Glossary
Pick a letter from the menu below to show the available word descriptions.
A
Absence Management Consultation Services
A program comprised of:
- AMCS - Ad Hoc Services
- AMCS - All Cases
- AMCS - Occupational Management
This is an early-intervention program intended to help the front-line managers in an organization manage their employee’s short-term absences from the workplace. Manulife Case Managers evaluate each absence looking at medical and non-medical influences that may have contributed to the absence. The goal is to ensure the best outcome for employee and employer, and avoid transition to the next phase of the disability management continuum – short-term disability.
Accident & Sickness
This term generally appears in the context of accidents and illnesses that affect covered employees and dependants – especially in relation to health-related coverage and products.
It can also be referred to as A&H (Accident and Health) or Casualty and Disability coverage.
The more familiar industry term is Health Insurance.
Accidental Bodily Injury
An injury sustained as a result of an accident.
Accidental Death and Dismemberment (AD&D)
Coverage in the event of death or dismemberment due to an accident (the term accident as defined in the contract). If a death is accidental, payment is made to the insured's beneficiary; if bodily injury is accidental (e.g.., loss of limb), insured receives a benefit (usually a percentage of the overall benefit amount) which has been predefined in the contract.
Accidental Death Benefit
A lump sum payment upon the accidental loss of life of an insured person.
Accidental Means
The unexpected and unforeseen cause of an accident. The "means" which caused the mishap must be accidental to be able to claim the benefit described in the policy.
Accumulation Period
The period of time where expenses accumulate towards satisfying any deductibles outlined in the policy. The plan member generally is responsible for the full cost of these expenses. It is important for these to be submitted as claims so they are recorded against the deductible. Once the required plan deductible has been satisfied, the plan member will begin eligible for reimbursement under the plan in accordance with all other provisions.
Actively-At-Work Requirement
This refers to the requirement that an employee must be actively at work on his or her usual and customary basis on the date the employee’s insurance normally becomes effective. The purpose of this requirement is to ensure that an employee who is not well enough to attend work is excluded from the plan until either evidence of health is provided or the employee returns to work on the usual and customary basis.
Activities of Daily Living (ADL)
An account of what activities a claimant does each day. These are usually reported by the claimant on an ADL questionnaire or recorded through an interview.
Add on the fly
This term refers to distinct periods of time when information is added to a plan member’s records established with Manulife. Both plan member and over-age dependant information is collected during the initial enrolment process. Information about a plan member’s dependants is “added on the fly” – meaning that it is only collected when a claim has been submitted.
Dependant and COB information is not verified at the time of a claim.
Administration
Performing of functions related to the operation of the group insurance plan (e.g. issuing, amending, billing, claims processing, etc.) once it has become effective.
Administrative Services Only (ASO)
A type of policy arrangement where the insurance company handles claims administration services for the plan sponsor. Liability for funding of those claims paid under the policy remains with the policyholder.
Administrator
The individual or firm (third party administration) responsible for administering a group insurance program. The administrator is responsible for all accounting, plan member certificate issuance and claims settlement.
Advisor Support Team (AST)
A team that operates within Manulife’s Small Business Unit. This team focuses on responding to plan advisor inquiries submitted by phone and through e-mail.
Advisors
Advisor means a person or organization working with the plan sponsor to provide advice about their group benefits program. Advisors must be licensed to provide advice and registered with an insurance carrier to be able to discuss products and services with a plan sponsor. The terms “agent,” “consultant,” “producer,” “broker,” and “consulting house” are sometimes used interchangeably and have the same definition as “advisor.” The term Advisor is the preferred term at Manulife Financial.
Age Limits
Stated in the policy, these are ages that restrict coverage to plan members and/or dependants. When the age limit is attained, coverage available prior to the age limit changes. Sometime the coverage is reduced, and sometime coverage is no longer valid or terminated.
Age Reduction
A reduction in the amount of insurance on an individual who attains a specified age.
Age Restriction
The limitation on benefits when the insured person reaches a specified age.
Agent
A term generally used to describe one who is licensed to sell group insurance products, normally represents a single insurance company. See Advisor.
Aggregate Amount (Limit)
The maximum sum than an insurance company is liable for in any single loss, series of losses, or for the entire duration of a contract.
Aggregate Stop Loss
Under this kind of arrangement, all of the claims paid in excess of a stated percentage of paid premium are pooled, regardless of whether claims can be attributed to significantly costly claims for individual plan members.
All Source Maximum
Relating to disability coverage, the ASM is the total amount of money payable to a claimant from all sources, including any employment and all public and private insurance plans under which the claimant is entitled to claim benefits. Usually set at 85% of pre-disability earnings, for any amounts exceeding the total ASM, the insurer may apply a dollar-for-dollar deduction against the disability benefit otherwise payable.
Allowable/Eligible Expense
Any necessary, reasonable or customary expenses covered by the policy.
Alpha Plus
One of Manulife Group Benefit’s four market segments. Alpha Plus plans range from 2-24 lives and are administered by the Small Business Unit.
AlphaQuote
Proprietary quotation software Manulife produces for the Alpha Plus market segment. AlphaQuote enables Advisors to input specifications to the software and obtain instant quotes for clients.
Alternate Benefit Clause (ABC)
This clause indicates that when there are two or more courses of dental treatment available for a dental condition, Manulife will reimburse the cost of the least expensive treatment that will provide a professionally comparable result, as determined by our Dental Consultant.
Amendment
A formal document changing the provisions of the group contract and signed jointly by authorized representatives of the insurer and the policyholder.
It may increase or decrease benefits, waive a condition or coverage, or in any other way amend the original contract.
Amount Eligible
The portion of the amount submitted that may be eligible for whole or partial reimbursement by a plan.
Anti-Selection
The risk that an individual will only apply for coverage when they are aware of an adverse health condition and are highly likely to make a claim. For example, a plan member may select health coverage if they become aware they will need large prescription reimbursements, or they may request additional life insurance knowing of a recent diagnosis. The purpose of Medical Underwriting is to reduce the risk of anti-selection in the pool of covered individuals.
Application for Group Benefits
The document signed by the plan sponsor requesting/applying for group benefit coverage. It outlines detailed benefit coverage information and forms part of the contract when issued.
Assignment of Benefits
A direction to pay benefits to a third party. For example, benefits may be assigned to a dentist, hospital or the health care provider, as permitted in the contract.
Attained Age
The age of a person, the day before he or she reaches a specific age defined in the policy.
Attending Physician Statement/Update (APS)
A document completed by a plan member’s attending physician that includes medical information about the plan member that will be used during medical underwriting.
Authorization to Pay Benefits
The portion on a health and dental claim form that allows the plan member to direct the insurer to pay the claim directly to the service provider.
B
Basic Life Insurance
Life insurance that provides a lump-sum payment to the plan member’s beneficiary.
Basic Services
Coverage for dental services such as routine examinations, cleanings etc. Exact services are delineated in the policy.
Beneficiary
The person(s) designated by a plan member to receive Group Life or Accidental Death benefits upon the plan member’s death.
Benefit
The amount payable by the insurer to a claimant, assignee, or beneficiary under the policy.
Benefit Booklet
A benefit booklet is a document that helps plan members understand their group benefits plan, including instructions on how to submit a claim. The booklet describes specific details of the coverage provided under the plan but does not constitute a contract. The contract terms govern in all situations.
