Accidental Death and Dismemberment (AD&D) – Provides benefits in the event of Paralysis, loss of life, limbs or eyesight/hearing as the result of an accident.

Accumulated Sick Leave – The number of sick days accumulated by an employee. May be used in conjunction with a Long Term Disability (LTD) policy Elimination Period.

Accumulation of Elimination Period – In some Long Term Disability (LTD) contracts, if a disability stops during the Elimination Period for less than “x” days (varies by contract & length of Elimination Period inforce), the disability will be treated as continuous. Concurrently, days that the insured is not disabled will not count towards satisfying the Elimination Period. Refer to your specific contract for more information.

Actively at Work – An employee is deemed actively at work when they are performing the regular duties of their own occupation.  An employee on vacation or holiday is also considered actively at work.

Activities of Daily Living (ADL) – Activities such as bathing, dressing and toileting that are needed for self-care. ADLs are measured to evaluate the continued feasibility of self-care.

Acute Care – Treatment for a short-term or episodic illness or health condition.

Actuary – An individual professionally trained in the mathematical and technical aspects of insurance, pensions and related fields. An Insurance Actuary determines reserves, policy rates and dividends. Also may conduct statistical studies.

Addition – An employee who has completed the required waiting period and comes under the provisions of the plan after the effective date.

Administration – Denotes the broad aspect of handling all functions of the Group Insurance plan once it has been submitted; claims functions may or may not be included.

Administrative Services Only (ASO) – A type of Employee Benefit Plan that is administered by an Insurance Company or Third-Party Administrator (see TPA) and in which the Employer is at risk for claims.

Administrator – The person responsible for the Administration of a Group Insurance Plan.

Admitted Carriers (International Benefits) – Insurance companies licensed to conduct specific types of business in a given country.

Advance Binder Payment – The premium deposit paid by the Employer when an application is completed for a Group Insurance policy. Typically, it is equal to the estimated first month’s premium. The Binder Payment is applied as such when the actual premium for the first premium frequency is calculated. 

Adverse Selection – also referred to as Antiselection.         A tendency for poorer risks to seek or continue insurance to a greater extent than normal risks; the process by which risks not contemplated by the company become insured. A person with an impaired health status or with expected medical care needs applies for insurance coverage financially favorable to himself/herself; and detrimental to the insurer. The tendency of an individual to recognize his/her health status in selecting the option under an insurance plan that tends to be most favorable to the individual (and/or dependents).

Agency/Agent – A relationship in which one person acts for, or represents another by the latter’s authority.

Amalgamation – Merger; combining of two or more corporations or companies.

Amendment – An addition, deletion or change in a legal document. A change in the provisions of an existing Master Policy; or the initiation of a new plan.  A plan amendment may increase benefits, including those attributed to years of service already rendered (see Retroactive Benefits). A formal and legal documented change to an employee benefits plan.  An amendment may increase or decrease benefits, change benefit provisions, or eligibility.

Ancillary Services – Hospital services exclusive of routine services such as room, board, dietary, nursing & supplies. Examples: Radiography and Lab tests.

Anniversary Date – The date on which the policy becomes effective; and at 12 month intervals from the original effective date.

Annual Report (or Statement) – The Annual Statement is a report showing the assets, liabilities, summary of operations and other exhibits and schedules that is required to be filed with various state insurance departments, as of December 31^st each year.

Anti-Selection – Please refer to Adverse Selection.

Antitrust Issues (Health Care) – Issues to be addressed in any joint efforts that may involve restraint of trade.

Application – A statement of information made by a person applying for insurance. It identifies: the plan, the beneficiary/beneficiaries, the life insured, the amount applied for, as well as other useful data in assessing the overall risk.

Assignment of Benefits – The signed transfer of certain benefits by the insured person to a Third Party. For example, Insured persons exercise “Assignment of Benefits” at the Dentist whereby Dental work is provided and the insured “signs-off” on the Dental Claim Form. Behind the scenes, the Dentist submits the claim directly to the Insurer. In turn, the Insurer pays the Dentist directly. Assignment of Benefits may also be used for services such as Vision Care, Massage, and Physiotherapy, to name a few. Assignment of Benefits is most often at the discretion of the service provider.

