 if you are injured or killed through the fault of a motorist who has no insurance, or by an unidentified vehicle. You receive payment under this protection through the Uninsured Automobile coverage in your policy - unless the Canadian province, territory, or U.S. state where you were injured has a special fund from which to claim. You will be reimbursed for the money you would otherwise be entitled to receive from the uninsured/unidentified motorist. Boiler and Machinery Insurance: Coverage for loss arising out of the operation of pressure, mechanical, and electrical equipment. It covers loss of the boiler and machinery itself, damage to other property, and business interruption losses. Broker: An individual licensed to sell insurance, who places business with a variety of insurance companies. The broker is paid a commission by the insurer. This commission is part of the premium paid to the insurer by the policyholder. The broker is the policyholder's representative. Business Interruption Insurance: Protection for a business owner against losses resulting from a temporary shutdown because of fire or other insured peril. The insurance provides reimbursement for lost net profits and necessary continuing expenses. Business Life Insurance: Life insurance purchased by a business enterprise on the life of a member of the firm. It is often bought by partnerships to protect the surviving partners against loss caused by the death of a partner, or by a corporation to reimburse it for loss caused by the death of a key employee. Business Use: Vehicles used for business purposes, other than farming, including any driving done in the course of the client's occupation or for which direct or indirect compensation is received. It does not mean driving from home, or to and from place of employment. Buy-Sell Agreement: An agreement made by the owners of a business to purchase the share of a disabled or deceased owner. The value of each owner's share of the business and the exact terms of the buying-and-selling process are established before death or the beginning of disability. Back to Top C Canada Pension Plan (CPP): This government-administered social security program is funded by employee and employer contributions on a partial pay-as-you-go basis. The CPP operates in provinces other than Quebec. Carrier: A commercial insurer, government agency or other organizations that underwrite or administer programs that pay for health, life or other insurance services. Cash Surrender Value: The amount available in cash upon voluntary termination of a life policy by its owner before it becomes payable by death or maturity. Claim: A request to the insurer or reinsurer for payment of a loss that may come under the terms of an insurance contract. Claims Fluctuation Reserve (CFR): This reserve is designed to stabilize the experience of the plan in any given year when the plan has had adverse claims experience. Employee benefits such as life insurance, accidental death and long term disability are based on long term assumptions and so in any given year the experience of the plan will fluctuate greatly. Funds are drawn from the CFR to fund deficits created in a year when claims and retention charges exceed the premium paid. Claims Frequency: A measure of the number of claims, rather than the severity or seriousness of losses. Calculated by dividing the number of claims by the average number of policies in force. Claims Occurrence/Event: An event that results in an insured loss. Measured as the number of claims. Claims Service Advisor (CSA): An individual appointed to investigate and settle your claim. He or she may be employed by our company or working on our behalf for an independent adjuster. Coinsurance: The insurer and plan member commonly share the cost of eligible health and dental expenses, for example 80%: 20%. 'Coinsurance' generally refers to the insurer's share of the cost. Commercial Property Insurance: Insurance for businesses which provides coverage for fire and extended coverages, inland marine and multiple peril, among other risks. Commercial Vehicle: Commercial usage occurs when the main purpose of a vehicle's operation is to carry goods or materials for either distribution, delivery, or use; but does not include farm trucks as defined in this section. Consultant: A person or firm specializing in the design, sale and service of employee benefit plans. Consultants are commonly paid by their clients on a fee for service basis but may also be paid on a commission basis (see Broker). Consumer Price Index: Used to measure inflation, this is a measurement of the price of a basket of goods and services typically purchased by an urban family. Contribution to Pension: While the plan member is receiving long term disability benefits, the insurer will also make payments to a pension plan equal to the pre-disability payments made by the plan member and/or plan sponsor. Contract - See Policy. Conversion: Privilege given to plan members to convert to individual policies on termination of group insurance without providing health evidence. Coordination of Benefits (COB): The COB guidelines are designed by the health insurance industry to eliminate duplicate payments and stipulate the sequence in which coverage will apply when a person is insured under two contracts. Find Out More About COB in the FAQ Section. Co-pay: Similar to coinsurance but refers to the plan member's share of the expense and is usually used in relation to prescription drug benefits paid via a pay direct drug card. Example: 20% co-pay - the plan member pays 20% of the expense, the insurer pays 80%. Cost of Living Adjustment (COLA): An adjustment to long term disability (LTD) benefits according to the rise in the cost of living as measured by an index such as the consumer price index. COLA is an optional benefit which the plan sponsor may choose to include in the LTD plan. Cost Containment: Activities aimed at controlling or reducing benefit plan costs. Cost Plus: An arrangement between an employer and a benefits administrator where the administrator agrees to pay claims for employees and the employer promises to reimburse the cost of such claims plus an administration fee to the plan administrator. Expenses eligible for reimbursement are those allowable under a Private Health Services Plan as defined by the Income Tax Act. Coverage (Group): Benefits available to eligible plan members and their dependents under an employee benefit plan. Coverage (Indivual): The scope of the protection provided under a contract of insurance. Otherwise stated as an illness, injury, death, property loss, legal liability, or any other situation or loss for which an insurance company will pay benefits under a policy when such event occurs. More than one claims coverage may be created by one claims event. Claims operations typically monitor and manage claims coverages, whereas organization-wide key performance indicators typically monitor and manage number of claims.
