|June 2, 2020|
In an effort to continually improve the glossary, we welcome all suggestions. If you need help with a particular word and cannot find it in the glossary, please let us know.
Accidental Death & Dismemberment: A lump sum payment if the insured dies as a result of an accident or loses eyesight, hearing, or appendages (i.e. arms, legs, feet and hands).
Administrator: The individual or company responsible for administering the group insurance contract including the accounting and enrollment.
Adverse Selection: Persons poorer-than-average health (or health expectations) tend to apply for greater insurance coverage than do persons in average or better health.
Aggregate: When referring to a family deductible or out-of-pocket maximum, aggregate implies that the family charges may total up to the maximum, as long as one member meets the individual amount.
Allowable Expense: Any claims that meet the criteria of the insurance policy which you are covered by.
Annual Maximum: The maximum amount any one individual may receive, per year, under an insurance contract.
Anti-selection: The selection of coverage beneficial to the employee but not beneficial to the plan itself.
Association Group Plans: Plans designed for members of an association.
Basic Life Coverage:The base (core) life insurance plan, offered either as a lump sum or in multiples of salary. If desired, additional life coverage can be added to Basic Life to increase the coverage: see Optional Life Coverage.
Beneficiary: The person designated by the insured to receive Group Life and/or Accidental Death Benefits upon the death of the insured.
Benefit: The amount payable by the insurance company to the holder, assignee or beneficiary of the insurance policy when a loss covered by the policy occurs.
Carrier: The insurer who agrees to underwrite the group contract and provide certain types of coverage and service.
Child, Handicapped: Specific provision in contract for the continuing coverage of dependent child regardless of age, if handicapped and unable to provide for themselves.
Chiropractic: Services provided by a member the Canadian Chiropractic Association or an affiliated provincial association.
Claimant: A plan beneficiary exercising his/her right to receive benefits.
Claims Paid: Cheques made out to claimants by the insurance company. The cheques are considered Paid Claims if they either are dated within the policy year or are cleared by the banks within the policy year.
Class: A categorical listing of insurance coverage which an individual is placed into to determine eligible coverage under the policy.
Co-ordination of Benefits: A policy which will determine how benefits will be calculated if the claimant is insured under several group contracts insuring the same event.
Coinsurance: The insured and the insurer share the cost of the claim within a specified ratio. For example, the insurer pays 80%, the insured pays 20% of the claim expense.
Common-Law Marriage: Two persons who have been cohabiting and residing with each other for a continuous period of at least one year, and who’s spousal relationship has been publicly recognized.
Consultant: A person or firm specializing in the design, sale and service of employee benefit plans.
Contributory: A portion of the premium paid by the employee is required.
Contributory Plan: A plan which requires employees to pay part of the cost for the benefit plan.
Convalescent Hospital: Facility that provides rehabilitative care and is eligible under the provincial hospital insurance legislation.
Conversion: The individual has the right to convert group insurance coverage to an individual plan without presenting evidence of insurability if converted within 31 days of termination.
Coverage: A classification of benefits provided under a group policy or the amount of insurance or benefits stated in the group policy for which an insured is eligible.
Deductible: An amount of expenses that must be paid by the insured before any benefits become payable.
Dependent: The employee's spouse or children.
Dependent Life: Life Insurance issued for the spouse and children with the employee as the beneficiary.
Effective Date: The date a policy becomes effective. If the hour is not specified, the effective time is 12:01 a.m. on the appropriate date.
Eligible Employees: Employees who have met the requirements under the group policy for insurance.
Employee Benefit Program: A program through which various benefits are offered to employees by their employer to cover such contingencies as medical expenses, disability income, retirement and death; usually paid for wholly or in part by the employer. Such benefits frequently are referred to as "fringe benefits" because they are separate from wages and salaries.
Evidence of Insurability: Proof presented through written statements on an application form, and/or through a medical examination, that an individual is eligible for a certain type of insurance coverage.
Explanation of Benefits (EOB): Once a claim has been processed, the subscriber will receive an EOB statement. The following information is detailed on the EOB: actual charges, allowed charges, deductible and coinsurance amounts, total benefits payable and the claimant responsibility.
Family: Two spouses who are legally married or living common-law, or one or two adults (legally married or living common-law) and their dependent children.
Group Insurance: Insurance issued, usually without medical examination, on a group of people under a master contract. It is usually issued to an employer for the benefit of employees.
Group Insurance Change Form: A form used to submit additions, changes and terminations for processing by the premium administrators.
Group Life: Insurance covering a group of employees under one life insurance policy.
Insured: The member who is covered by the policy.
Insurer: The insurance carrier who agrees to underwrite the group contract and provide certain types of coverage and service.
Indemnity Plan: Plan which restores or reimburses one to the extent of their loss.
Long Term Disability (LTD): Long Term Disability insurance provides income protection in the event of time lost due to sickness or accident of long term nature. Generally monthly payments commence after a specified waiting period and continue while the employee remains disabled usually up to a specified age. See Definition of Disability, Permanent and Total Disability, Period of Disability, Two Year Own Occupation and Offsets.
Massage therapy: Services provided within their specialty by individuals authorized by a recognized provincial association to practice massage therapy. (Where such an association does not exist, individuals who, in the insurer’s opinion, have similar qualifications.)
Naturopathy: Services provided within their specialty by members of the Canadian Naturopathic Association or an affiliated provincial association.
Non-Evidence Maximum (NEM): The maximum amount of insurance coverage one may receive before Evidence of Insurability is required.
Notice and Proof of Claim: The policy will specify time limits for giving notice, and then proof of claim. It also specifies the manner in which the proof of loss must be submitted.
Occupational Therapy: Services provided within their specialty by occupational therapists authorized to practice occupational therapy in Canada or in the province where the services are provided.