Benefit Card
The insurer issues a benefit card to each covered individual. The card specifies that the individual named is covered under the plan document and provides some essential details of the plan. The benefit card does not constitute a contract or proof of coverage where the holder is not eligible.
Benefit Formula
A formula or rule for determining the disability benefit payable based on the provisions of the policy or ASO plan document. The formula frequently takes into account salary, position, or years of employment at the time the benefit is paid.
Benefit Maximum
The benefit maximum is the highest amount eligible for payment before applying any deductibles, co-insurance or limitations outlined in the policy.
Benefit Period
A benefit period is the maximum duration for which disability benefits may be payable.
Benefit Schedule
This outlines the type and amount of insurance selected by a plan sponsor and provides a summary of coverage outlined in the plan documents.
Benefit Summary Plan
A term used to describe participation, co-insurance, deductibles, maximums, schedule of insurance, the main eligible expenses. Forms part of the ASO Plan Document (for non-insured groups) and Policy for insured groups. There is usually a BSP page for each division within the contract.
Benefit Type (HealthPro)
In the HealthPro administration system, refers to either health or dental.
Benefit Year
A 12-month period over which the maximum accumulates for all plan members. It may be a calendar year, or any other 12 month period as specified in the contract.
Benefit Year Maximum
A benefit year maximum can apply to certain types of coverage within a plan depending on the contract. It may limit the number of visits to a particular practitioner, the number of times that a specific procedure can receive payment as a claim. It may limit a practitioner or procedure to a specific dollar maximum.
Benefits Waiting Period
The period before benefits begin (e.g. 3 month probationary period).
Bill Group
A bill group is a grouping of plan sponsors who are billed at the same time using the same bill layout.
Bill Sort Group
A method of grouping plan members used for billing and reporting purposes. Each bill sort group represents a group of members.
Billed in Advance (BAD)
Billing a client for claims and expenses for a future period.
Billed in Arrears (BAR)
Billing a client for their claims and expenses for a past period, rather than a future period. (e.g. Billing for March is done at the beginning of April).
Billing division number
A number used for billing purposes which provides a new location for every bill and expands the level of premium reporting. Manulife bills can provide a sub-total for plan, class and other data element.
Binder Cheque
The initial premium deposit paid by the prospective policyholder when an application is made for a group insurance policy; It must be equal to the first month's estimated premium. It is applied toward the actual premium when the bill is prepared.
Broker
A term used to describe one who places business with more than one company and who also has no exclusive contract requiring that all his or her business first be offered to a single company. This is in contrast to an agent, who normally represents a single company. Manulife refers to all distribution chain partners as plan advisors.
C
Calendar Year
The 365-day period beginning on January 1st each year.
Calendar Year Maximum
The maximum amount payable as a benefit or group of benefits during a calendar year, delineated in the contract. Maximums usually apply to each individual separately The calendar year maximum is the more commonly used, but sometimes the maximum may run on the benefit year or plan year.
Canada Pension Plan (CPP)
A federally administered pension plan that offers disability benefits to eligible contributors to the Plan. Primary benefits are payable to and on behalf of the disabled contributor. Dependant benefits may be payable either to the disabled contributor or the dependant (e.g. spouse, child) but in either case they are paid on behalf of the dependant.
Canadian Life and Health Insurance Association (CLHIA)
A regulatory association representing member companies in the life and health insurance industry and providing information and services to life and health insurance consumers.
Carrier
The party (insurer) to the group contract who agrees to underwrite (carry the risk) and provide certain types of coverage and services.
Census Data
Any statistical information such as age, sex, income, insurance classification, or dependent status on persons eligible for or insured under a group policy that is used to determine premium rates or benefits. This is information maintained by Underwriting.
Certificate Holder
The employee insured under a group plan. Manulife prefers the term plan member.
Certification type (HealthPro)
A reference to a dataset on the HealthPro administrative system that indicates how a group is enrolled and how claims are adjudicated.
Claim
A request by an eligible plan member for payment of covered expenses for health, dental, disability benefits. A claim can also be a request to pay out policy proceeds upon a loss (such as a death or disability of the insured).
Claim Lag
The time interval between incurred date of a claim and its submission to the insurer for payment. It is also used to mean the time between claim incurred and payment.
Claim Payment
The benefit payment payable by the insurer to a plan member, service provider, or beneficiary as outlined in the group contract.
Claim Reserves
Funds set aside by an insurer to settle incurred but unpaid claims, future claims, and may also include reserves for potential claim fluctuations.
Claim statement
A statement (generally attached to the claim payment or direct deposit notification) that outlines how benefits have been calculated or why benefits have been denied. Sometimes referred to as an Explanation of Benefits (EOB).
Claimant
Any eligible plan member making a claim.
Claims Fluctuation Reserve (CFR)
A policy holder fund where MLI has 1st call on money to cover a financial deficit associated with the plan.
Class
A group of plan members within a plan that have similar characteristics (and who are eligible for the same benefits), that allow the group insurer to determine an appropriate premium rate based on the benefits they receive.
Class number
The unique identification number to group/categorize claims; Provides a level of claims reporting.
Clerical Error Provision
A clerical error is a mistake in writing or copying data. A clerical error made by the policyholder or Manulife Financial will not invalidate insurance otherwise in force, or continue insurance otherwise terminated under the terms of the policy.
Client Administered or Self Administered
Under a client administered Group Benefits plan, the plan sponsor administers the benefits; This may include maintaining and updating records for the plan members and their dependants (i.e., spouse, child(ren)) and preparing and submitting the premium statement for each payment date to the insurance company.
Client Billed or Self-Billed
In this circumstance, Manulife Financial validates the claims and the plan sponsor prepares and submits the premium statement.
Client Financial Arrangement (CFA)
A legal document prepared to detail all financial obligations between the plan sponsor and Manulife. Usually applies to plans with unique administration combinations/types.
Client ID Number
Unique identification number to distinguish a group. The number is system-generated, used internally only; Clients do not have to provide the internal Client ID number to communicate with Manulife Financial.
There could be multiple policy/contract numbers under the one client ID.
Client Retention
An insurer's attempt to prevent the lapse of a policy or its transfer to another insurer.
Clients II (CII or C2)
Manulife’s claim adjudication system used to settle EHC and Dental claims but not drug claims.
Co-insurance
The amount or percentage of expenses the plan covers under a group plan. For example, if a plan covers 80% of the cost of eligible prescription drugs, the remaining 20% is paid by the plan member.
Collective Bargaining Agreement
A negotiated agreement between a union and an organization that may include among other things the provision of group benefits.
Combining For Experience
An underwriting term that describes the process of combining the premiums and claims of two or more benefits for experience rating purposes.
Commission
A fee paid to a licensed plan advisor, usually as a percentage of the premium generated by a sold policy.
Commuted Value
The single sum that represents the present worth, or equivalent value, of a stipulated number of installments (benefits) payable at fixed future dates. The commuted value is computed on the basis of a given rate of interest. It is often called "discounted value" and is normally used in reference to Survivor Income Benefits (Group Life benefit).
Company of Origin (HealthPro)
A system term used to reference which company's internal back-end suite of applications is used for a particular contract or policy.
Compassionate Assistance Program (CAP)
A program available under a Manulife Group Life Insurance benefit that allows a terminally ill plan member (who has been approved for Waiver Premium) to collect a portion of his or her Life Insurance benefit in advance of his or her death. The amount paid to the plan member is treated as a loan, and is deducted from the proceeds paid to the beneficiary upon the plan member's death.
Complications of Pregnancy
Contractually defined covered conditions of pregnancy that are "in addition to" or "in lieu of" a normal pregnancy. For example, complications of pregnancy usually include Caesarean section, spontaneous miscarriage or abortion, and any other condition that is not usually associated with a normal pregnancy.
Consultant
A person or firm specializing in the design, sale and service of group benefit plans. Manulife refers to consultants collectively as Plan Advisors.
Contingency Reserve
A reserve established to share among all policyholders the cost of the insurer of unpredictable, catastrophic losses.
Contingent Beneficiary
The person(s) or party legally entitled to the proceeds of an insurance policy upon death of the insured plan member if the primary beneficiary does not survive the insured.
Continuation of Benefits
The extension of certain benefits under specific conditions, beyond the termination of a plan member's participation in a plan or the termination of a policy.
Contract
An agreement, similar to a policy but for non-insured groups only. (ASO groups can only have a contract) The signed agreement between Manulife and the plan sponsor. The entire contract is made up of the group benefits application, the enrolment application, the plan document and any plan amendments that have occurred after the plan/policy document is issued. The contract is usually kept on file by the insurer.
Contribution
That part of the insurance premium paid by either the policyholder or the insured, or both.
Contributory plan
The plan member is contributing either in part of in whole to the cost of the coverage. Plan member and plan sponsor contributions are forwarded together to the insurer by the plan sponsor.
Conversion Charge
A charge made by the Group department for credit to the Individual Insurance department whenever group life insurance is converted. This charge is made because experience has shown that the average mortality on individual policies issued as conversions of group insurance is excessive.
Conversion Privilege
The privilege given to a terminating plan member to convert his group life and/or health without providing evidence of insurability. The conditions under which conversion can be made are defined in the contract.
Co-ordination of Benefits (COB)
Co-ordination of Benefits (COB) allows a plan member, who is covered under another plan, to claim under both plans and recover up to 100% of the expense.
Guidelines have been established by the insurance industry, which allow a plan member to coordinate benefits with another insurance plan and dictate the order in which the plans pay benefits.
Co-payment
The amount or percentage of expenses the plan member may be required to pay under the Group Plan. For example, if a plan covers 80% of the cost of the drug, the remaining 20% is paid by the plan member. The co-insurance plus the co-payment add up to 100% for any given service.
Corporate Account
One of Manulife’s four market segments, where plans include 400+ lives.
Cost Of Living Adjustment (COLA)
A contractual provision in the disability Contract or ASO Agreement that provides for a periodic recalculation of the scheduled payments to adjust for inflation
Cost Plus
Cost Plus allows a plan sponsor to pay for plan member(s) health and dental expenses that aren’t covered under the core health or dental plan.
It is an arrangement whereby a plan sponsor is charged for the claims paid outside the contract plus an administration fee.
Coverage
The amount of insurance or benefits stated in the contract for which a plan member is eligible.
Coverage Database
Coverage Database is one of Manulife’s proprietary systems that holds a policy's coverage (benefit) details and is used to feed coverage information (for Life and Disability) into Navigator 2 for any policies maintained on that system.
Coverage Database (Cov DB)
Coverage Database is one of Manulife’s proprietary systems that holds a policy's coverage (benefit) details and is used to feed coverage information (for Life and Disability) into Navigator 2 for any policies maintained on that system.
Credibility
The weighting or “believability” of the client’s own experience during underwriting evaluations.
Critical Illness (CI)
A separate benefit which may or may not be attached to LTD coverage.
The CI Benefit is only payable for specific diagnoses which are outlined, in detail, in the policy. Adjudication is based on diagnosis, not disability.
Customer Profile Maintenance (CPM)
Customer Profile Maintenance (CPM) is a proprietary system used to update the Group/Division, Plan Administrator and Plan Member information on the client profile database (CPD) for groups using the Group Benefits Websites.
D
Date of Disability
The date from when the claimant is deemed no longer able to carry out the duties of occupation (per Contract or ASO Agreement provisions and definition).
Death Benefit
The payment made to a beneficiary at the time of death of an insured.
Decrease
The amount of coverage reduction because of a change in classification due to attainment of a specified age, demotion, salary decrease, etc., as provided by the master policy.
Deductible
The amount of covered expenses that must be incurred by a plan member each calendar year before benefits become payable by the insurer.
Deficit
When Manulife has paid out more in claims and expenses than received in paid premium.
Dental Care
Generally, dental services and supplies not covered or in excess of those covered by any Provincial Plan.
Dental Fee Guide
Dental associations publish dental fee guides which summarize recommended charges for each dental procedure. Guides are updated annually to account for inflation and other factors.
Dependant
The spouse and/or children of an insured plan member who meet the eligibility requirements as defined in the contract.
Deposit Premium
The premium deposit paid by a prospective policyholder when an application is made for a group insurance policy; It is usually equal to the estimated first month's premium and applied toward the actual premium when billed. Also called Deposit or Initial Deposit.
Designated Beneficiary
The person(s) or party designated by the insured to receive the proceeds of an insurance policy upon the plan member’s death.
Diagnostic Services
Diagnostic services required to assist the dentist in evaluating the existing condition of a patient's mouth. These services are used to determine what dental treatment, if any, is needed.
Direct Claim Submission
A plan setup where the plan member submits a claim directly to the insurer, who verifies eligibility based on information provided by the plan sponsor.
Direct Deposit
The electronic credit of claim reimbursement expense funds or disability payments from the insurer to the plan member's bank account.
Direct Enrolment (DE)
Plan member, over-age dependant and coordination of benefits information is collected at the time of enrolment. Dependant information is collected at the time of the claim and subject to some checking criteria. When a claim is made at a pharmacy, COB information is verified and used to adjudicate the claim. If dependants have other coverage based on COB rules, the claim is declined and the plan member is directed to submit the claim to the other insurer first. Dependant information does not have to match in order for a claim to be paid.
Direct Withdrawal
The electronic debit of funds from a plan sponsor or plan member's bank account to pay premiums for benefits.
Disability
A physical or mental condition which makes an insured incapable of performing duties based on the specific Definition of Disability in each contract.
Disability Benefit
A contract benefit or benefit provision that provides some type of compensation for disability.
Disabled Life Reserve (DLR)
The future liability set up for claims that are active. This reserve is calculated on a claim by claim basis.
Dismemberment
The accidental loss of limb, sight, speech, or hearing.
Dispensing Fee
The dollar amount charged by the provider for dispensing the benefit and/or service (e.g.., pharmacist charges a "fee" for dispensing prescription drugs).
Dispensing Fee Cap
The upper limit of how much the plan will pay for the dispensing fee depending on the contract. The plan member may pay the balance charged over this amount, depending on the contract.
Division
A number to identify specific plan member groups organized by active and retired, different locations, management and non-management.
Drop to Pay
A term referenced in HealthPro claim payment system that means to auto-adjudicate (without any manual intervention) and pays a claim as soon as it is 'dropped' into the HealthPro system.
Drug
A substance intended for use in the diagnosis, cure, treatment or prevention of a disease. There are various terms used to describe drugs. These include drugs, generic drugs, prescription drugs, over-the-counter drugs, depending on the contract.
Drug Formulary
A restricted list of prescription medications covered under a prescription drug program.
Drug Identification Number (DIN)
A unique number that identifies a specific drug. Each type, form, strength and package size has a different DIN.
