Insurance Terms, Definitions and GBG/TieCare Terminology

• Accident – Any sudden and unforeseen event occurring during the policy year period, resulting in bodily injury, the cause or one of the causes of which is external to the victim’s own body and occurs beyond the victim’s control.


• Accidental Death (AD) – Death as result of an accident. Annual Term Life Insurance covers death by natural causes as well as death by accident. Coverage for Accidental Death (AD) can be purchased on stand-alone basis. Accidental death is also available with our Accidental Death and Dismemberment (AD&D) product.


• Accidental Death & Dismemberment (AD & D) – A special limited type of term insurance, Accidental Death and Dismemberment pays out a cash benefit if a member is disabled or dies in an accident. This coverage can be thought of as "catastrophic protection." AD&D can be purchased as a stand-alone product or as a rider to term life insurance.


• Accident Event – All individual losses arising out of and directly occasioned by one sudden, unexpected unusual specific event occurring at an identifiable time and place. There also are distance and time restrictions applied to Accident Events, normally a 10-mile radius and 72 hours.


• Active Service/Actively at Work – An employee will be considered in active service on any day if he/she is then performing in the customary manner all the regular duties of his/her employment as performed or were capable of being performed on the last regularly scheduled work day.


• Activities of Daily Living (ADL) – Activities of daily living are those activities normally associated with the day-to-day fundamentals of personal self-care, including but not limited to: walking, personal hygiene, sleeping, toilet/continence, dressing, cooking/feeding, medication and transferring (getting in and out of bed).


• Acupuncture – Treatment of a medical condition by needles or laser provided by or ordered by a licensed physician.


• Acute Care – Medically necessary, short-term care for an illness or injury characterized by rapid onset, severe symptoms, and brief duration, including any intense symptoms, such as severe pain.


• Adjudication – The process of paying claims and reimbursing one for covered losses.


• Annual Salary – The annual salary shall mean the monthly base salary multiplied by 12. Annual salary means the basic salary (excluding any allowances and bonuses) currently being paid to an Insured Person on the last day of being actively at work preceding any illness, bodily injury, debility or other incident.


• Agreement – The agreement between the Company, and the policyholder; who is providing coverage under this policy.


• Annual Renewable Term Life Insurance (ART) – Term life insurance for one year.


• Attention Deficit Disorder (ADD) – Attention Deficit Disorder is a biologically based condition causing a persistent pattern of difficulties resulting in one or more of the following behaviors: inattention; hyperactivity; impulsivity.


• Attention Deficit Hyperactivity Disorder (ADHD) – A problem with inattentiveness, over-activity, impulsivity, or some combination of these. For these problems to be diagnosed as ADHD, they must be out of the normal range for the child's age and development.


• Bereavement Counseling – Counseling of a terminally ill or deceased member’s family by a licensed counselor, psychiatrist, psychologist, or pastor.


• Broker (Agent, Consultant) – A person who functions as an intermediary between two or more parties in negotiating agreements, bargains, or the like.


• Cash value – Amount of cash fund that is built up (on a tax-deferred basis) in a Universal Life policy.


• Catastrophic Illness – For the purposes of Global Benefits Group and TieCare policies, catastrophic illness is defined as the following conditions:
• Cancer: The presence of uncontrolled growth, and the spread of malignant cells and invasion of tissue. Incontrovertible evidence of such invasion of tissue or definite histology of a malignant growth must be produced. The term “Cancer” also includes leukemia, lymphomas and Hodgkin’s disease. Non-invasive carcinomas in situ, localized non-invasive tumors showing only early malignant changes, tumors in the presence of any human immune-deficiency virus and all skin Cancers except malignant melanomas are excluded from the definition of Catastrophic Illness.


• Major Organ Failure and/or Transplant: The process, as a recipient, of a transplant of any major organ and the medical treatment preceding and following the approved transplant.


• Heart Attack: Death of a portion of heart muscle as a result of abrupt interruption of adequate blood supplies to the area.
The diagnosis will be based upon all of the following criteria:
• A history of typical chest pain.
• New electrocardiograph changes.
• An elevation in cardiac enzyme levels.


• Stroke: Any cerebrovascular incident producing neurological sequelae lasting more than 24 hours and including infarction of brain tissue, hemorrhage or immobilization from an extra cranial source. Evidence of permanent neurological deficit must be produced. The catastrophic illness must be diagnosed by a registered medical practitioner and must be supported by clinical, radiological, histological, and laboratory evidence acceptable to the insurer.