Attained Age – The age attained at one’s last birthday which does not change again until the next birthday. 

APS – Attending Physician Statement

Audit, Claim – An audit performed by an Insurance Company representative, which consists of checking the accurate payment of claims in accordance with the contract provisions and further verifying that the claimant was eligible for benefits at the time the claim was incurred.

Basic Monthly Earnings (BME) – The insured’s monthly rate of earnings from the employer in effect just prior to the date that a disability begins. The standard BME definition is Salary only. However, some insurers may consider an alternate definition such as: Salary + Bonus, Commission and/or Overtime pay, if a pre-determined formula is supplied at time of initial Underwriting.

Beneficiary – Person(s) named by the plan member in an insurance policy to receive any benefits provided by the plan, upon death of the plan member.

Beneficiary (Irrevocable or Absolute) – Unalterable Beneficiary. The owner relinquishes the right to change the beneficiary designation.

Benefit – The amount payable by the Insurance Company to a claimant, assignee, or beneficiary under each inforce coverage.

Benefit Percentage – The percent of covered salary allowed under the contract to determine the benefit payable.

Benefit Booklet – A booklet for the employee that contains a general explanation of benefits and related provisions of the Group Insurance plan.

Brand Name Drug – is referred to as the first drug  developed, said to be the original, and permitted on the market.

Broker – Brokers represent the buyers of Insurance, rather than the Insurance Companies. These Brokers are licensed individuals who place business with a variety of Insurance Companies. Most often, Brokers are paid commissions by the Insurance Companies. In some instances, Brokers are paid on a “fee-for-service” basis.

Business Travel Accident Insurance – Coverage for an accident while traveling on company business. Generally applies to all accidents occurring while away from home, not just those during actual travel.

Calendar Year – Runs from January 1st to December 31^st inclusive.

Canada Pension Plan/Quebec Pension Plan (CPP/QPP) – The two major social security programs here in Canada. The provisions of these two government-administered plans are virtually the same. Both are funded by Employee & Employer contributions on a pay-as-you-go basis. QPP operates in the Province of Quebec. CPP operates in the balance of Canada.

CAPSA – Canadian Association for Pension Supervisory Authorities. 

Cardiopulmonary Resuscitation (CPR) – Emergency medical procedure to deal with the respiratory arrest or insufficiency, obstructed airway and cardiac arrest. Involves removing airway obstruction, rescue breathing and external chest compressions.

Carrier – The party (Insurer) to the group contract who agrees to Underwrite (carry the risk) & provide certain types of coverage & services.

Case Rate – The rate derived by combining the Experience Rate and the Manual Rate. The Experience Rate is weighted by the credibility factor and the Manual Rate is weighted by (1 – credibility factor).

Cede - To transfer to a reinsurer, all or part of the insurance (or reinsurance) written by a given insurer (the ceding or direct writing company).

Census Data – Statistical information such as Dates of Birth, Gender, Income, Occupation, etc. Census Data is used by the Insurers to determine premium rates or benefits.

Certificate of Insurance – A document that is given to insured members of a Group Insurance plan. This document outlines the plan coverage parameters.

Chemotherapy – Treatment of internal disease by chemical reagents (including drugs), primarily involved in the treatment of cancer

Claim – A demand by an insured person for the benefits provided by the group contract. 

Claimant – Plan Participant who files a claim for Benefits. See Beneficiary.

Claims Adjudicator – An organization that provides the services of reviewing submitted claims & determining the eligibility of such claims, based on the terms of the contract.

Claims Experience – Measures Paid Premiums versus  Paid Claims. 

Claim Frequency – A measurement of the use of a plan of insurance. It is the number of claims in a given period.

Claims Incurred – The total number of claims paid for the period plus changes in the reserves held for incurred but unreported, unsettled or continuing claims. It represents the estimate of the total liability created in the policy year by the plan of benefits in effect for that policy year.

Claim Lag – The time interval between incurred date of a claim and claim submission to the insurer for payment; also used to mean the time between incurred date of a claim and payment (cheque or redemption).