Drug Stop Loss (DSL)
Drug Stop Loss Pooling (DSL) protects the plan sponsor’s EHC renewal rates from the impact of high drug costs. Claims over a certain threshold are removed from experience rating analysis and replaced with a pool charge.
Drug Utilization Review (DUR)
Drug utilization review is a pharmacy benefit management feature that helps protect the health of plan members by seeking to alert the pharmacist to dangerous drug interactions, too-early refills and duplicate drug therapies.
Due & Uncollected Premium
Premium due an insurer that has not been received as of some specified date.
Due Date
The date premiums become due on a case; also called premium due date.
Duplication of Coverage
It exists when an insured is covered under two or more policies for the same exposure to loss. Non-duplication provisions are utilized to control this situation, especially when such double coverage results in over insurance.
See Over insurance .
Dynamic Maintenance
A pharmacy benefit management feature that determines how many days supply of a drug will be covered per prescription refill, based on whether a plan member uses the drug for a short or long-term medical condition.
E
Earnings
The basic salary or wages paid to an employee, sometimes including regular overtime and bonuses. It may or may not include commission income. Basic compensation is often used as a means of establishing an employee's benefits and contributions.
Earnings Schedule
A type of schedule of insurance whereby insureds are classified by wage or salary and the insurance benefits (type and amount) vary by earnings classes.
Education, Training and Experience
Information that is obtained to determine a disabled claimant's eligibility for benefits and/or suitability for rehabilitation.
Effective Date
The date on which coverage goes into effect. The term may reference the date a contract, coverage, a particular benefit or an insured plan member, their dependant (ie., spouse or child(ren)) comes into effect.
Electronic Data Interchange (EDI)
The electronic transmission of data from the provider to a Third Party (e.g.., transmission of a dental or drug claim).
Electronic Funds Transfer (EFT)
The electronic debiting or crediting of funds to or from a plan sponsor, plan member, provider or insurer's bank account.
Eligibility
The provision of the group policy which state requirements that the members of the group must satisfy to become insured with respect to themselves or their dependants.
Eligibility Date
The date on which a member of an insured group becomes eligible to apply for insurance.
Eligibility Period
The period of time following the eligibility date (usually 31 days) during which a plan member of a group plan can apply for insurance without evidence of insurability.
Also known as Enrolment Period.
Eligible Expense
The benefits that have been identified under the contract for which reimbursement will be paid.
Elimination Period / Qualifying Period
A period of time of continuous total disability that the plan member must complete in order to qualify for benefits.
Employee Census
Employee census includes data, such as age, sex, occupation, earnings, and dependency status, relating to the insured persons under a group policy.
Employer Administered (EA)
An arrangement where the plan sponsor validates plans member eligibility for claims prior to submission of the claim for payment.
These types of arrangements are now very uncommon in view of privacy legislation.
Employer Certified Claim Submission
A plan set-up where the plan member submits a claim via the employer, who forwards the claim to the insurer after verifying the eligibility of the person for benefits.
Enrol
A process to sign up plan members for group benefits.
Enrolment application
Form used to sign up plan member for group benefits.
Enrolment period
The period during which plan members may enrol in a new group plan without providing evidence of eligibility and before becoming a late applicant.
Also known as Eligibility Period.
EVA
ESI Visual Administrator - A claims adjudication system for claims submitted by pharmacies and employee reimbursement claims.
Evidence of Insurability (E of I)
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 coverage.
Evidence-based adjudication
Adjudication is the process of determining whether a claim is eligible for payment.
Expectation of Life (Life Expectancy)
The average number of years of life remaining for persons of a given age according to a particular mortality table.
Expense Loading Factor
This is a cost that is included in the premium rate to cover costs for installing and administering a plan.
Expense Ratio
The ratio of expenses to earned premiums. May also be called the insurer's retention.
Experience
The term used to describe the relationship between the premiums paid to an insurer and the benefits paid out over a fixed period of time, for example, a policy year, or the three most recent complete policy years.
Experience Analysis
Any statistical analysis of experience for all or any segment of the group business such as a line or a territory; any group of cases, coverage, or benefits, or any single cases, coverage, or benefit. It may include single or multiple experience periods, analysis of past and projection of future trends, plus various descriptive or inferential statistics.
Experience Rating
The process of determining the premium rate for a group based wholly or partially on the group's claims experience. Where the group's claims record is worse than expected the premium rate may be increased to compensate; favourable experience may be rewarded with a premium discount.
Experience Refund
The amount of premium returned by an insurer to a group policyholder when the financial experience of the particular group has been more favourable than anticipated.
Experience-Rated Premium Rates
Premium rates for a group coverage which are based, wholly or partially, on the past claims experience of the group to which they will apply.
Explanation of Benefits (EOB)
EOB is a claim statement explaining what health or dental treatments or services were paid for under their group insurance plan.
Extended Death Benefit or Extended Disability Benefit (EDB)
Provides coverage for a distinct period of time to the plan member's surviving spouse and dependents, after the death of a plan member.
Extended Health Care (EHC)
Medical services, drugs and supplies provided under a group benefit plan in excess of those covered under the Provincial Plan.
Extension of Benefits
The granting of certain benefits under conditions beyond the termination of a plan member's participation in a plan or the termination of the master policy.
F
Family coverage
Insurance coverage for the plan member as well as his/her dependants (ie., spouse and/or child(ren)).
Family deductible
A type of deductible that may be satisfied by the combined expenses of all covered members rather than an individual family member.
Fee Schedule
Maximum dollar or unit allowances for dental services that apply under a specific contract.
Financial Adequacy Adjustment (FAA)
An adjustment on Renewals based on product code.
Flat Schedule
A type of schedule of insurance under which everyone is insured for the same benefit(s) regardless of salary, position, or other circumstances.
Flexible Benefits
Plan design that permits an eligible plan member to select their benefits from a range of options to best meet their needs. Typically only larger plan sponsors offer Flex Plans.
Functional Abilities Assessment/Evaluation (FAA/E)
Term for an assessment of a disabled claimant's physical restrictions and limitations.
Functional Capacities Assessment/Evaluation
Term for an assessment of a disabled claimant's physical restrictions and limitations.
G
Generic Drug
A drug that contains the same active ingredient but is generally less expensive that its brand-name equivalent.
Generic Substitution
A drug plan formulary that reimburses drug expenses based on the least expensive generic alternatives of the drug.
GFM
An original Manulife System that has now been replaced by ManuConnect. Business that converted from this system is shown on Navigator 2 as Source of Business GFM to differentiate from new business set up on ManuConnect (VNCov)
Grace Period
A specified time (usually 31 days) following the premium due date during which the premium may be paid and during which the insurance remains in force.
Grandfathering
When Manulife accepts the existing amounts of coverage for all plan members at the time of Quotation or New Issue without obtaining Evidence of Insurability.
Gross Benefit
This is the total contractual amount of monthly benefit a claimant would be entitled to receive in the absence of any Income Offsets.
Group Benefits (GB)
Employer-sponsored benefits.
Group Information Detail (GRID)
GRID is a view function that displays the coverage (benefit) information stored in the coverage database.
See CovDB.
Group Information Processing System (GIPSY)
GIPSY is the administration system for plan sponsors whose information is maintained in the Coverage Database (CovDB). This is an integrated system, binding information related to premium payment, billing type and plan member data.
Group Policy Master (GPM)
An internal database that lists contracts and policies across all blocks of business, as well as the applications used to provide specific services such as plan set-up, health and dental claim administration, life and disability claim administration.
