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A family deductible is structured so that any claim filed by a family member within a year counts toward the deductible for the entire family. Family deductibles are usually paired with a common accident provision, under which only one deductible applies if more than one family member is injured in the same accident.
The grace period is the period of time after the premium due date during which the premium may still be paid before the policy lapses for nonpayment. Although the length of the grace period can vary by state, in most cases it may not be shorter than 7 days for weekly premium policies, 10 days for monthly premium policies, and 31 days for all other modes. Coverage remains in force throughout the grace period.
An accident and health insurance policy's grace period is directly tied to the premium payment mode.
The waiting period is the period of time before insurance benefits begin. During the waiting period the policy is in force, but the insurer has not yet started paying benefits for covered events.
The elimination period is functionally the same as the waiting period. Insureds may choose an elimination period of 30, 60, 90, 180, or 365 days, though some policies begin paying benefits after only a 7- or 14-day elimination period. A longer elimination period lowers the premium for disability policies, and offering a choice of elimination period lets clients balance premium cost against how quickly benefits begin.
Individual health and disability policies contain a provision giving the insurer the right to terminate coverage. Right-to-terminate provisions vary from policy to policy and apply to all insureds covered under a particular type of policy or within a specific group, known as a class. A class of insureds might be defined by geographic location, age, or occupation.
The carry-over provision allows an insured who incurs medical expenses during the last 90 days (calendar quarter) of a calendar year to apply those expenses toward the following year's deductible.
When a client replaces a health policy while a claim is already in progress, the no-loss/no-gain rule prevents the pre-existing condition provision in the new policy from applying to that claim. The new policy must immediately take over payment of the claim.
Plans built around either a corridor or integrated deductible each provide first dollar coverage. With first dollar coverage, up to 100% of covered claims are paid beginning with the very first dollar of expense incurred by the insured. A corridor plan provides basic medical expense coverage at 100% up to a pre-established limit — such as $3,500, $5,000, $7,500, or as high as $10,000. After the basic benefits are exhausted, the insured pays the next $3,500–$10,000 of covered expenses before major medical benefits take over at 100%. Plans built on an integrated deductible also provide first dollar coverage, but all covered expenses up to a pre-established limit are shared between insurer and insured on an 80/20 coinsurance split, with a stop-loss limit set between $5,000 and $25,000; under this structure, the insured pays $1,000–$5,000 of the total first-dollar claims expense.
The restoration of benefits provision allows an insured to regain their full lifetime benefit level over time following a large or catastrophic loss.
The purpose of policy exclusions is to protect the insurer from claims arising from losses that were not contemplated in the initial risk assessment. By specifically excluding certain intentional, catastrophic, criminal, or excess losses, the insurer maintains control over its risk. The most common types of excluded losses result from: