Glossary

Adjudication: The process of paying claims submitted or denying them after comparing claims to the benefit or coverage requirements. The adjudication process consists of receiving a claim from an insured person and then utilizing software to process the claims and make a decision or doing so manually

Administrative Fee: The cost associated with having your health care claim processed and filed by your insurance handler. Often this is a percentage of the total claim

Arete Group of Insurance Advisors Conference (AGIAC): Advisors focused on the group insurance marketplace Managing the human and financial impacts of employee health is among the challenges facing today’s group insurance advisors at Arete Human Resources’ first annual conference for group insurance advisors

Business Insurance: is a broad name for different coverage available to the business owner to protect against losses and to insure the continuing operation of the business. There are several types of business insurance including (but not limited to) property, casualty, liability, commercial auto and worker’s compensation

Benefit Plan: A major type of pension plan in which an employer/sponsor promises a specified monthly benefit on retirement that is predetermined by a formula based on the employee’s earnings history, tenure of service and age, rather than depending directly on individual investment returns

Claim Form: The standardized documents issued by insurance companies, brokers and administrators to collect personal information regarding paid for medical and health services by a licensed practitioner

Corporate Insurance Plans: Most common for senior executives of a firm insurance on employees’ lives that is owned by the employer, with benefits payable either to the employer or directly to the employee’s families

Cost-Plus Accounts: A cost Plus Account allows for reimbursement of eligible medical and dental expenses which otherwise would have been payable by the individual with after tax dollars. A Cost plus usually replaces a standard medical or dental plan as a Stand Alone program

Coverage: The total amount and type of insurance carried

Critical Illness: A medical condition that affects and changes the way you are able to live your life. This may be the result of a disease that prevents you from continuing with your work, earning regular income and preventing you from managing your life and expenditures

Critical Illness insurance: Critical Illness Insurance provides financial resources and security during the survival and recovery time due to a critical illness. Critical Illness Insurance Policies provide Lump Sum – Tax Free benefits to you – the insured, and are designed for you to use in any manner you choose

Deductible: The amount of expenses that must be paid out of pocket before an insurer will pay any expenses

Dental Insurance: Preventative cleaning and polishing, routine examinations and X-rays, fillings and extractions, fluoride treatments for children, pit and fissure sealants for children, space maintainers for children, general anesthetics, periodontal treatment, including cleaning and scaling, endodontics/root canal therapy, denture cleaning, repairs, rebasing and relining, dentures (full or partial), standard crown restorations or onlays on natural teeth standard bridges, including pontics, abutment retainers/crowns, son natural teeth, standard repair or recementing of crowns, onlays and bridgework on natural teeth, orthodontic treatment to straighten teeth and correct the bite

Dental Benefit: Payment for your dental claims resulting from services performed by a licensed dental practitioner

Dependent: A person who relies on another, especially a family member, for financial support

Disability Insurance: A form of insurance that insures the beneficiary’s earned income against the risk that a disability creates a barrier for a worker to complete the core functions of their work. For example the inability to focus or maintain composure as with psychological disorders or an injury, illness or condition that causes physical impairment or incapacity to work. It encompasses paid sick leave, short-term disability benefits, and long-term disability benefits

Disability Insurer: The person, organization or employer that provides disability insurance coverage

Education: The process of informing plan owners the costs, processes, functions and full utilization of their health plan

Employee: A person who is hired to provide services to a company on a regular basis in exchange for compensation and who does not provide these services as part of an independent business

Employee & Family Assistance Program (EFAPs): Employer paid benefits that support both the employees and the workplace. These services are designed to enable employees to resolve personal and work issues so that optimal work productivity is maintained. They include health, wellness and other strategic solutions for smaller employers

Employer: Person or institution that hires employees or workers. Employers offer wages or salary to the workers in exchange for the worker’s work or labour

Employer Paid Benefits: The monthly contribution that your employer pays to cover the cost of your benefits plan that is not a deduction of gross income. These paid benefits are considered a taxable benefit

Extended Health Insurance: Coverage for the cost of healthcare (medical, dental, vision) and wellness products and services not covered by provincial healthcare plans

Fee for Service Products: is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good

Flexible Spending Account: A FSA allows an employee to set aside a portion of earnings to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes, resulting in substantial payroll tax savings

Group Insurance Benefits: Insurance that covers a group of people, usually who are the members of societies, employees of a common employer, or professionals in a common group. Group coverage can help reduce the problem of adverse selection by creating a pool of people eligible to purchase insurance who belong to the group for reasons other than for the purposes of obtaining insurance

Group Life Insurer: The person, organization or employer that provides group life insurance products

Health & Wellness Strategy: A program or protocol for individuals in the workplace to follow which promotes healthy eating, physical activity, stress and sickness prevention tactics and a clear and healthy mind

Health Benefits Claim: A formal application and submittance of details for reimbursement of costs associated with services rendered for medical, dental, or vision requirements

Health Benefits Program: An employer provided or self-funded program that provides options for cost coverage of medical, dental, critical illness, disability, and death & dismemberment incidents. It also provides insurance payouts for loss of life, mortgage loss, incidents during the course of travel and damages to business resulting form a person’s inability to continue operating that business.

Health Services Plan: A program for individual or group use that includes employer health benefits, health insurance providers, program administrators and educational programs and support to administer a health program

Health Spending Account (HSA): A HSA resembles a personal bank account as it works with debits and credits. With a positive account balance, an individual may obtain reimbursement for eligible medical and dental expenses and the account is debited by the paid amount. The amount deposited into each account must be used within a specified period (1 or 2 years), after which an unused balance is forfeited. This “use it or lose it” principle is required by Revenue Canada for the HSA to qualify as a private health services plan and is necessary to maintain a reasonable element of risk in the benefit plan for insurers

Independent Financial Brokers (IFB): Independent Financial Brokers (IFB) is a not-for-profit Association representing independent insurance, mutual fund and other financial service professionals As an Association, our role is to enhance and protect the businesses of our members and to support consumer choice

Insurance (Health Insurance): Insurance coverage that pays for medical and surgical expenses that are incurred by the insured. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly

Insurance Broker: (also insurance agent) sells, solicits, or negotiates insurance for compensation

Insurance Brokerage: An insurance broker (insurance agent) sells, solicits, or negotiates insurance for compensation

Insurance Program: is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss

Insurance Requirement: The coverage need to maintain a health benefits program for health and medical services and render it cost-effective for both employer and employee

Insured Products: Claims and loss handling is the materialized utility of insurance; it is the actual ” product” paid for

International Travel: Travel that takes its participants overseas or out of the country of which they reside

Investment Program: A mix of investments for which the risk of investment usually varies in proportion to the return. Investments may include but are not limited to immediate annuities, total return portfolio, retirement income funds, bonds, property and equities

Life Insurance: A contract between an insured insurance policy holder and an insurer, where the insurer promises to pay a designated beneficiary a sum of money (the “benefits”) upon the death of the insured person. Depending on the contract, other events such as terminal illness or critical illness may also trigger payment. The policy holder typically pays a premium, either regularly or as a lump sum. Other expenses (such as funeral expenses) are also sometimes included in the benefits

Long-Term Care: can cover expenses such as care by a certified nurse, rehabilitation and therapy, personal care & home care services (assistance with daily activities such as: dressing, cooking, cleaning), supervision by another individual

Long-Term Disability: An illness or injury where it is determined that the employee is incapable of performing the essential duties of his/her job and is being treated by a physician for the related illness or injury. The terms and conditions of long-term disability pay will depend upon the insurance provider

Loss of Independence: A condition that occurs as people age, as they suffer physical, social or emotional setbacks which prevent them from functioning independently

Medical Benefit: Medical insurance that pays for medically required services of physicians and surgeons, as well as dental and oral surgery when it is medically required to be performed in a hospital

Mortgage: A loan secured by real property through the use of a mortgage note which evidences the existence of the loan and the encumbrance of that realty through the granting of a mortgage which secures the loan