Groups Services Offering (GSO)
A term used in HealthPro claims adjudication system.
H
Head Office Administered Group (HO or HO Admin)
For H.O. Admin (Direct Billed) Groups, Manulife maintains the records on employee coverage, movement, etc. and bills the policyholder for premiums due.
Health Care Spending Account (HCSA)
An account where credits (supplied by the plans sponsor) are deposited for plan members to use for paying selected health and/or dental care services and supplies. Eligible expenses are limited by what Canada Revenue Agency deems eligible for tax purposes, which include but are not limited to plan deductibles and/or percent payable amounts, or other services/supplies that are not covered under the Extended Health or Dental Care plan. A HCSA is generally a supplement to the group benefit plan designed to give more flexibility and control to plan members.
Health Services Navigator (HSN)
Health Service Navigator (HSN) is a health care navigation service designed to support plan members and their eligible dependants facing a critical, chronic or episodic health event.
The service provides a centralized resource for medical and health information and will assist plan members in navigating the Canadian health care system (both public and private), effectively and proactively. When appropriate, HSN also enables users to gain access to “world-class‟ medical second opinion services and treatment facilities.
HealthPro
Health and dental claims adjudication and payment system.
I
IDEAS
A billing and administration system that provides policy information to Navigator 1.
Income Offsets
These are income sources that are to be deducted from the gross benefit in the manner as set out in the Contract or ASO Agreement provisions.
Incontestable Clause
The provision in a group life and/or disability insurance policy which prevents the insurance company from disputing the validity of:
- an insurance policy once it has been in force for a specified period of time (e.g., two years) as long as premiums are paid, except in the case of fraud.
- an individual's insurance, on the basis of statements made by the individual in connection with insurability at the time he or she applied for the coverage, once the insurance has been in force for two years during the individual's lifetime, except in the case of fraud.
Incurred
Date of Loss (Death, Disability, Dismemberment)
Incurred Basis
Basis which segregates experience based on the date of incural of a claim.
Incurred But Not Paid (IBNP)
Incurred But Not Paid Claims - Incurred claims which have not been paid as of a specified date (may include both reported and unreported claims).
Incurred But Not Reported (IBNR)
Incurred But Not Reported Reserve - A reserve of funds Manulife must maintain to cover the cost of claims that have not formally been made yet.
Incurred But Unpaid Claims
Incurred claims that have not been paid as of some specified date (may include both reported and unreported claims).
Incurred Claims
Incurred claims equal the claims paid during the policy year plus the claim reserves as of the end of the policy year, minus the corresponding reserves as of the beginning of the policy year. The difference between the year end and beginning of the year claim reserves is called the increase in reserves and may be added directly to the paid claims to produce the incurred claims.
Incurred Claims Reserves
These reserves represent an estimation of claims actually incurred in the policy year but not settled as of the end of the policy year. They may be established as a function of premiums earned, claims paid, or benefits in force, using average factors, or in exceptionally large cases they may be result of a detailed study of that particular policyholder's actual claims. Reserves for known pending claims, generally restricted to Life, AD&D and LTD claims may be added to these claim reserves.
Independent Medical Examination (IME)
An examination of a disabled claimant by a specialist who is not actively treating the claimant. Manulife requests the examination.
Inforce
The total volume of insurance in effect on the lives of covered employees at any given time. Measured in terms of cases, lives, premium and amount (volume) of insurance.
Initial Deposit
The deposit paid by the plan sponsor upon completion of a group insurance application. It is usually equal to the first month's premium payment and is applied as such when the actual premium is calculated. Also called Deposit or Deposit Premium.
Installation
The process of assisting a policyholder to set up the administrative practices essential to the proper handling of records, reports, claims, changes, conversions, ordering of supplies, who to contact when and how, hospital admissions, certification of eligibility, etc., under a group insurance plan.
Insurance Class
A classification of insured persons (described in a group policy) which determines the types and amounts of insurance for which they are eligible under the policy.
Insurer
A company offering protection through life, health, dental and disability benefits due to the sale of an insurance policy. The Manufacturers Life Insurance Company is an insurer.
Integrated Absence Solutions (IAS)
A component of the Absence Management Services program.
Integrated Administration Solutions (IAS)
The Integrated Administration Solutions (IAS) team provides full administration services for all types of benefit programs to our Corporate Account customers.
Internal Wholesalers (IWS)
Internal Wholesalers are sales professionals who are members of the Small Business Unit. Internal Wholesalers work closely with the Account Executives to expand Manulife’s advisor relationships.
Irrevocable Beneficiary
A beneficiary designation which may not be changed without the beneficiary's consent.
J
Joint Beneficiary
People defined by the plan member who are entitled to a shared percentage of the proceeds of an insurance policy upon the plan member’s death and as directed by the insured. In the absence of specific percentages, joint beneficiaries receive equal amounts.
L
Labour Market Survey
A direct canvassing of employers in order to obtain accurate and current information regarding specific occupations. It is usually carried out via telephone and may be coupled with local or national labour statistics. A Rehabilitation Specialist with CRC credentials typically performs the LMS.
Lapse
It is the termination of the coverage provided in a contract because of the non-payment of premium(s) within the time due. The contract is then cancellable subject only to the insurer’s reinstatement provisions.
Lapsed Policy
A group master contract that has automatically expired, as provided by its terms, due to nonpayment of premium.
Late Applicant
A plan member who applies for insurance after the normal 31 day enrolment period, at which point evidence of insurability is required.
Learning Management System (LMS)
A software application (such as Manulife Financial’s Compass system) that is used for the administration, documentation, tracking, and reporting of training programs, classroom and online events, e-learning programs, and training content.
Liability
The probable cost of meeting an obligation.
Life Claim
A request by a beneficiary of a Life insurance plan to pay the proceeds of that benefit upon the death of the insured.
Lifetime Maximum
The maximum amount payable as a benefit during the plan member’s lifetime. Maximums usually apply to each covered individual separately.
Limits
The maximum amount of insurance an insurer will write on one risk. The maximum and minimum ages above and below which an insurer will not issue or offers restricted coverage.
Litigation Reserve
The amount held to cover the liability that may result from existing legal action as reported to and calculated by Manulife’s Actuaries.
Long Term Disability (LTD)
Disability income insurance that provides long-term benefits to the plan member when income is interrupted for a time because of an illness or accident. Benefits are paid monthly, semi monthly, or weekly, bi-weekly, typically a percentage of salary to a stated maximum or fixed amount.
Long Term Disability Benefit
The LTD benefit provides income replacement on behalf of the plan member in the event that the plan member is totally disabled as defined in the Contract or ASO Agreement.
There is normally a 3 month or longer period of Total Disability required before an insured is entitled to this benefit, and the maximum benefit period is normally age 65 although this can vary each contract defines the maximum benefit period.
Loss Ratio-Paid Basis
The ratio of paid claims to earned premiums.
M
Major Services
Coverage under a dental care plan. Plan that reimburses for major restorative dental services depending on the contract.
Mandatory
A term used to describe a group insurance plan under which the employee is required to participate in the plan as a condition of his or her employment.
Manual rating system (MERIT)
The MERIT system produces quotations for new business and amendments. Its manual rating capabilities are also used in developing rates for renewal of self-administered groups. It is used primarily by the Underwriting areas.
ManuConnect (MC)
ManuConnect is a proprietary administration system that stores employee and plan sponsor information on contracts.
Manulife Administered
Manulife Financial maintains the records regarding all plan members in the group insurance plan, prepares the premium statements and forwards it to the plan sponsor for payment. The plan sponsor provides the insurer with a monthly listing of plan member changes and pays the premium as billed. The plan member submits claim directly to the insurer for payment and the insurer reimburses the plan member directly for those expenses.
Manulife Billed
Premium statements prepared by the insurer and sent to the plan sponsor for a certain period of time (e.g.., one month).
Manulife’s Financial Small Business Research Report
An annual survey of small business owners sponsored by Manulife Financial Group Benefits.
Manulife's Automated Policy Publishing System (MAPPS)
A proprietary document assembly/content management system that uses coded benefit details to create plan documents (including booklets, contracts, amendments, administration guides).
Master Policy Contract
An agreement between the insurance company and the contracting party (usually referred to as “the employer.”) The employee is the “life insured” and is not a party to the contract, although legal obligations exist between the insurance company and the lives insured under the contract.
Maximum Allowed
The maximum benefit amount eligible for reimbursement before the deductible and coinsurance is applied.
Maximum amount payable
The maximum benefit amount payable after the deductible and coinsurance is applied.
Medical Disability Advisor (MDA)
An on-line disability management tool which provides information on diagnoses, medical procedures and recovery times Medical equipment, supplies and services (either for purchase or rent) designed primarily for therapeutic purposes. The list of covered supplies and services may vary depending on the terms of the contract.
Medical Equipment & Supplies
Medical equipment, supplies and services (either for purchase or rent) designed primarily for therapeutic purposes. The list of covered supplies and services may vary depending on the terms of the contract.
Medical Management Questionnaire
Pre-formatted questionnaire for a specific condition.
Member Coverage Statement
A summary on the Secure Sites that shows all the coverage/benefits for a plan member, his or her dependants, as well as COB information for health and dental coverage. The summary reflects only Manulife eligible benefits information.
Memorandum of Agreement (MofA)
A formal document produced as an addition to the standard policy. It allows for coverage or exceptions that would not ordinarily be allowed under the group's regular benefit plan.
Misrepresentation
A false statement as to a past or present material fact, made in an application for insurance, that induces an insurer to issue a policy it would not otherwise have issued.
Misstatement of Age
The declaration by an employee of an age that is lesser or greater than his or her actual age.
Morbidity
The incidence and severity of sicknesses and accidents in a specific class or classes of persons.
Mortality
The death rate of each age is determined from prior experience. A mortality study (table) shows the probability of death and survival at each age for a credible unit of population.
N
Navigator 2 (Nav 2)
The primary life and disability claims management, adjudication and payment system. There are two versions: Navigator 1 will be retired when all the records are moved to Navigator 2.
Non-Contributory plan
A plan where the plan sponsor pays the entire cost of the plan.
Non-Evidence Limit (NEL)
The maximum amount of life and disability insurance that is specified in the group plan for which a plan member does not have to submit evidence of insurability.
Non-occupational Coverage
Coverage that protects a person against an off-the-job accident or sickness. It does not cover disability resulting from injury or sickness caused by the plan member's employment. Group health insurance is frequently non-occupational.
Non-Refund Accounting (NRA)
Non-refund accounting is an underwriting arrangement where the plan sponsor does not participate in the financial results of the plan: whether a surplus or deficit arrangement. Also known as pooled.
O
Occupational Coverage
Insurance covering death, sickness and accidents which arise from a plan member's employment, as well as those which do not (ie., 24-hour coverage).
Open Enrolment
A set period of time during which employees may apply for new or increased insurance coverage without supplying Evidence of Insurability.
Optional Life
Additional Life insurance, which the plan member can purchase under the group plan at a group premium rate. Evidence of insurability is usually required. Rates are generally age-banded and may also be gender and smoker-status distinct.
Orthodontics
Coverage that reimburses for services that correct the misalignment of the teeth.
Orthotics
Corrective appliances for the feet.
Out of pocket Maximum
The portion of eligible expenses (including deductibles and the plan member's portion of the reimbursement percentage) which may be paid out by the plan member before the plan will pay 100% subject to any other plan maximums and limitations.
Over-age Dependant
Dependants who are over the child limited age (generally 18 or 21), and are either full-time students, or functionally impaired. Full-time students under the student limiting age (generally age 25).
Overdue Premium
Premium that is due to the insurer which has not been paid by the end of the grace period.
Over-insurance
Insurance exceeding in amount the probable loss to which it applies. This serious problem can be controlled in EHC and Dental coverage by the contractual use of non-duplication of benefits provisions (e.g. Co-ordination of Benefits). It can be controlled on Disability coverage by integration of all disability payments so they do not exceed a specific percentage of pre-disability earnings.
Over-the-counter Drugs
Medications that are legally available without a prescription, and which do not generally require one.
P
Package (HealthPro)
The term referenced in HealthPro claims adjudication system for a group of client benefit offerings. The client benefit offerings contain the actual benefits that a plan member is eligible for.
Paid Basis
Basis which analyzes experience based on the financial transactions and reserve movement during the period.
Paid vs Eligible
Benefits based on dollars paid: (standard): dollar amount paid to member is accumulated toward benefit maximum or sliding coinsurance. Benefits based on dollars eligible: (elective): eligible amount of claim (not paid amount) is accumulated toward benefit maximum or sliding coinsurance/out of pocket.
Paramedical Practitioners
Health practitioners who are not medical doctors. These may include but are not limited to Chiropractors, Osteopaths, Naturopaths, Podiatrists, Chiropodists, Acupuncturists, Registered Massage Therapists/Masseurs (RMTs) Physiotherapists, Psychologists, and Speech Therapists.
Participant (HealthPro)
A subscriber (plan member) and their dependants.
Participation
A ratio determined by the number of insured plan members covered under the group plan in relation to the total number eligible to be covered, usually expressed as a percentage.
Period of Disability
The period when an employee is prevented from performing the usual duties of his or her occupation or employment, or unable to perform 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.
Persistency
A ratio determined by the number of insured plan members covered under the group plan in relation to the total number eligible to be covered, usually expressed as a percentage.
Pharmacy Benefit Strategy (PBS)
Strategy where an external independent, clinical advisory committee applies scientifically based guidelines to review all new drugs entering the Canadian market to assist in determining eligibility.
Physical Capacities Evaluation
A questionnaire sent to a claimant's treating physician(s) to determine the claimant's physical restrictions & limitations.
Plan
A set of benefits under a contract, or policy or plan arranged through a plan sponsor or government.
Plan administrator (PA)
The individual who administers a group benefits plan on behalf of the plan sponsor.
Plan advisor
A plan advisor represents a plan sponsor in their search for insurance coverage. Advisors may or may not sell products of more than one company.
Plan Anniversary Date
The annual date separating the claims experience under a group plan between one period of time and the next (for client financial accounting purposes). The period of time is normally 12 consecutive months.
Plan Benefit Option (PBO)
An internal code used to identify a plan benefit option for each choice within a benefit.
Plan Contract Number
A unique identifying number assigned to a group that identifies the plan to the insurer.
Plan Document
A document prepared for ASO groups that describes the specific benefits to be provided to plan members by the plan sponsor on a self-insured basis. Note - the plan document does not represent a contract. The contract terms govern.
Plan member (PM)
A person who participates and is covered under a group benefits plan.
Plan Member Administration
Administration area in MLI responsible for validating, adding, and updating Member Data for Home Office administered groups.