Offsets: Reductions to one’s Long Term Disability benefit in order to offset other sources of income such as Worker’s Compensation, CPP, QPP, etc.
Old Age Security (OAS): A federal retirement income program providing pension benefits to those 65 or older, with residence in Canada for at least 10 years.
Optional Life Coverage: Option to purchase additional life insurance over and above Basic or core life insurance coverage. Optional Life requires applicants to provide additional personal information. See Evidence of Insurability.
Orthotherapy: Services provided within their specialty by orthotherapists authorized to practice orthotherapy in Canada or in the province where the services are provided.
Osteopathy: Services provided within their specialty by holders of a doctorate in osteopathy conferred by a college of osteopathy approved by the Canadian Osteopathic Association.
Out-of-Country Expenses: Expenses incurred by an insured or insured dependent for emergency services and treatment of bodily injury or disease while travelling outside Canada.
Out-of-Pocket Expenses: Those medical expenses which an insured is required to pay because they are not covered under the group contract.
Out-of-Pocket Maximum: The maximum amount of coinsurance an insured is required to pay before the plan will pay 100% .
Over-the-Counter Drug: Drug that can be purchased without a prescription.
Payroll Deduction: The amount taken from the employee's earnings with their consent, as contribution toward the cost of the group insurance plan.
Period of Disability: The period during which an employee is prevented from performing the usual duties of his/her occupation or employment or during which a dependent is prevented from performing the normal activities of a healthy person of the same age or sex. More than one cause (accident or sickness) may be present during or contribute to a single period of disability. See Two Year Own Occupation.
Physiotherapy: Services provided within their specialty by members of the Canadian Physiotherapy Association or an affiliated provincial association..
Podiatry: Services provided for foot health by individuals authorized to practice (podiatrists).
Pooling: The combination of all premiums, claims and expenses in order to spread the risk.
Pre-Existing Condition: Any physical and/or mental condition or conditions that existed prior to the effective date of coverage under a contract.
Premium: The amount paid to the insurer for the insurance protection.
Prescription Drug: Drug that cannot be obtained without a prescription from a physician or dentist.
Provision: A part of a group insurance contract that explains or describes a feature, benefit, condition, requirement, etc., of the insurance protection afforded by the contract.
Psychology: Services provided within their specialty by permanently recognized psychologists whose names appear in the registry of psychologists of the province where the services are provided.
Reasonable and Customary: This term refers to limiting benefit payments to fees which are reasonable and representative for the service rendered, under the circumstances rendered, by the physician rendered.
Recurring Disability: A case where if a second disability occurs related to the first disability within a specified period of time, the second disability will be a continuation of the first disability claim.
Rehabilitation: Refers to a provision in many long-term disability (LTD) plans that enables the insured claimant to receive at least partial benefits while undergoing retraining and seeking new employment.
Rehabilitative Employment: Any occupation or work for compensation or profit approved by the Insurer and undertaken by the insured while unable to work on a full-time basis usually in conjunction with a LTD plan.
Renewal Date: The date when the insurance policy is to be reviewed for experience and the rates are adjusted.
Retention: The portion of the premium retained by the insurance company to cover expenses and provide profits.
Retirement: Permanent withdrawal from the labor force.
Salary: Base salary, excluding bonuses and overtime.
Secondary payer: The plan that pays second when you have coverage through two benefit plans (yours and your spouse's plan). This is known as co-ordination of benefits where you can be reimbursed up to 100% (but not more) when you submit your claim to both benefit plans.
Short Term Disability (STD): Short Term Disability Benefit provided to employees who are absent from work due to illness or disability. STD (also known as Weekly Indemnity or Sick Leave) usually has a maximum amount of time the benefit will last.
Sickness: Illness not arising from accident or injury.
Single: An unmarried person with no dependent children.
Smoker: Person who has used any tobacco products (cigarettes, cigarillos, cigars, pipe, marijuana, chewing tobacco or nicotine gum or patch) in the past 12 months.
Speech Therapy: Services provided within their specialty by holders of a master’s degree in speech therapy who are a member of the Canadian Association of Speech-Language Pathologists and Audiologists or an affiliated provincial association or who satisfies the conditions for membership in this association.
Spouse: The person to whom you are lawfully married; or a person who has been cohabiting and residing with you for a continuous period of at least one year, and has been publicly represented by you as your spouse.
Subject to Insurability: Requiring a statement of proof of a person’s physical condition, occupation or other factor affecting his or her acceptance for insurance coverage.
Term Life Insurance: Life insurance plan that terminates when employment ceases. Conversion policies are available.
Termination: An employee who terminates employment with the employer or withdraws from a group plan offered by the employer.
Total Disability: Inability to perform all of the duties of one's regular occupation or the duties of any occupation for which the individual may become fitted due to education, training or experience.
Twenty-Four Hour Coverage: Insurance providing benefits for an accident or sickness incurred either on the job or off the job.
Two-Year Own Occupation: Common disability definition stating that the employee is disabled for his or her own occupation during the first two years of disability and thereafter is disabled for any occupation that is suitable by virtue of past training, education or experience.
Underwriting: The process by which an insurance company determines whether or not it will accept an application for insurance.
Voluntary: Chosen by one's own consent. Often refers to lack of minimum enrollment requirements.
Waiting Period: A period of time that must pass in order for an individual to become eligible for benefits under a group insurance policy.
Waiver of Premium: A provision that under certain conditions a person's insurance will be kept in full force by the insured without further payment or premiums. It is used most often in the event of permanent and total disability.
Worker's Compensation Act: A statute imposing liability on employers to pay benefits and furnish care to employees injured and to pay benefits to dependents of employees killed, in the course of and because of their employment. See Offsets.