Covered Person - See Plan Member Critical Disease Benefit: This benefit was developed by The Co‑operators as an add-on to our Accidental Death & Dismemberment (AD&D) benefit. Losses normally payable only due to accident are also payable when resulting from a specified critical disease. In addition, a lump sum benefit is paid if the plan member becomes totally disabled as the result of a critical disease which was diagnosed while insured under the plan.
Critical Illness (CI) Insurance: This coverage, available from some insurers, pays a lump sum benefit, usually following a specified survival period such as 30 days, on the diagnosis of a specified critical illness. The benefit is intended to help offset the costs associated with surviving a critical illness. CI generally covers cancer, heart attack or stroke plus a number of additional illnesses which vary from plan to plan. Crop-hail Insurance: Protection against damage to growing crops as a result of hail or certain other named perils. Back to Top D Dental Benefits: May be part of an employee benefit plan. Generally covering basic dental services and could also cover major dental services and orthodontics. Dental Fee Guide: Except Alberta, provincial dental associations publish a guide of suggested fees for dental services. Dental plans generally reimburse expenses in accordance with the suggested fees in the guide. Dependent: The spouse or child of a plan member, as defined in the policy. Dependent Life Insurance: Provides a life insurance benefit for the plan member's spouse and dependent children. Direct Compensation-Property Damage: In Ontario only: the portion of an auto policy that covers damage to your vehicle, its contents, equipment and loss of use if another vehicle causes damage to yours. There is no deductible unless you elected to have one for a reduction in your premium.
Direct Writer: An insurer that markets and sells insurance directly to its insureds without the assistance of independent brokers. Disabled Life Reserve (DLR): This reserve is established to fund the probable pay out by the insurer under a long term disability (LTD) claim. When an LTD claim is approved by the insurer, the insurer retains the claim whether the group policy remains in force with the insurer or not. Accordingly, the insurer must legally retain adequate reserves to fund this liability. Disability: A medically diagnosed condition that renders a plan member totally disabled as defined in the policy. Disability Management: The process of coordinating the activities of labour, management, insurer, health care provider and vocational rehabilitation professionals in order to minimize the impact of a worker's disability on the worker and the workplace and return the person to work as soon as is safely possible. Dividend: A return of part of the premium on participating insurance to reflect he difference between the premium charged and the combination of actual mortality, expense and investment experience. Such premiums are calculated to provide some margin over the anticipated cost of the insurance protection. Driver Training Course: An approved Driver Training Course is a course which observes the standards as agreed by the automobile insurance industry and administered by an approved Driving School Association on behalf of the Canada Safety Council. Driving Record: An operator's driving record is based upon the number of years accident free and the number of years for which a valid operator's licence has been held continuously for the type of vehicle or for which credit has been given because of an approved driver training course. Drug Formulary: A restricted list of prescription medications covered under a managed drug plan. Drug Plan: Eligible prescription medication covered as part of a group benefit plan.
Drug Utilization Review (DUR): A review system to monitor usage of prescriptions by subscribers. The DUR identifies potentially harmful drug to drug interactions, pharmacy hopping, double doctoring and non-compliance of prescribed medications. Back to Top E Early Intervention: Steps taken during the plan sponsor's self-insured sick leave period that will help to minimize absenteeism. Eligibility: The criteria for membership in the plan. Eligibility Period: A specified length of time, frequently 31 days, following the eligibility date during which an individual member of a particular group will remain eligible to apply for insurance under a group life or health insurance policy without evidence of insurability. Eligible Expense: A benefit listed in the policy. Elimination Period: The duration of time between the beginning of a disability and the start of the disability benefit payments. Emergency Medical Travel Assistance: This service, included with some extended health care plans, provides travellers with 24-hour emergency medical assistance including: referral to local doctors, the location of hospitals, confirmation of coverage to the hospital and advance payment if required, maintaining contact with doctors and family, arranging for medical transfer home by air ambulance and providing legal referrals, consulate and embassy references and telephone assistance with interpreters.
Employee Assistance Program (EAP): A program designed to help employees and their dependents resolve a broad range of personal problems that may affect job performance. Services may include psychosocial, financial, and legal counselling. Employee Benefit Booklet: A booklet in hard copy or electronic format, that provides plan members with a description of the benefits, eligibility requirements, limitations and exclusions. Employee Benefit Plan: A plan established by an employer or employee organization, or both for the purpose of providing certain benefits such as life insurance, disability, accident, medical and dental benefits. Employment Insurance (EI): A government-sponsored program to provide workers with unemployment, maternity, parental and sickness benefits. The plan is funded by employer and employee contributions. Endodontics: Dental treatment of the tooth pulp and roots. Endorsements: An additional piece of paper, not a part of the original contract, which cites certain terms and which, when attached to the original contract, becomes a legal part of that contract. Enrollment: The process by which an employee and/or dependents register to become insured members of a group benefit plan. It may be done by completing an enrollment form or electronically through on-line enrollment. Ergonomic Assessment: The study of factors in the workplace and the application of this study to adapt equipment and other technology to more effectively accommodate human needs and abilities. Excess Insurance: Generally refers to the amount of life or long term disability insurance in 'excess' of the non-evidence maximum. If, because of salary level, the plan member qualifies for excess insurance he/she must have health evidence approved before the excess coverage becomes effective. Exclusions - See Limitations and Exclusions. Experience: The relationship between the premiums paid to an insurer and the benefits paid to plan members by the insurer in a given period of time (usually one year). Experience Rating: The process of determining the premium rate for a group, based either partially or wholly on that group's past claims experience. Explanation of Benefits (EOB): A statement from the insurer sent to a plan member giving details about the claim which was submitted. The EOB summarizes the charges submitted, the amount deducted, the amount allowed, the amount paid, and the balance. Extended Health Care: Coverage for an extensive list of medical services generally including: prescription drugs, home nursing, out of country emergency medical services, hospital room, paramedical practitioners, medical equipment, eye exams, ambulance, etc. Back to Top F Facility Association (FA): A mandatory, shared market-pooling arrangement which provides automobile insurance to individuals who are otherwise unable to voluntarily purchase such coverage from private insurers. All insurance companies share in the results of the pool according to their percentage of voluntary business written. Fee Schedule - See Dental Fee Schedule. FindBestCare®: The third of three progressive services available through Best Doctors®. This service provides care management for employees and their families while receiving medical care due to serious illness or injury.
FindBestDoc™: The second of three progressive services available through Best Doctors®. This service helps employees to identify the care provider most qualified to meet their specific medical needs when seriously ill or injured. First Party: The person in whose name the policy is issued; technically the 'first party' of the contract. Also known as the 'policyholder' and 'named insured'. First Payor: Where insurance is provided under more than one policy, this is the insurer who pays first. See also Coordination of Benefits. Flat Benefit Formula: A formula that bases the benefit on a flat dollar amount, for example, a group life benefit of $50,000. Flexible Benefit Plan: A benefit plan that allows the plan member to select from a number of choices, the level of benefits most desirable to him/her. Selection is generally made on an annual or biennial basis. Fraud: If you try to gain by deliberately lying about a claim to your insurer, you forfeit your right to payment for the whole claim. To keep costs down for honest policyholders, insurers prosecute those who make fraudulent claims. Fully Insured Plan: A group