• Coronary Artery Disease and Peripheral Vascular Disease: Coronary Artery Disease is defined as a disease of the arteries that supply blood to the heart muscle, causing damage to or malfunction of the heart. Peripheral Vascular Disease is defined as narrowing of blood vessels in the legs, and sometimes in the arms, restricting blood flow and causing pain and other medical complications in the affected area.


• Certificate of Insurance – The document (among others) that describes the outline of the policy type, the name of the policyholder, and endorsements (if any).


• Chronic Illness – An injury, illness or condition, which does not require hospitalization, which may be expected to be of long duration without any reasonably predictable date of termination, and which may be marked by recurrences requiring continuous or periodic care as necessary.


• Claims – Requests for payments or reimbursements on covered losses.


• Claims Administrator – The Claims Administrator is the company appointed by the underwriter for the processing and evaluation of claims. All claims must be submitted to the Claims Administrator.


• Claims Reimbursement Card (CRC) – A MasterCard debit card issued by GBG/TieCare through a U.S. bank. The CRC is used to reimburse claims and medical charges to the insured members.


• Class One Occupations – Persons employed as administrative, clerical and office workers.


• Compulsory Plan – See “Mandatory” plan.


• Commission – The portion of the premium the sales representative or broker/ consultant includes in the premium for their payment on making the sale.


• Congenital Defects/Disorders – Congenital Defect/ Birth Defect is a term that means an abnormality that has been present since birth. It may have been inherited genetically from the parents, may have occurred as a result of damage or infection in the uterus, or may have occurred at the time of birth. Note that “congenital” is not the same as “hereditary.” Not all congenital abnormalities are inherited, and many hereditary diseases are not apparent at birth. Diseases and disorders that are not congenital are called “acquired”.


• The Continental Scale – The European based schedule that determines the amount or percentage of the benefit that will be paid upon a claim for Accidental Death & Disability/Dismemberment.


• Contribution – Portion of the premium that the employer and employee are each responsible for.


• Co-payment (sometimes called co-insurance) – The portion of the eligible medical treatment expenses that the Insured Person must pay in addition to the annual deductible as stated on the Certificate of Insurance and the member’s Identification Card.
• Co-payments are applied to each Insured Person per policy year.
• There are two types of co-payments: general policy co-payments and benefit specific co-payments.


• Credible Coverage – Credible coverage refers to the time an insurance applicant has spent covered under a health insurance plan directly prior to the inception of this Policy. Coverage under a National Health Insurance Plan does not qualify is creditable coverage.


• Critical Condition – An immediate life threatening or perilous illness or conditions due to an accident or natural causes, which requires urgent specialized treatment without delay.


• Critical Illness – A high deductible medical insurance plan ideal for individuals who desire international critical illness coverage. Critical illness can be purchased as a supplemental or stand-alone product. With relatively inexpensive rates, critical illness provides personal lifetime maximum of $1,000,000 benefit as well as high benefits for hospitalization and surgery.


• Curtailment – Abandonment of a journey/holiday by returning to the individual’s home country. This benefit is typically included in a Travel Insurance policy.


• Custodial or Long-Term Care – Includes a wide range of support services for patients with a degenerative condition, a prolonged illness, or cognitive disorder due to disease or trauma or a congenital condition. Custodial or Long-Term Care is not a covered benefit.


• CVS Caremark – GBG’s prescription drugs management program.


• Death benefit – Also called Face Amount or Sum Insured. Amount paid to beneficiary of an employee or individual covered by life insurance in the event of a covered death.


• Disability benefit – Amount paid to the insured in the event that a disability occurs and after the insured meets the waiting period.


• Deductible (Excess) – The amount paid on an annual or per office visit basis by each of the Insured Persons for eligible medical treatment expenses.


• Direct bill providers – Providers whom GBG has negotiated pricing and or discounts and have established a direct bill relationship with International Claims Services. (Note: Direct bill providers are not automatically considered to be Preferred Providers.)


• Disability Income (LTD, STD) – Covering insureds in the event of their inability to work in their own occupation or any occupation for the short or long term.


• Effective date – The date the policy begins.


• Elective treatment -
• Cosmetic treatment whether or not for psychological purpose, including dental treatment. Elective Surgery and procedures treatment and/or surgery that is not medically necessary as defined by a qualified, licensed medical practitioner.
• When the insured elects treatment in a certain country (home country).
• A medically necessary treatment that the insured postponed for any reason.


• Eligibility – The requirements established by an employer that permit employees to be covered under a policy and be eligible to receive benefits. Relates to determination of voluntary or mandatory and employer contribution.


• Eligible dependent(s) – A group member’s spouse and/or children who are legally eligible for coverage according to the terms of the policy.


• Elimination Period (sometimes called “Waiting period” or “Deferred period’) – Period of time the insured must wait before he/she is eligible to be paid disability benefits under a long- or short-term disability policy.


• Emergency Dental Treatment – Treatment necessary to restore or replace sound natural teeth damaged in an accident.


• Emergency Medical Transportation – In the event of a Life Threatening emergency, when appropriate treatment is not available locally, this policy provides Emergency Medical Transportation to the closest medical facility capable of providing the required care. (Also known as Emergency Evacuation).


• Employee – The Insured Person based on the definition of eligibility as defined by the employer and accepted by GBG.


• Enrollment – Process of maintaining proper listings of employees and dependents covered and not covered on a plan.


• Emergency Evacuation – (See Emergency Medical Transportation).


• Excess – Same as Deductible. British and European terminology for deductible.


• Exclusions – Conditions or events not eligible for reimbursement under an insurance plan.


• Expatriate or ex-pat – Any person residing outside their home country.


• Explanation of Benefits (EOB) – As part of the claims adjudication process, an EOB is provided to all claimants showing what medical expenses were reimbursed and the percentage of reimbursement for those expenses.


• Facultative business – Requests for insurance coverage submitted to the Underwriter(s) on a one-by-one basis for quoting. This is done when such coverage falls outside the boundaries of GBG’s Binder Agreements.


• Free Cover Limit (FCL or GI) – Also called Non Medical Limit. The benefit limit up to which insurance companies do not require medical underwriting.


• Multi-Year Term life insurance – A term life insurance product that provides long-term coverage for a minimum period of 10 years and can provide coverage for up to 30 years. Keeps premium the same during the coverage period and requires medical underwriting only at issuance.


• Full-time student – A person taking a minimum 12 semester units at an accredited educational institution.


• GBG Assist – Managed by Europ Assist, GBG Assist is the company that manages and coordinates the North American PPO (Preferred Provider Organizations) and manages the 24/7 hotline for emergency evacuation, network assistance and pre-authorizations.


• Global Advantage – Health Plan for non-school groups, including corporations.


• Global Protector – European-style health insurance plan for individuals or groups. Global Protector offers four geographical areas of coverage: Worldwide, Worldwide Excluding North America (United States, Canada & Caribbean), Worldwide Excluding North America and Asia; and Europe Only. Global Protector offers age-banded rates at four coverage level options: Basic Care, Silver Care, Gold Care and Platinum Care.


• Global Benefits Group (GBG) – The sales and marketing company that targets individuals and companies (non-school groups) around the world.


• Global Benefits Group, Inc. – The umbrella company that owns Global Benefits Group, TieCare International, International Claims Services, ATMSafe and several other insurance and benefits products and services.


• High Deductible Health Plan (HDHP) – A medical plan with a higher-than-normal deductible that is designed to cover catastrophic occurrences or to be combined with a Health Savings Account (HSA.)


• High Net-Worth Individuals – Wealthy individuals and professionals from local area.


• HIV – All diseases caused by and/or related to the HIV Virus.


• Home Country – The home country of any insured individual is deemed to be the country from which the primary insured holds a passport. In the event that a citizen of the United States holds more than one passport, the United States shall be deemed the home country.


• Homeopathy – A system of alternative medicine that seeks to treat patients by administering small doses of medicines that would bring on symptoms similar to those of the patient in a healthy person. For example, the homeopathic treatment for diarrhea would be a miniscule amount of a laxative.


• Hospice – Part of a hospital or recognized in-home medical care unit devoted to the care of patients with progressive disease where curative treatment is no longer possible; as an inpatient or on a domicile basis.


• Hospital – An institution that is legally licensed as a medical or surgical hospital in the country in which it is located. Illnesses/diseases of acute nature, as well as emergencies, can be treated in this facility. It must be under the constant supervision of a resident physician. A hospital is not a spa, hydro-clinic, sanitarium, rehabilitation institution, nursing home, or homes for the aged.


• Hospital Cash – Provides an Average Daily Benefit that covers the portion of hospital expenses that are left unpaid. Plan covers deductibles, coinsurance, services not covered and/or lost wages. This coverage is especially important for prolonged hospitalizations. Benefits are payable the first day following 24 hours of continuous hospitalization after an accident, and the first day following 48 hours of continuous hospitalization after an illness. Benefits can be received for up to 365 days.


• Hot Spots – Countries whose political situation is so unstable or dangerous that coverage cannot be provided using standard rates.


• Inbound Students – Students coming to study in North America (United States and Canada).


• Incurred Date – The actual date when treatment was administered or an insurable event occurred.


• Independence plan – Individual health plan with age-banded rates. Designed for U.S. expatriates.


• Identification Card – The document provided the individual member and his/her dependents, which outlines the medical policy benefits, name of the policyholder, Insured Persons, and endorsements, if any. On this card, members will find benefit information, as well as contact information for submitting claims and emergency medical treatment. Primary members may in certain circumstances be provided with 2 identification cards.


• Inpatient – An Insured Person who occupies a bed for 24 hours or more in a hospital for the sole purpose of receiving treatment.


• Insured Person – A covered group member or an eligible dependent.


• International Coverage – Full medical coverage in all countries with the exception of the United States and Canada.


• International Claims Services (ICS) – A third-party administrator (TPA) of claims that is a GBG Company and GBG’s primary claims adjudication facility.


• International Plus Coverage – Full medical coverage in all countries, only emergency coverage in the United States and Canada


• Life insurance – Insurance that pays the face amount of the policy to a designated beneficiary in the event of a covered death. Includes Death by accident and death by natural causes.


• Local national – Citizen and resident of country where client is located.


• Long Term Disability – In the event that an insured person becomes totally disabled as a result of illness, bodily injury or debility for which medical evidence must be provided, Long Term Disability provides an income benefit based on a percentage of the annual salary. The benefit becomes payable after a waiting period until either recovery, death or attainment of retirement age. The purpose of Long Term Disability insurance is to provide individuals protection against financial hardships resulting from disability, sickness and accidents.


• Managing General Underwriter (MGU) – Any entity that has underwriting authority from an insurance carrier and/or reinsurer. GBG is an MGU.


• Mandatory Group – A plan that requires all eligible employees be covered. Underwriting implications.


• Maternity Care – The cost of prenatal care, Delivery, Medically Necessary C-Sections, and postnatal treatment subject to the specific limit. Any complications related to pregnancy including Cesarean section will be treated as maternity and will be subject to the specified limits. Elective C-Section excluded.


• Medical Practitioner – A general medical practitioner is registered (licensed) or recognized by the law of the country in which he/she practices.


• Medical History Disregarded (MHD) – For an additional surcharge medical history requirement can be waived. The additional surcharge will cover the cost of any claims rising as the result of the medical history. Applies to Global Protector groups of more than 40 lives.


• Medically Necessary – A treatment, service, supply, or drug, is medically necessary if it is prescribed by a Physician and is appropriate and essential to diagnose or treat the patient’s Illness or Injury.


• Multinationals – Companies with operational in multiple countries.


• Moratorium – Relates to Pre-existing conditions. A rolling period of time that must be completed before any recurring symptom that requires treatment will be covered.


• New Hire – New employee added to a group plan.


• Non admitted – An insurance that is doing business in a country outside of its own country and is not licensed in that country.


• Nuclear, chemical, & biological weapons of mass destruction (NCB) – Additional part of War & Terrorism coverage.


• Offshore (or non-admitted) – An Insurance carrier that is not under any country’s jurisdiction and is not recognized by any country.


• Out-bound students – Traveling from the United States to other countries.


• Out of pocket (OOP) – Portion of the treatment cost that is the insured’s responsibility.


• Outpatient – An Insured Person who receives treatment at a hospital, specialist’s consulting room, or other facility recognized by the Company, where the Insured Person does not remain overnight.


• Personal Accident (PA) – Typically a policy that covers Death, Disablement or Disability resulting from an accident.


• Permanent Total Disability (PTD) – Unable to perform any occupation for the remainder of one’s life.