Claim Reserves – Must be held by an Insurance Company to cover the liability that has been incurred by reason of carrying the risk to a certain point of time. Even though the risk may be discontinued at that point, claims may still be due under the terms of the contract, and other claims may not be reported until after the actual date of termination of the contract. The claim reserve must be sufficient to meet all such claims that are properly payable even though they may not be reported at the precise time of cancellation

Coinsurance – A policy provision whereby the Insured Person and the Insurance Company share in a specified ratio: such as 20%/80%, after the deductible is satisfied (if any). Also referred to as a Percentage Participation clause.

Composite Rate – A group premium rate that does not differentiate between Single and Family coverage. For example, a Group LTD (Long Term Disability) rate would be an example of a Composite Rate.

Consumer Price Index – Measures changes in the cost of living, via tracking cost changes in common household expenses. This "basket" of goods consists of food, shelter, clothing, transportation, health care and other average household expenditures.

Contributory Plan – A benefit plan under which Employees bear part of the cost.

Conversion Privilege – A privilege granted in an insurance policy for individuals to convert to a different plan of insurance, usually without providing evidence of insurability. The privilege granted by a Group policy is to convert upon termination of Group coverage.

Coordination of Benefits (COB) – A policy provision that assigns the order in which coverage will be applied in the case where an insured is covered under two contracts. COB was designed to eliminate duplicate payments & provide the sequence in which coverage will apply. For example, if both spouses elected Family coverage through their employer’s Health & Dental Plans, the responsibility for primary coverage falls to the parent having the earlier birthday in the Calendar Year, regardless of which parent is older. In the event that the birthdays occur on the same day, the employer-provided Health plan that has covered a parent the longest pays first.

Co-payment - Payments made by consumers, in addition to deductibles & coinsurance. Co-payments are normally a  pre-determined payment amount  that is paid by the insured with every claim submitted.  Most often, Co-payments are used as a cost containment measure to deter superfluous utilization of a benefit.  For example, a Prescription Drug plan may have a $ 10.00 Co-pay.  Hence, the Insured will be required to pay the first  $10.00 of every Prescription Drug claim.

Cost-of-Living Adjustment (COLA) – Also may be referred to as Cost-of-Living Allowance. An across-the-board adjustment to wages (or pension benefits) according to the rise (or fall) in the cost of living as measured by an index. In Canada, the Consumer Price Index (CPI) is often used as a measurement for the cost of living.  (See CPI).

Coverage – The amount of insurance or benefit stated in the group policy for which the insured employee is eligible.

Covered Payroll – The amount of salary that will be covered by the LTD (Long Term Disability) payroll. Used in calculating the indemnity.

Credibility – The degree of belief given to individual case claims /premium experience.

Credibility Factor – Actuarial factors based on the number of lives, gender composition and age distribution of a group. Used to determine how much weight is put on the pure experience rate.

Day Surgery – means any surgery performed by a Physician that requires General or Local Anesthesia, with the exception of any minor surgery performed in the office of a Physician.

Deductible – A pre-defined dollar amount & out-of-pocket expense that must be paid by the Insured, before benefit payments will begin.  Deductibles are used as a cost containment measure.  For example, a Dental Plan includes a $50 deductible.  Hence, the claimant is required to pay the first $ 50 of eligible Dental claims.  Once the $50 Deductible  is paid (or satisfied), the remaining eligible Dental expenses will be adjudicated by the Insurer.

Dentist – A person who is licensed to practice Dentistry by the appropriate authority of the jurisdiction where the services are provided.

Dismemberment ­– Los of body member (limbs) or use thereof; or loss of sight/hearing due to injury.

Dispensing Fee – The Pharmacist’s charge that is included in the total price of a dispensed Prescription Drug.  Dispensing fees differ from one Pharmacy to another.

Drug Formulary - A pre-determined listing of Prescription Drugs that will be covered by a Plan or Insurance Contract. These Formularies often foster substitution of Generic or Therapeutic equivalents on a cost-effective basis.

Drug Identification Number (DIN) – DIN’s can be assigned to both Prescribed medications, as well as OTC’s (Over the Counter) medications. 