Mutual Fund: A type of professionally managed collective investment vehicle that pools money from many investors to purchase securities. While there is no legal definition of the term “mutual fund”, it is most commonly applied only to those collective investment vehicles that are regulated and sold to the general public

Nutritional Awareness: The educated and learned concepts of what a person has available to eat, what is eaten and the effect of what the actual food intake has on the body and physical and mental abilities to perform in the workplace

Personal Insurance: Self-funded or employer supported coverage for incidents and costs associated with critical illness, disability, life, long-term care, loss of independence, home mortgage, travel, creditor protection and/or dependent

Practitioner: Someone who engages in an occupation, profession, religion, or way of life specifically noted in the field of medicine or medical services

Private Health Services Plans (PHSPs): an alternative method of providing medical and dental benefits for self-employed individuals, small business owners and larger sized businesses with several employees. PHSPs will cover virtually 100% of ALL medical and dental services performed or prescribed by a registered or licensed practitioner

Premium: The dollar amount registered on the books of an insurer or a reinsurer at the time a policy is issued and paid for

Prescription Drug Plan: Insurance coverage for prescription drugs provided through supplemental health plans sponsored by their employers. Others have coverage through publicly-funded plans offered by the provincial or federal governments

Program Design: Summary of a full list of health benefits requirements and “wishes” and design a program to include each of these components that works well with the structure and operations of your business. This can include but not limited to Health Spending Accounts, Cost Plus Accounts, Traditional Plan design, Individual/Personal Plans with Applicable health Benefits, Combination Plan (Include any of the components above) products and an annual review and adjustment

Property & Causal Insurer: The company or organization that provides insurance coverage against circumstances that create loss or damage to property or stoppages and downtime to the operation of a business

Reinsure: To insure again, especially by transferring all or part of the risk in a contract to a new contract with another insurance company

Return on Investment (ROI): A performance measure used to evaluate the efficiency of an investment or to compare the efficiency of a number of different investments. To calculate ROI, the benefit (return) of an investment is divided by the cost of the investment; the result is expressed as a percentage or a ratio

Securities: A tradable asset of any kind

Self-Funded Benefits Programs: Benefits programs for which the insured or owner of the plan makes the monthly and/or annual contribution to finance health insurance requirements. The funds allocated to this account are tax-free

Short-Term Disability: A benefit designed to provide temporary income replacement for worker absent due to illness or injury, but who is expected to return to work within a specified timeframe.

Stand-Alone Program: A program or portion of health insurance coverage that is purchased separately or on it’s own from other health benefits coverage

Third Party Administrator: A service or business other than the insuring company itself, that will process Extended Health, Dental and Short Term Disability Claims as well as verify and adjudicate all claims based on their eligibility according to the plan and to Revenue Canada’s guidelines. All necessary documents and receipts for tax purposes and co-ordination of benefits will also be provided

Traditional Group Insurance Plan: Sometimes called fee-for-service plan, you can use any medical provider (such as a doctor and hospital). You or they send the bill to the insurance company who pays part of it. Usually, you have a deductible, the amount of the covered expenses you must pay before the insurer starts to reimburse you — such as $200 — which you pay each year before the insurer starts paying

Travel Insurance: is insurance that is intended to cover medical expenses, financial default of travel suppliers, and other losses incurred while traveling, either within one’s own country, or internationally. Temporary travel insurance can usually be arranged at the time of the booking a trip to cover exactly the duration of that trip, or a “multi-trip” policy can cover an unlimited number of trips within a set time frame

Vision Plan: A financial protection plan that requires the policyholder to pay a monthly fee in exchange for reduced-cost fees on some eye health and vision correction services and products. Vision care insurance will often cover routine eye health expenses such as eye exams, contact lens fittings, contact lenses and eyeglass lenses and frames and may provide a discount on LASIK procedures. The plan may cover the cost of these items in full, up to a preset limit, or may require the policyholder to pay a flat fee or percentage fee to share the expense with the insurer

Wellness: The healthy and positive physical and mental state of an individual, employee and or employer