benefit plan in which the insurer pays all claims and assumes all risks in exchange for premium payment. Back to Top G Generic Drugs: Drugs manufactured by generic drug manufacturers after a patent expires on the brand- name drug. Generic drugs contain the same active ingredients as the original brand-name drug and are less expensive. Grace Period: A specified period that allows for payment of the premium after the premium is due and during which the policy remains in force. Graduated Licensing: Graduated licensing is a stepped program for all drivers applying for their first driver's licence in Alberta, Nova Scotia, New Brunswick, Ontario, and Newfoundland and Labrador. The conditions and time frames associated with Graduated License varies provincially, but the objective is similar - allow drivers time and opportunity to gain experience and skills to operate a vehicle safely. Grandfathering: A term used to signify that prior benefit levels will be continued for specified individuals when coverage transfers to a new insurer. Gross Income: Refers to the client's income before taxes and expenses. Gross Salary: The plan member's regular earnings paid by the employer, generally excluding bonuses, commissions, dividends and overtime earnings. Group Benefit Plan: Generally refers to an employer/association sponsored benefit plan providing coverage to a group of employees or association members. Group Insurance - See Group Benefit Plan. Group Life Insurance: The benefit amount is paid to the named beneficiary upon the plan member's death, from any cause. Back to Top H Hazard: A condition which increases the chance of loss occurring. Health Evidence: This may be a questionnaire about one's health or could involve a medical examination by a physician, blood work, x-rays, etc. The insurer uses this information to approve or decline applications for all benefits where the plan does not have non-evidence limits or for late applicants, for excess insurance and optional life insurance. Health Evidence Maximum: The maximum benefit that will provided with approval of health evidence. Health Spending Accounts: Plan members allocate funds to be deposited to this account. During the plan year plan members are reimbursed tax free for health care expenses. Eligible expenses include those allowable by a private health services plan as defined in the Income Tax Act, which are not covered by other private or provincial health insurance plans.
Hold Harmless Agreement: An agreement in which the liability of one party is assumed by another. For example, the owner of a marina may request the owner of a boat to sign a Hold Harmless Agreement. The boat owner would then be liable for any damage caused by him or his boat while in the marina. The owner of the marina would assume no responsibility. Home Insurance: Property and general liability insurance available for homeowners, condo owners, and tenants. Home Nursing Care: The services of a professional nurse provided in the covered person's home. Back to Top I Incurred But Not Reported (IBNR): A reserve, based on estimates, to set up claims that have occurred but have not yet been reported to the insurer as of the date under consideration. Incurred Claims: The dollar amount of all claims paid or reserved during a period of time. Indemnity: A benefit paid by an insurer for a loss covered under a policy. Independent Medical Examination (IME)
The medical examination of a plan member who is claiming disability benefits. The examination is requested by the insurer and is conducted by a physician other than the plan member's own physician(s). The purpose is to determine whether the plan member qualifies for the benefits. Individual Stop Loss: This is an arrangement where individual claims above a pre-determined level (e.g. group life amounts over $250,000) are the responsibility of the insurer and are not charged to the experience of the plan. The insurer will charge a stop-loss or pooling charge to assume this risk. Integration: An adjustment in the benefit amount (usually refers to disability benefits) based on receipt of benefits from other sources. For example: long term disability benefits are commonly reduced by the amount received from the Canada Pension Plan as a result of disability. InterConsultation™: The first of three progressive services available through Best Doctors®. This service provides employees and their families with medical advice and treatment planning when seriously ill or injured. Back to Top L Legal Liability: Legal liability means liability at law for the consequences of some negligent act (as opposed to liability for breach of contract, for example). Liability Insurance: Insurance which serves to protect the insured from the financial consequences of damages claimed by third parties. Limitations & Exclusions: Conditions or circumstances for which benefits are limited or not allowed. Living Assistance Benefits: Advance of a partial life insurance payment to meet the expenses of terminally ill plan members who meet the conditions outlined in the policy. Long Term Disability (LTD): A plan that provides income protection to plan members who are totally disabled for an extended period of time, typically more than six months. LTD will generally reimburse a percentage of income between 50 and 70 percent. Loss Ratio: The ratio of claims and expenses to premium. Back to Top M Major Dental Services: Dental services including crowns, gold inlays, gold onlays, full dentures, partial removable dentures and fixed bridgework. Manual Rate: Premium rate for a group benefit coverage from the insurer's standard rate tables, based on the experience of an average group, not a specific group. Master Policy: A legal contract between an insurer and group policyholder in which the insured individuals (plan members) are not party to the contract. Maternity Leave: The period of time a plan member is absent from work and receiving employment insurance benefits while pregnant or after having given birth and while caring for a new-born baby or after adopting a child. Maximum Benefit:
The highest amount available under an insurance policy. Morbidity: The rate of disability or proportion of disabled individuals within a group or population. Mortality: Frequency of deaths within a group or population. Back to Top N Negligence: To fail to do what a reasonable and prudent person would do (or to do what such a person would not do); possibly resulting in property damage, injury, or death). Net Salary: Gross salary less involuntary deductions for income tax, CPP and EI. Non-Evidence Maximum: The maximum benefit allowable without having to submit health evidence for approval. No-fault Insurance: An insurance program/policy where, regardless of who caused the accident, you file a claim with your own insurance company. Nevertheless, it really does matter who caused the accident; the guilty party's future premiums may increase. No-fault insurance applies in Ontario. Quebec also had a degree of no-fault for bodily injury and death benefits. The other provinces have no-fault accident benefits coverages. In Newfoundland and Labrador, accident benefits coverage is not mandatory. Back to Top O Optional Accidental Death & Dismemberment: Accidental Death & Dismemberment benefits that the plan member may purchase on an optional basis. Optional Life Insurance: Life insurance available to the plan member and his/her spouse on an optional basis. Optional life requires approval of health evidence. Orthodontics: The treatment and appliances used in the correction of faulty meeting of the upper and lower teeth. Out of Country Emergency Medical Care: Benefits for emergency medical expenses incurred while travelling outside Canada. Expenses may include hospital room, physicians' services, medical supplies, x-rays, prescription drugs and ambulance service. Over the Counter (OTC) Drugs: Drugs for which a physician or dentist may write a prescription but which are legally available without a prescription for a lower cost. Most drug plans do not cover OTC drugs.
Own Occupation Period: The period of total disability during which the policy requires the plan member be unable to perform the duties of his/her type of work, typically a two-year period after which the policy changes to an any occupation definition. Ownership: Vehicles should be registered in the name of the real owner - the person who has a financial interest in the vehicle. For instance, if a son or daughter is buying a vehicle from a parent, or on installment payments, he or she is considered to be the real owner. Back to Top P Paramedical Practitioner: The services of health practitioners, for example: physiotherapist, chiropractor, massage therapist, psychologist, speech therapist, osteopath, naturopath, podiatrist or acupuncturist. Parental Leave: The period of time a plan member is absent from work and receiving employment insurance benefits while caring for a new-born baby or after adopting a child. Partial Disability: Some group benefit plans provide a level of income replacement when, due to a medically diagnosed condition, the plan member is only able to work in a reduced capacity. Participation Requirements: The percentage of employees who must join the plan. Pay Direct Drug Card: Electronic submission of drug or dental claims directly from the provider to the plan administrator. A card identifies the policyholder name, subscriber name and number. Peril: Something that causes or has the potential to cause damage or loss. Periodontics: Treatment of the soft tissue and bone surrounding and supporting the teeth. Pharmacare: The term for a drug benefit plan sponsored by some Provincial Health Insurance Plans.
Physical Hazard: The condition of, or pertaining to property, which could lead to the occurrence of loss. PID Number: The unique personal identification number assigned to each plan member. Plan Administrator: An individual or company responsible for administering a group benefits plan. Administration may include enrollment, record keeping, eligibility verification, premium processing and settlement of claims. The term is also used to describe the employee benefit contact person at the plan member's workplace. Plan Member: An employee or association member of the policyholder or affiliated company who has met the eligibility requirements for participation in the benefit plan. Plan Sponsor: The party that establishes the benefit plan, usually the employer. Policy: The legal contract between the insurer and the policyholder under which the insurer agrees to pay the policy benefit when the loss specified in the contract occurs and the policyholder agrees to pay the insurer the premium for providing this coverage. Policy Period: The duration of the policy, most often one year. Policyholder (Group): The owner of the policy, usually the employer. Pooled Benefits: The rates for pooled benefits are not affected by the actual claims experience of the group. Instead, the rates are affected by the claims experience of a collection of groups - the pool. Groups benefit from the spread of risk among the pool. Life and long term disability benefits are generally "pooled." Pooling Charge: The premium charged by the insurer to assume the risk under an aggregate stop loss or individual stop loss arrangement. Posaction® Employee Assistance Program (EAP): An EAP service available to clients of The Co-operators that provides counselling services for employees and their dependents who are experiencing family, work-related, personal, substance abuse, legal, and