Drug Utilization Review (DUR) -  An analysis of Prescription Drug utilization.  The purpose of the DUR is to monitor usage of Prescription Drugs & to identify drugs, types of drugs &  therapeutic classifications with high usage.  DUR  also ensures compliance.  

Eligibility Period – A time period when potential members of a group can enroll in the Group Insurance plan without providing medical evidence. 

Elimination Period – A pre-defined period of time between the beginning of a Disability and the start of the policy’s benefit payments to the eligible claimant.

Endorsement – An alteration to a policy. Can be attached to the policy or written on a page of the policy itself (see Rider).

Enrolment Card – A document signed by the Employee as notice of his/her desire to participate in the Group Insurance plan.

Enrolment Period – Period during which employees can enroll in the Group Insurance plan. This period includes the eligibility period & the 31 day enrolment period during which time the may enroll for insurance without supplying medical evidence/evidence of insurability.

Evidence of Insurability – A statement or proof of a person’s physical condition; and/or other factual information affecting his/her acceptability for insurance.

Exclusion – Specified conditions or circumstances for which the policy does not provide benefits.

Expatriate – An employee assigned outside of his or her base country.

Full Integration – The LTD (Long Term Disability) benefit is reduced, dollar-for-dollar by, for example CPP benefits, paid or payable. This includes any benefits paid or payable to eligible Spouse and/or Child(ren). 

Gainfully Employed – Regularly engaged in an occupation for a wage or profit.

General Provisions – These provisions, in addition to the regular insuring and benefit provisions, specify the rights & obligations of the Insured and Insurer; also may be referred to as Additional Provisions.

Generic Drug  – means any reproduction of a Brand Name Drug. An example of the differences between Brand Name Drugs and Generic Drugs may include, but are not limited to  the binding ingredients and dyes used. 

Grace Period –  A pre-determined period of time (usually 31 days) after a premium payment is due, in which the policyholder may make such payment. During this Grace Period, coverage remains inforce.

Group Contract – A contract of Insurance made with an Employer, or other entity. The contract covers a group of persons identified as Insureds by reference to their relationship to the entity.

Incurred But Not Reported Reserve (IBNR) –  A reserve that is established for the purpose of paying claims which are incurred during the policy period, but are not submitted to the Insurer until after the policy period ends. 

In-patient – A person admitted to and assigned a bed in a Hospital In-patient area, by order of an attending Physician.

Insurance Carrier –  A company that receives Premiums & accepts the responsibility for fulfilling the policy contract terms.

Lapsed Policy – A policy terminated upon the policyholder’s failure to pay premiums within a time stipulated in the contract.

Late Applicant –  An eligible Employee who applies for benefits after  expiration of their Eligibility Period. Late Applicants typically must submit Medical Evidence/Evidence of Insurability to the Insurer.

Life Insurance –   A type of insurance that provides a sum of money if the Insured dies while the policy is inforce.

Long Term Disability (LTD) –   A type of insurance that provides a sum of money, most often in the form of Monthly Benefit payments to the Insured, in the event of Disability. LTD benefit payments replace a portion of salary that was earned by an Insured who becomes disabled and is unable to work.

Loss Ratio –   The ratio of Paid & Incurred Claims + Expenses to Premiums.  For example, if Paid & Incurred Claims + Expenses = $ 80,000;  Premium = $ 100,000; the Loss Ratio = 80%.

Magnetic Resonance Imaging (MRI) - A 3-D (three-dimensional) image used to visualize certain parts of the body. Uses are similar to those for a CT Scan, however the technology is completely different.

Managed Care -  Control of Utilization, quality & Claims using a variety of current cost containment methods. The primary goal is to deliver cost effective health care, without sacrificing quality or access.

Maximum Benefit – The highest amount an individual may receive under an insurance contract.

Medical Emergency – Any acute and unexpected condition, injury or illness requiring immediate medical treatment. 

Medical Evidence of Insurability – Any statement or proof of a person’s physical condition and overall health. Medical Evidence is often required for late applicants, as well as  Voluntary and/or Optional benefit offerings.

