This area contains definitions of common words and phrases you may run across when reading MedBen forms, claims, EOBs and other documents. Most of the definitions are reprinted from materials published by the Health Insurance Association of America (HIAA).

Should you have questions regarding terms not defined here, please contact the MedBen customer service department at 1-800-686-8425 or e-mail medben@medben.com.

LATE APPLICANT
An eligible person who applies for insurance after the normal 31-day open enrollment period.

LEGAL RESERVE
The minimum reserve that a company must keep to meet future claims and obligations as they are calculated under the state insurance code.

LIMITATION
A provision that sets a cap on specific coverage.

LONG-TERM CARE
A wide range of health and personal care, ranging from simple assisted living arrangements to intensive nursing home care, for elderly or disabled persons.

LONG-TERM DISABILITY (LTD) INCOME INSURANCE
A benefits plan that helps replace earned income lost through inability to work because of disability caused by accident or illness.

MAJOR MEDICAL EXPENSE INSURANCE
A form of health insurance that provides benefits for most types of medical expense up to a high maximum benefit. Such contracts may contain internal limits and usually are subject to deductibles and coinsurance.

MANAGED CARE
The terms used to describe the coordination of financing and provision of health care to produce high-quality health care on a cost-effective basis.

MASTER POLICY (OR MASTER CONTRACT)
The policy issued to a group policyholder setting forth the provisions of the group insurance plan.

MATERIAL MISREPRESENTATION
A false or misleading statement of fact on an application for an insurance policy, which influences the insurer’s decision as to the prospective insured’s insurability. Such statements may serve as a basis for voiding the policy.

MATERNITY BENEFIT
Benefits for a normal pregnancy are paid under this provision of the hospital or medical policy rather than the regular provisions that apply to sickness, since maternity is not normally considered a sickness.

MAXIMUM BENEFIT
The maximum length of time for which benefits are payable during any one period of disability.

MEDICAID
A government insurance program for persons of all ages whose income and resources are insufficient to pay for health care; Medicaid is state-administered and financed by both the state and the federal government.

MEDICAL EXAMINATION
The examination given by a qualified physician to determine an applicant’s insurability or whether an insured claiming disability is actually disabled.

MEDICALLY NECESSARY
Term used by insurers to describe medical treatment that is appropriate and rendered in accordance with generally accepted standards of medical practice.

MEDICARE
A federally sponsored program that provides hospital benefits, supplementary medical care, and catastrophic coverages to persons aged 65 and older, and to some other eligibles.

MINIMUM GROUP
The fewest number of employees permitted under a state law to constitute a group for insurance purposes; the purpose of a minimum group is to maintain a distinction between individual and group insurance.

MISREPRESENTATION
A false or incomplete statement of relevant fact on an application for an insurance policy.  (See Material Misrepresentation.)

MONTHLY INDEMNITY
Benefit amount paid monthly under a health insurance policy.

MUTUAL INSURANCE COMPANY
An insurer in which the ownership and control is vested in the policyholders. MedBen is a mutual insurance company.

NETWORK PROVIDERS
Limited grouping or panel of providers in a managed care arrangement with several delivery points. Enrollees may be required to use only network providers or may have financing liability for using non-network providers for medical services.

NONCONTRIBUTORY PLAN
A group insurance plan under which the employer does not require employees to share in its cost.

NON-NETWORK PROVIDERS
Noncontracted or unapproved health providers who are outside a managed care arrangement.

OCCUPATIONAL HAZARDS
Dangers inherent in the insured’s occupation that expose him or her to greater than normal physical danger by their very nature.

OCCUPATIONAL RATE
A variation in premium based upon occupational class, due to difference among occupations in the incidence of accidents or illness.

OPEN ENROLLMENT
A time during which uninsured employees and/or their dependents may obtain coverage under an existing group plan without presenting evidence of insurability. Differs from a resolicitation in that a minimum number of applications are not required.

OUT-OF-NETWORK CARE
Medical services obtained by managed care plan members from unaffiliated or noncontracted health care providers. In many plans, such care will not be reimbursed unless previous authorization for such care is obtained.

OUT-OF-POCKET EXPENSE
Those medical expenses that an insured must pay that are not covered under the group contract.