financial problems. Posaction® Plus: A management assistance program designed to provide managers with the resources they need to reduce the number and length of employee absences due to illness and disability. Posaction® Plus is provided through The Co‑operators arrangement with Solareh. Visit Solareh's Posaction® Plus website. Predetermination: Insurers typically ask plan members to submit a cost estimate for dental or health care expenses likely to exceed a certain amount (e.g. $400). The insurer responds in writing outlining how much of the expense the plan will pay if the service is rendered while the coverage is in effect. Pre-existing Condition: A medical condition that existed prior to becoming insured. Some plans may cover these conditions after a certain period of time (e.g. one year) while others may permanently exclude benefits if the loss is caused by the pre-existing condition. This is most commonly found in long term disability policies. Premium: The amount of money a policyholder agrees to pay an insurer for providing the benefits outlined in the policy. Premium Tax: A provincial tax charged on group benefit premiums. Pre-Natal Benefit: This benefit, found in relatively few group benefit policies, reimburses the cost of a funeral for a still-born infant. Prescription Drug Plan - See Drug Plan. Prescription Drug Formulary - See Drug Formulary. Primary Insurance: The provision of primary coverage by an insurer. The primary insurer has a direct contractual relationship with the insured and is named in the insurance policy. Principal Residence: The dwelling where the insured resides more than 50% of the time. Principal Sum: The lump sum payment made for accidental death and sometimes for loss of sight, loss of hearing and certain dismemberment losses in an accidental death & dismemberment (AD&D) plan. Proof of Loss: The information the plan member is required to provide to prove his/her entitlement to benefits under the policy. Property and Casualty (P&C) Insurance: All types of insurance excluding life insurance and governmental insurance. Property Insurance: Covers an insured's property against damage, destruction or loss by an insured peril. Proposal: A proposed plan of action; an offer that is presented for acceptance or rejection. Provider: An individual or organization providing health or dental services. Provincial Health Insurance Plan: Provincial government-sponsored plans that provide some degree of coverage for services such as hospital care, chronic care and drugs. Back to Top Q Quebec Pension Plan: Operated in the province of Quebec it is the equivalent of the Canada Pension Plan (CPP). Back to Top R Rate Category/Class: A grouping of factors into a single category, so as to reduce the number of variables, for determining a premium. Rate/Rating: Rate is the cost per unit of insurance coverage. Rating factors such as rate class, amount of insurance, location, etc., will determine a policy or coverage premium. Reasonable & Customary Expense: The current common charge made for a similar procedure in a particular geographic area. Refund Accounting: In its simplest form, refund or retention accounting means the annual determination of the past year's surplus or loss. Funds are then either owed by the policyholder to the insurer, or to the policyholder by the insurer. The plan is credited with premiums and interest and charged with claims and expenses. Rehabilitation Program: Provided at the discretion of the insurer, this program is designed to assist disabled workers return to work. It may include assessment, treatment, rehabilitative employment and other services. Reimbursement Plan: Plan members submit a claim for payment (reimbursement) by the insurer. Reinsurance: Basically, this is insurance for insurance companies. When an insurance company has too large a risk to carry alone, they purchase insurance from a reinsurer. Part of their risk is covered by another insurer, known as the reinsurer. The process would be transparent to the policyholder. Reinsurance Company: To protect the insurance company from major losses, the primary insurer will typically hold a designated amount of the risk themselves. Amounts in excess of that are placed with a reinsurance company under a reinsurance agreement. In the event of a claim, the primary insurer would pay the claim and collect from the reinsure company. The process would be transparent to the policyholder. Renewal: Continuance of coverage under a policy beyond its original term by the insurer's acceptance of the premium for a new policy term. Reported But Not Paid Reserve (RBNP): A reserve established to fund the eventual payout of claims that have been received but remain unpaid at the end of the accounting period. Reserve: A sum set aside by an insurer as a liability to fulfill future obligations. Retention Accounting - See Refund Accounting. Retention Charges: Also known as expense charges, this is the portion of premium charged by the insurer for expenses and profit. Return-to-Work Program: A program of rehabilitation and job modification to get disabled workers back to work as quickly as possible. Reunderwriting: Reviewing policies to ensure that they are adequately rated to reflect the risk involved. Rider: Additional coverage for a basic policy in order to provide insurance for a specific item or peril. Risk (Group): The probability of an event occurring. Risk (Individual): The subject of the insurance coverage. Risk Factors (Group): Conditions that influence risk (e.g. age, sex, occupation, industry). Back to Top S Salary - See Gross Salary. Salary Continuation Plan - See Short Term Disability and Long Term Disability. Schedule of Benefits: A summary of the benefits and amounts of insurance available under the policy. Second