Member – Synonymous with Plan Participant. Any employee of former employee of an employer, member or former member of an employee organization, sole proprietor, or partner in a partnership who is eligible, or may become eligible to receive a benefits of any type from an Employee Benefits Plan, or whose beneficiaries may be eligible to receive such benefit.

Morbidity – The relative incidence & severity of sickness and accidents in a well-defined class, or classes of persons.  

Morbidity Table – Demonstrates the average number of persons befalling a large group of persons (ie. An average of “x” persons per 1,000).  The Morbidity Table indicates the incidence of sickness the way a Mortality Table shows incidence of death.

Mortality – The number of deaths resulting from each specific type of illness or disease.

Mortality Rate – The number of persons out of a large group who, experience demonstrates, will live to reach each age up to the death of the last survivor; inferentially establishing the expectancy of life of the average person of each age.

Mortality Table – A record of past experience showing the number of deaths per 1,000 persons at each age.

Multinational Employee (International Benefits) – A person working in a country other than his or her own for a company based in another country other than his or her own. May also be referred to as a third country national.

Necessary Treatment (Dental coverage) – A necessary service or procedure, as determined by a dentist, to either establish or maintain a patient’s oral health. Such determinations are based on the professional diagnostic judgment of the dentist and the standards of care that prevail in the dentist’s professional community.

Noncontributory Plan – Also referred to as a ‘non-contrib plan”. This term is applied to Employee Benefit Plans under which the employer bears the full cost of the benefits for all employees. 100% of all eligible employees must participate/be insured. 

Non-Evidence Maximum –   The maximum amount of coverage that can be applied for without submitting medical evidence.  

Notary – A public officer authorized to administer oaths by way of affidavits and depositions. Attests deeds and other formal papers, in order that they may be used as evidence and can be qualified for recording.

OAS (Old Age Security) - The Canadian basic federal income security plan for seniors attaining 65 years of age and over.

Outpatient – A person who visits a medical clinic, emergency department or health facility and receives health care without being admitted as an over-night patient.

Outpatient Services – Outpatient services are medical & other services provided by a hospital  or another qualified facility or supplier, such as a mental health clinic, rural health clinic, mobile x-ray unit or free-standing dialysis unit, etc. Such services include outpatient physical therapy services, diagnostic X-ray and laboratory tests and other radiation therapy.

Outpatient Surgery – Same day surgery without anticipation of an overnight stay for the patient.

Over the Counter (OTC) Medications – Although these medications have an assigned DIN (Drug Identification Number), they can be purchased from the Pharmacist, hence Over the Counter. Some Health plans cover OTC’s, while others do not. Please refer to your contract for verification of the same..

Paid Claims - Claims that are paid out during the policy year, regardless of when the claims are actually incurred.

Paid Premiums - Premiums that are paid during the policy year for insured benefits.

Palliative Care Establishment – Typically refers to an establishment (in Canada) designated as such by law that provides, under the supervision of a Physician, treatment & care to patients, mainly during the terminal phase of their illness. Also, provides Nursing Care 24-hours a day by a Registered Nurse and maintains records of each patient under the care of a duly licensed Physician.

Paperless Claims System – The process under which Employees do not have to submit a claim for the payment of benefits from the medical plan. The claim is made directly by the provider to the insurer. 

Paramedical Practitioner -   may include, but not limited to: Acupuncturist, Audiologist or hearing therapist, Chiropractor, Christian Science Practitioners, Ergotherapist, Homeopath, Naturopath, Osteopath, Speech Therapist, Physiotherapist, Physiatrist, Physical Rehabilitation Therapist, Sports Therapist, Podiatrist, Chiropodist, Psychologist, Social Worker, Guidance Counsellor. Your contract will outline eligible Paramedical Practitioners.

Parent Company – Used when describing a company that owns a majority or controlling interest in another company.

Pay-Direct ­– An arrangement whereby the claimant does not have to pay for an incurred claim.  For example, a pay-direct prescription drug card will allow the claim to be electronically submitted (i.e. billed) to the organization holding the risk. If there is a co-pay or deductible, the claimant would be responsible for paying the same.