Plan member certificate number
A unique identifying number issued to a plan member of a group plan.
Plan Member Contributions
The amount of premium the plan member contributes towards the cost of the benefit or the benefit plan.
Plan Member Data Listing
The plan member eligibility information required by the insurer (e.g.., date of birth, name, certificate number) for claim certification purposes.
Plan number
Refers to the level of categorization below account/division for plan members with the same set of coverage. A new plan number is issued for each unique set of benefits, across contracts.
Plan Sponsor (PS)
An entity such as an employer, association or union that offers a benefit plan such as life, disability, health and pension to its members.
Plan Year
The period of time between two contract anniversary dates, usually 12 months in length.
Policy
A contract for insured groups only (excludes ASO groups who can only have a contract).
Policy Anniversary
The annual date the policy became effective, normally twelve consecutive months.
Pooling
The combining of all premiums, claims, expenses, etc., for certain size cases in order to spread the risk.
In a pooled situation the financial report charges the client for claim amounts up to the pooling point, individual claim amounts above the pooling points are charged to Manulife s pool. There are 3 types of pooling arrangements;
1. Large Amount Pooling,
2. Aaggregate Stop Loss Pooling and
3. Large Amount Combined with Aggregate Stop Loss Pooling.
Positive Enrolment (PE)
Plan member, dependant and co-ordination of benefits information is collected at the time of enrolment. When a claim is made at the pharmacy, the dependant and COB information is verified and used to adjudicate the claim. If the dependant information does not match, the claim is denied. If dependants have other coverage based on COB rules, the claim is declined and directed to the other insurer.
Pre-determination (PDR)
A provision under a dental care plan requiring plan members to submit their proposed treatment program and its cost to Manulife Life in advance of the services being delivered. The treatment plan is evaluated, and the plan member is provided with an estimate of what would be covered under the dental care plan.
Pre-disability Gross Earnings
Pre-disability gross earnings are the plan member s earnings as defined in the Contract or ASO Agreement before any deductions (e.g. Federal and Provincial income taxes).
Pre-disability Net Earnings
Pre-disability net earnings are the plan member s earnings less deductions, both as defined in the Contract or ASO Agreement.
Pre-Existing Condition
Any physical and or mental condition or conditions that existed prior to the effective date of coverage under a contract.
Pre-existing Condition Limitation
A restriction on payments on those charges directly resulting from an accident or illness for which the insured received care or treatment within a specified period of time (e.g. 3 months) prior to the date he or she became insured.
Preferred Provider Network (PPN)
Health care professionals who enter into preferred agreements with the insurer, plan sponsors and/or plan administrators to provide their professional services for a set fee. That fee is usually less than the usual and customary fee. The sum owed to the insurer based on the applicable rates and the eligible volumes or number of lives.
Premium
The sum owed to the insurer based on the applicable rates and the eligible volumes or number of lives.
Premium Refund
Premium returned to a policyholder (usually because of favourable experience; i.e. an experience rating refund).
Premium Statement
A statement prepared by the plan sponsor or the insurer to report the premium that is due to the insurer the period.
Premium Tax
An assessment levied by a Federal or Provincial government, on the Premium income collected in a particular jurisdiction by an insurer.
Preventative Plan
A package of benefits that provides coverage for dental services intended to prevent tooth decay, depending on the contract.
Primary Beneficiary
The first person designated to receive proceeds of an insurance policy upon the plan member’s death.
Prior Authorization
Medical information provided for review purposes, prior to adjudicating a claim.
Private Hospital accommodation
A hospital room with a single bed, as requested by the plan member or required as a condition of treatment.
Probation Period
The length of time a person must wait from the date of his or her entry into an eligible class or application for coverage to the date his or her insurance is effective. Also referred to as the Waiting Period.
Proof of Loss
Documentary evidence required by an insurer to prove a valid claim exists. For group life insurance, it usually consists of a completed claim for and proof of death (death certificate or acceptable substitute); in EHC for instance, it usually consists of a completed claim form and itemized medical bills.
Protected ID (HealthPro)
An internally-assigned number that uniquely identifies a plan member; used for privacy reasons instead of the plan member certificate number on reports that will be distributed externally.
Provincial Plan Replacement
Coverage for plan members and dependants who reside in Canada and are not covered by the Provincial Health Plan.
Q
Qualifying Period
The period of continuous disability which must be completed by the plan member in order to qualify for benefits.
Quebec Pension Plan
A provincially administered plan that operates like the Canada Pension Plan but for residents of Quebec only.
See Canada Pension Plan.
Quotation
The offer to a prospective policyholder to underwrite specified insurance benefits at quoted premium rates. The quoted premium rates may be firm or estimates subject to recalculation based on enrolment. Also known as a Proposal.
R
RAMQ
Is the result of legislation that requires all Quebec residents to have access to basic drug coverage through a Group Benefit plan or RAMQ.
Rate Group
A set of rates that can be used by many plan benefit options. Generally the rate group will be specific for one type of benefit such as health, dental or LTD.
Reasonable & Customary (R&C)
A fee is reasonable and customary if its dollar value falls within the usual range of charges for the same or comparable services (or supplies) made by similar practitioners in an area as determined by Manulife Financial.
Recall Procedures
Dental procedures which are normally provided on a regular basis, depending on the contract.
Recurrent /Recurrence
A specific contractual provision that deals with an attempt by claimant to return to full time work. The approved claim is terminated at the date of return to work.
If within the recurrent period set out in the contract, the employee becomes disabled again due to same or related medical reasons as in the initial claim, and the disability is medically supported and meets the definition of disability effective at the time of the subsequent work stoppage, then benefits are paid from the first day of disability without the need to complete another elimination period. This provision encourages return to work attempts without penalizing the claimant for trying.
Re-enrolment Period
The period during which plan members have the opportunity to choose or reselect benefits. This generally applies to Flexible Benefit programs.
Refund Accounting (RA)
Refund Accounting is the underwriting arrangement under which the plan sponsor participates in financial results of the plan, whether a surplus or deficit occurs.
Regional Group Office (RGO)
Part of our Distribution organization, a Regional Group Office is a base for sales and service interactions with plan advisors, as well as existing and prospective clients. Sales Directors, Account Executives and Service Associates are tied to one of these nationally based centers. A Regional Vice President oversees operations of the RGO.
Reimbursement
The payment of actual incurred charges as a result of an accident or illness but not to exceed any maximum specified in the plan provisions.
Reinstate - Claims
This would have previously been an approved claim, where benefits were stopped and Manulife informed the claimant that no further liability was accepted. Subsequently the claim is approved again and benefits continue as if it had never been closed.
Reinstatement
To place in force again or re-activate, without the usual waiting or service period an individual's group insurance or a group contract which has terminated.
Reinsurance
Is an arrangement where one insurance company shares the risk with another Specifically, one insurance company is responsible for liability up to a specified dollar amount and the other company is responsible for the balance.
Renewal
An offer and acceptance of a premium for a new policy term.
Renewal Date
The first anniversary date of the contract.
Renewal Rate
The next year's contract rate.
Renewal Rate Date
The date the renewal rates are effective.
Renewal Rating
The setting the premium rate at a level which will support the emerging claims experience and projected expenses of a specific benefit for the coming period.
Renewal Underwriting
Renewal underwriting is the review of a group case and the establishment of the renewal premium rates and terms under which the insurance may be continued.