Opinion Consult: A service that provides plan members access to advice from specialists at top North American hospitals if diagnosed with a serious illness. Second Party: The insurance company issuing the policy is considered to be the second party. Two parties, the insured and the insurer, are necessary to form a contract; i.e., the policy. See also First Party. Selection of Criteria: Particular criteria or features of a risk that determine whether or not it is an acceptable risk to insure. Self-Billed Group: Records are kept by the plan sponsor and positively enrolled with the insurer, eliminating the need for the plan sponsor to verify health and dental claims. Self-Reporting Group: The policyholder maintains records for each plan member, verifies the plan member's eligibility, calculates the required premium and remits premium to the insurer. Service Partners: Our Service Partners include body shops, contractors, and rental companies who provide claims service to you in the event of a loss. Established parameters determine who we do business with. We research and meet our Service Providers to ensure they share our business objectives - quality and customer service that exceed your expectations. Short Term Disability (STD): Also known as weekly indemnity, this is a plan that provides income protection to plan members who are totally disabled for a short period of time, typically less than six months. STD will generally reimburse a percentage of income between 50 and 70 percent. Sick Leave: An employer-administered income replacement plan that replaces full salary on a short term basis in the event of the plan member's disability. Subscriber: Term used describe a plan member under a pay direct drug card plan. Subscriber Number: The unique personal identification number assigned to each plan member with a pay-direct drug and/or online dental plan. Superintendent of Insurance: The chief officer of the Government Insurance Regulatory Department that governs the insurances industry. Surcharge: The increase in base premium due to accidents, convictions or a specific uses of the vehicle. Survivor Benefit: In the event of the death of the plan member, provides continuation of health and dental benefits to the plan member's dependents. Back to Top T Term Insurance: Life insurance coverage for a specific length of time, as specified in the contract; for example, a 20-year term. Termination: The conditions that result in the plan member's benefits ceasing (e.g. termination of employment). Third Party Administrator: The party such as a professional insurance administrator or broker who maintains all records regarding the individuals covered under a group benefits plan. The TPA will generally be responsible for premium calculation and collection and may also pay claims. Third Party Liability: A disability caused by an injury or sickness that another party is responsible for. For example, injuries from an automobile accident where the other driver was responsible. If you have a group disability plan, it is common for the group disability insurer to pay disability benefits in this situation after receiving a signed agreement from the plan member to reimburse the group disability insurer when the third party claim is settled. Total Disability: As the result of a medically diagnosed condition, the plan member is prevented from performing the usual and customary duties of his/her occupation and is not engaged in any other occupation or performing any work for profit. Back to Top U Underwriting: The process of selecting risks for insurance and determining the dollar amount and coverage terms under which the insurance company will accept the risk. Underwriting Profit (or Loss): (1) The profit or loss realized from insurance operations, as contrasted with that realized from investments. (2) The excess of premiums over losses and expenses (profit) or the excesses of losses over premiums (loss). Uninsured Motorist: Coverage for damage to your auto, its contents and loss of use where a third party who is responsible for the accident is identified and uninsured. This coverage is subject to a deductible. See also Third Party. Universal Life Insurance: A flexible premium life insurance policy under which the policyholder may change the death benefit from time to time (with satisfactory evidence of insurability for increases) and vary the amount or timing of premium payments. Premiums (less expense charges) are credited to a policy account from which mortality charges are deducted and to which interest is credited at rate which may change from time to time. Back to Top V Vision Care Benefit: A benefit that reimburses a portion of expenses for prescription eyewear. Some plans also include a benefit for laser correction surgery.
Vision Provider Network: A network of providers offering plan members access to an expanded array of vision care benefits. Void ab initio: To cancel a policy ab initio is to cancel from the beginning. Back to Top W Waiting Period - See Elimination Period. Waiver of Premium Reserve: This reserve is set up when a plan member qualifies for the waiver of premium. It funds the potential liability of a life insurance claim as premiums are no longer received but the insurer retains the liability even if the policy is cancelled. Weekly Indemnity - See Short Term Disability. Whole Life Insurance: Life insurance payable to a beneficiary at the death of the insured whenever that occurs. Premiums may be payable for a specified number of years (limited payment life) or for life (straight life). Workers Compensation: Provincially sponsored, employer-funded income replacement plan for work-related accidents and illness. In Ontario this is referred to as the Workplace Safety & Insurance Board. Back to Top | 