Pending Claim – A description of the status of a claim for benefits during the processing stage. Essentially, the time period between the date of the first notice of claim is received by the insurer or his representative and the date the final determination of the insurer’s liability is paid or denied.

Permanent and Total Disability – Disability presumed to endure for a lifetime, prevents the insured from engaging in any gainful occupation.

Plan Administrator –   The party in charge of overseeing the Plan as a whole and acts in the best interest of the Plan participants.

Plan Participant – Any Employee or former Employee of an Employer, member or former member of an Employee organization, sole proprietor, or partner in a partnership who is eligible, or may become eligible to receive benefits of any type from an Employee Benefits Plan, or whose beneficiaries may be eligible to receive such benefit.

Plan Sponsor – The party that is responsible for maintaining the plan.  A plan sponsor could be an employer, employee organization or association.

Policy – The legal document issued by an insurance company to the policyholder that outlines the terms & conditions of the insurance; also may be referred to as the Policy Contract or the Contract.

Policy Period – The period during which the policy provides protection.

Policy Reserves – The amounts set aside by an insurance company to meet future policy obligations.

Policy Year – The time period that elapses between Anniversary Dates, as specified in the policy. A policy year does not necessarily have to run from January to December.

Policyholder – A person or company to whom an insurance policy is issued.

Pool –  In some cases refers to a large number of small groups that are analyzed and rated as a single large group. Risk Pools may be any account that attempts to find the claims liability for a group with a common denominator. A group of policies joined together for the purpose of spreading the risk.

Pooled Claims – Claims applicable to pooled risks which are excluded from individual case experience rating or retention.  

Precedent – A previously decided court case that can serve as an authority in deciding a present controversy. In law, the term stare decisis refers to the practice of adhering to decided cases & settled principles, providing for the development of a consistent body of law.

Predetermination – An administrative procedure whereby a Health and/or Dental provider submits a treatment plan to a third-party (i.e. insurer) before treatment is initiated. The third-party usually reviews the treatment plan, indicating one or more of the following: patient’s eligibility, guarantee of eligibility time, covered service, amounts payable, application of appropriate deductibles, co-payment factors and overall deductibles.

Pre-Existing Condition – A mental and / or physical condition that exists prior to coverage beginning for an insured person.

Pre-Existing Exclusion – Means that a benefit won’t ever be paid for the specific injury or illness that has been determined to be pre-existing.

Pre-Existing Limitation – Means that a benefit will be paid for a while; or will not be paid until a certain limited of time has passed.

Premium – A payment; specifically the amount payable or paid, in one sum or periodically, for an insurance policy.

Primary Payer – The insurance carrier that has first responsibility under coordination of benefits (COB).

Proposal -  A quotation of a potential group which outlines the benefits and costs under the plan design proposed.

Prosthesis - An appliance used to replace all, or part of a limb, organ or other body part.

Provision - A Part (clause, sentence, paragraph, etc) of an insurance contract which describes or explains a feature, benefit, condition, requirement, etc., of the policy.

Qualification Period (Canada) – The period of time between the beginning of a disability and the start of a policy’s benefits. In the United States, this is more commonly referred to as waiting period.

Radiation Therapy – Use of ionizing radiation in the treatment of cancer patients, such service being provided by a radiation therapist or a physician qualified in therapeutic radiology. 

Rate – The price developed for a unit of Insurance. Used as a base or means for the determination of premiums.

Rated Policy – A policy issued to cover a person classified as a substandard risk. The policy’s premium rate is higher than the rate for a standard policy or the policy is issued with special limitations or exclusions, or both. Also referred to as an extra-risk policy.

Reasonable and Customary (R&C) Charge – The prevailing charge made by surgeons of similar expertise for a similar procedure in a particular geographic area.  See also, Usual, Reasonable & Customary Charges.

Recurrent Disability – A disability that is related to or due to the same cause(s) of a prior disability for which a monthly benefits was payable.

Rehabilitation – A provision in some Long-Term Disability (LTD) plans that provides for continuation of benefits or other financial incentives/assistance while a disabled insured is retraining or attempting to resume productive employment.

Reimbursement Plan – An arrangement whereby the insured individual pays for the covered expense and then submits the receipt to the insurance carrier for reimbursement.

Reinstatement – The resumption of coverage.

Reinsurance – The acceptance by one or more insurers, called reinsurers or assuming companies, of a portion of the risk underwritten by another insurer that has contracted for the entire coverage.

Renewal – The act of Underwriting/renewing an Insurance Policy in order to set an adequate rate level for the future policy term.

Renewal Date – Date on which the Underwriting action takes effect.

Repatriation – Preparation and return of the deceased (insured) to the principal city of residence.

Retention – The portion of premium retained by an insurer for commissions, contingencies, profits, taxes, expenses & other related charges.

Retirees – The group of plan participants that includes retired employees, their beneficiaries and covered dependents.

Retrospective Premium – Arrangement by which a policyholder agrees to pay an additional premium at the end of the contract year if claims and retention exceed paid premium.

Rider – A document of insurance that amends the policy or certificate. It may increase or decrease benefits, waive the condition of coverage, or in any other way amend the original contract. See Endorsement.

Risk Management –  A scientific approach to the problem of dealing with the pure risks facing an organization or an individual in which insurance is viewed as simply one of the several approaches for dealing with such risks.

Self-Administered –  The administration of the Group Benefit Plan is the responsibility of the Plan Sponsor.

Self-Funded –  100% of the risk is carried by the Plan Sponsor, therefore a self-funded benefit contains no true element of insurance.  The Plan Sponsor accepts liability for all claims and expenses.  The claims administration can be provided by an insurance carrier or a Third Party Administrator (TPA).

Sound Tooth – A natural tooth that is not afflicted with any pathology either by itself or in the adjacent structures. In addition, a tooth that has been treated or repaired & restored to normal function.

Subscriber – The employee of member who elects coverage under the plan.

Third Party Administration – Administration of a Group Insurance plan by an individual or a firm other than the insurer or policyholder.

Third Party Administrator (TPA) – The party to an Employee Benefit plan that may provide administrative services, collect premiums and/or pay claims. Typically, an out-of-house professional firm providing administrative services for Employee Benefit Plans. Synonymous with administrative agent, carrier, insurer, underwriter.

Trend Factor:  The measurement of the change in the cost of Health Care after weighing inflationary changes, changes in utilization & technology.

Ultrasound Scanner – A machine that uses sound waves to provide structural information on many parts of the human anatomy that cannot be obtained by traditional X-ray and radioscopic methods. It permits visualization of both surface and internal structured of many body parts.

Underwrite – The process of selecting those risks for insurance who meet the insurability requirements of the Insurer. Also, classifying risks according to degrees of insurability so that the appropriate premiums may be assigned.

Uninsurable Risk – A risk not acceptable for insurance due to excessive risk.

Usual, Customary and Reasonable – Usual is the fee usually charged for a given service by a provider; Customary  is a fee in the range of usual fees charged by similar providers in area; Reasonable is a fee, according to the review committee, that meets the lesser of the two criteria or is justified in the circumstances.

Utilization – The extent to which the members of a covered group use specified services over a period of time. Utilization rates are established to help in comprehensive planning, budget review and cost containment.

Waiting Period – As shown in the Contract, means the continuous length of time an employee must serve in an eligible class after beginning employment, to reach his/her Eligibility date.

Waiver of Premium – A benefit provision included in some policies that exempts the insured from paying premiums while he or she is disabled during the life of the contract.  

Wellness Programs –   A broad range of employer or union sponsored facilities and activities designed to promote good health & safety among employees. Purpose is to increase morale; concurrently reducing the cost of accidents and ill health such as absenteeism, lower productivity and health care costs. May include physical fitness programs, smoking cessation, health risk appraisals, diet information and with loss, stress management and high blood pressure screening.

Yearly Maximum Pension Earnings (YMPE)­ –  The maximum amount of annual earnings, not including reductions for the year’s basic exemption, that benefits and contributions for purposes of the Canada Pension Plan (CPP) and Quebec Pension Plan (QPP) are based.