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.

SCHEDULE
A listing of amounts payable for specified occurrences (e.g., surgical operations, laboratory tests, x-ray services, and such).

SECOND SURGICAL OPINION
An attempt to verify the need for surgery by encouraging insureds to seek the advice of another physician or surgeon whom will not perform the operation.

SELF-FUNDING
A medical benefit plan established by an employer or employee group (or a combination of the two) that directly assumes the functions, responsibilities, and liabilities of an insurer.

SELF-INSURANCE
A program for providing group insurance with benefits financed entirely through the internal means of the policyholder, in place of purchasing coverage from commercial carriers.

SHORT-TERM DISABILITY (STD) INCOME INSURANCE
Form of health insurance that provides benefits only for loss resulting from illness or disease, but excluding loss resulting from accident or injury.

SOLVENCY
Ability to pay all legal debts.

SPECIALTY PHYSICIANS
Those physicians practicing in areas other than internal medicine, family practice, or pediatrics.

STANDARD PROVISIONS
Policy provisions setting forth certain rights and obligations of insureds and insurers under health insurance policies.

STOP-LOSS INSURANCE
Protection purchased by self-insured and some managed care arrangements against the risk of large losses or severe adverse claim experience.

THIRD-PARTY ADMINISTRATION
That method by which an outside person or firm, not a party to a contract, maintains all records regarding the persons covered under the group insurance plan and may also pay claims using the draft book system.

THIRD-PARTY PAYER
Any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients.

TIME LIMIT
The set number of days in which a notice of claim or proof of loss must be filed.

TOTAL DISABILITY
Generally, a disability that prevents insureds from performing all occupational duties.  The exact definition varies among policies.

UNBUNDLING OF CHARGES
The practice of making separate charges for components of a surgical procedure that results in a total fee that is higher than the usual fee for the procedure as a whole.

UNDERWRITER
The term generally applies to: (a) a company that receives the premiums and accepts responsibility for the fulfillment of the policy contract; (b) the company employee who decides whether or not the company should assume particular risk; or (c) the agent who sells the policy.

UNDERWRITING
The process by which an insurer determines whether and on what basis it will accept an application for insurance.

UNIFORM PREMIUM
A rating structure in which one premium applies to all insureds, regardless of age, sex, or occupation.

USUAL AND CUSTOMARY CHARGE
A charge for health care that is consistent with the average rate or charge for identical or similar services in a certain geographic area.

UTILIZATION
Patterns of usage for a single medical service or type of service (e.g., hospital care, prescription drugs, physician visits). Measurement of utilization of all medical services in combination usually is done in terms of dollar expenditures. Use is expressed in rates per unit of population at risk for a given period, such as number of annual admissions to a hospital per 1,000 persons over age 65.

UTILIZATION REVIEW
A program with various approaches designed to reduce unnecessary hospital admissions and to control inpatient lengths of stay through use of preliminary evaluations, concurrent inpatient evaluations, or discharge planning.

WAITING PERIOD
The time a person must wait from the date of entry into an eligible class or application for coverage to the date the insurance is effective.

WAIVER (EXCLUSION ENDORSEMENT)
An agreement attached to the policy and accepted by the insured that eliminates a specified pre-existing physical condition or specified hazard from coverage under the policy.

WAIVER OF PREMIUM
A provision that, under certain conditions, a person’s insurance will be kept in full force by the insurer without further payment of premiums.  It is used most often in the event of permanent and total disability.

WELLNESS PROGRAMS
Employer programs provided to employees to lessen health risks and thus avoid more serious health problems.

WORKERS’ COMPENSATION
Liability insurance requiring certain employers to pay benefits and furnish medical care to employees for on-the-job injuries, and to pay benefits to dependents of employees killed by occupational accidents.