Reported But Not Admitted Reserve
The liability set up for claims which have passed their elimination period but for which no decision about approval or declination of the claim has been made.
Reporting Lag
A measure of the timeliness of the receipt of a claim from the date the disability occurred.
Formula is (Claim Received Date) (Date of Disability) + 1
Reserve
A measure of an insurer's liability, present and future for a particular obligation or a class of obligations.
An estimate of all future payments expected to be made for a claim at a given point in time.
Retention
That portion of the premium retained by the insurer for expenses, contingencies, and profits or contributions to surplus.
Retention Accounting
See Refund Accounting Also known in the industry as Experience rated.
Risk
The probable amount of loss foreseen by an insurer in issuing a contract.
S
Salary Continuance
Absence Management Solutions enhances an employer salary continuance program. This means that employer funds the STD portion of their employee's absence from work as an additional benefit. When an employee is totally disabled from completing the duties of their job - their absence and return to work is managed by Manulife but their employer continues to pay them. The pay may be a percentage of their full pay when working but this is up to the individual employer.
Schedule of Insurance
A list of the type and amount of insurance coverage for each person covered by the employer under a group plan.
Self-Administered Group (SA or Self-Admin)
Self Administered Groups are responsible for maintaining the records on employee coverage. They look after determining amount of coverage based on the policy, calculating & remitting premium payments.
Also Known as Employer Certified.
Semi-private Hospital accommodation
A hospital room with 2 beds.
Shared Accumulators
Maximums, deductibles, sliding coinsurance are shared across drugs and extended health care benefits for plans with pay-direct drugs and other EHC benefits.
Short Term Disability (STD)
Insurance that provides income to the insured plan member when income is interrupted for a short period because of illness or accident. Benefits are paid weekly and are typically a percentage of salary to a stated maximum, depending on the contract.
Signature
One of four of Manulife’s market segments catering to the mid-size business market with employers who have 25-399 lives.
Sliding Coinsurance
Benefits will be initially covered at a contractually defined coinsurance, once members reach a certain dollar threshold, the benefit coinsurance changes (slides) to a second contractually defined coinsurance.
Small Business
Groups between 2 and 50 plan members.
Small Business Advisor Week
A celebration of advisors and their small business clients that is held each year during the second week of October.
Split Funded
Split funded means that the client assumes all of the risk for the first agreed upon number of years of each claimant s benefit payment; Manulife assumes all of the risk for each claimant s payments which extend beyond that time period.
For example , the first 3 years are the client s risk and Manulife s beyond the 3 years
Split Recall
Split Recall happens when a client wants different time restrictions based on age (adults versus children).
Spread of Risk
There must be enough healthy members in a group to balance the unhealthy members so that the claims that are likely to be incurred can be funded. There must be a steady flow of individuals through the group.
Subrogation
The right of an insurance company to recover the amounts it has paid for a disability suffered by an insured employee when a third party is liable for that disability.
Survivor Income Benefit (SIB)
This coverage provides eligible dependents of a deceased employee with a monthly benefit. It is payable for a certain period of time as stated in the contract.
T
Taxable Spending Account (TSA)
Allows members to pay for items that are not generally CCRA-tax eligible.
Therapeutic Class
A classification of drug that identifies the drug's most common therapeutic use.
Third Party Administration/Administrator (TPA)
When a third party (such as a professional insurance administrator or a consultant) handles administrative functions including maintaining records regarding the persons covered under the group plan on behalf of the plan sponsor. In some cases, the TPA may also pay claims. In all cases, the underwriting and setting premium rates for insurance coverage remain the insurer's responsibility.
Third Party Provider (TPP)
A service provider or vendor who enters into an agreement with Manulife Financial to provide goods and/or services.
Total Disability
The definition of totally disabled can be one of the following: “Any Occ” Coverage - totally disabled means that as a result of sickness or injury, an employee is, during the elimination period and thereafter, unable to engage in any occupation for which he or she is or may become reasonably qualified by education, training, or experience. “Own Occ” Coverage - totally disabled means that as a result of sickness or injury, an employee is: During the elimination period and the subsequent time period specified in the contract, unable to perform the regular duties of his or her own occupation and thereafter, completely unable due to sickness or injury to work at any occupation for which he or she is or may become reasonably qualified by education, training, or experience.
Transferable Skills Analysis (TSA)
An assessment of work skills acquired during an individual's occupational history to determine if those skills can be utilized in an alternative occupation.
Also known as Vocational Assessment.
Twenty-Four Hour Coverage
Insurance providing benefits for an accident or sickness incurred either on-the-job or off the job, i.e., 24 hours a day.
U
Underwriting (U/W)
The process by which an insurer determines whether or not and on what basis it will accept an application for insurance i.e., what risk the insurer will assume by providing coverage to the members in the group.
V
Virgin Group
A Plan Sponsor that currently does not have a Group Benefit plan and a Request to Quote has been submitted on their behalf.
Vision Care Benefit
Coverage for eye care such as eye examinations, lenses and frames for eyeglasses, contact lenses, or laser eye surgery.
Vital Objects (VO)
ManuConnect, the go-forward plan administration system used at Manulife Financial.
VNCov
Source of Business code on Navigator 2 which identifies non CovDB policies that were never on GFM (new business since inception of ManuConnect).
W
Waiting Period
The duration of time that an employee must fulfill between the date of hire and the date of eligibility for group insurance coverage.
Waiver
The voluntary surrender of a right or privilege known to exist. Employee s may waive coverage for Health & Dental, or other Contract Benefits.
Waiver of Premium
A provision that under certain conditions a person’s insurance will be kept inforce by the insurer without further payment of premiums. It is used most often in the event of permanent and total disability. When a Plan Member has been disabled for an extended period, called the elimination period, (usually 119 days, occasionally longer), the Member may be eligible for the continuation of Life and Long Term Disability benefits without further payment of premiums for as long as he/she remains disabled according to the terms of the contract.
Waiver of Premium Provision (WOP or WP)
A policy provision that provides for coverage to remain in force without payment of premium while the insured is deemed to be totally disabled. It is not an automatic benefit - the policyholder must purchase it.
Waiver of Premium claims are normally received for the following benefits:
• LLTD (Long term disability)
• wwith other benefits that may have Waiver of Premium
• oon its own
• Llife (includes optional, dependent, etc.)
• AAD&D (includes optional, dependent, etc.)
• Survivor Income
WCB/WSIB/WCC/ WHSCC/ CSST
Workers Compensation Board
Workers Safety and Insurance Board (Ontario)
CSST (Quebec)
Workers Compensation Commission (Newfoundland)
Workplace Health, Safety and Compensation Commission (New Brunswick)
The agencies that pay disability benefits to employees injured on the job.
Weekly Income (Indemnity) Insurance
This benefit provides an income if short-term sickness or disability prevents the employee from performing his or her regular job. It is also referred to as Short-Term Disability Insurance.
Weekly Income or Weekly Indemnity (WI)
A weekly benefit providing continued income to the plan member in the event that the plan member is unable to work as a result of accident or sickness. Manulife prefers the term short-term disability. (STD).
Y
The Year’s Basic Exemption (YBE)
is the amount of base earnings on which you are not required to contribute to the CPP/QPP.
YMPE
The Year’s Maximum Pensionable Earnings (YPME) corresponds to the maximum amount of earnings of an individual that is used to determine the maximum amount of contributions and of benefits that must be paid to or from the Canada Pension Plan or the Quebec Pension Plan. The YMPE is revised annually.