• Physician – Is any person legally licensed to practice medicine in the country where treatment is provided and includes doctors of medicine, general practitioners, specialists and consultants and anyone who renders such treatment within the scope of their licensing and training.


• Policy – Our contract of insurance with the policyholder, under which the Company provides the coverage described in the policy document. The Application and Certificate of Insurance form part of the contract and must be read together with the contract of insurance.


• Policyholder – The employer or the Insured Person to whom the Certificate of Insurance is issued and who is responsible for the premium payment and for the reporting of additions and deletions to the coverage.


• Policy Effective Date – The date as shown in the Certificate of Insurance when coverage under this policy commences.


• Policy Period – The period of insurance coverage as stated in the Certificate of Insurance and any subsequent period for which the policyholder pays a premium that the Company accepts.


• Preferred Provider Network (PPN) – A network of medical providers and facilities that have direct billing discounts and procedures with insurance providers.


• Preferred Provider Organization (PPO) – see Preferred Provider Network.


• Pre-Authorization – Pre-Authorization is a process by which an Insured Person obtains written approval for certain medical procedures or treatments from the Care Coordination Company prior to the commencement of the proposed medical treatment.


• Pre-existing Conditions (Pre-ex) – Any medical condition(s) that, prior to the first day of insurance:
• Systems have manifested.
• Has been diagnosed.
• Has required hospitalization.
• Has required medical treatment.
• Has required medication.


• Prescription Drugs – Prescription drugs are medications a physician prescribes are not be available without a prescription. Certain treatments and medications, such as vitamins, herbs, aspirin, cold remedies, medicines, experimental or investigative drugs, or medical supplies even when recommended by a physician, do not qualify as prescription drugs.


• Prescription Tiers – Co-payment tiers for different types of drugs (brand-name or generic).


• Preventive Care – Services that are advanced screenings for any medical issues as opposed to getting medical treatment after symptoms arise.


• Proposal – Premium indication or quotation detailing the benefits offered. The proposal is subject to final approval by the GBG Underwriting Department.


• Qualified Physiotherapist or Chiropractor – A chartered or state-registered physiotherapist, or an individual whose professional advice GBG accepts as the equivalent professional status in the relevant country.


• Rehabilitation – Therapeutic services designed to improve a patient’s medical condition within a predetermined time period through establishing a maintenance program designed to maintain the patient’s current condition, prevent it from deteriorating and assist in recovery. Inpatient rehabilitation is only covered during the acute and sub-acute recovery phase of treatment and only when authorized by the Care Coordination Department.


• Reinsurance – The process whereby the insurance company shares risk with another company or companies to limit their exposure for a particular risk.


• Reinsurance panel – Group of reinsurers each covering a portion of the risk. Allows for more stability as opposed to one reinsurance carrier taking all of the risk.


• Renal Failure – End stage kidney failure due to chronic irreversible failure of both kidneys to function. This must be evidenced by the insured undergoing regular renal dialysis or having had renal transplantation.


• Renewal Date – The annual anniversary of the policy’s effective date.


• Repatriation or Local Burial – This is the expense of preparation and air transportation of the mortal remains of the Insured Person from the place of death to their home country, or the preparation and local burial of the mortal remains of an Insured Person who dies outside his/her home country.


• Request For Proposal (RFP) or Request For Quote (RFQ) – The process by which a representative or agent submits the required information to GBG in order obtain a quote.


• Residence – The location and physical address of the insured member and dependents.


• Respite Care – Inpatient care for a chronically or terminally ill patient, for the sole purpose of providing the patient’s primary caregiver with relief.


• Restricted Area – Countries and/or facilities, where medical treatment may not be covered under certain policies, as defined by the Company. Consult www.claimssite.com for a complete list of restricted areas and facilities.


• Rider (or policy rider) – Additional coverage or exclusion added to a policy.


• RX – See prescription.


• Self-insurance – Employer assumes all or part of the insurance risk. Also note self-funded.


• Skilled Care – Medical care that requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and effectively. Skilled nursing and rehabilitative staff include registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists. When covered on an Inpatient basis, it is only during the acute and sub-acute care phases of treatment, and only for the duration to be determined and approved by the Care Coordination Department.


• Short-term disability (STD) - Short-term disability insurance to cover the waiting period of the LTD policy.


• Skilled Nurse – One whose name is currently on any register or roll of nurses maintained by any statutory nursing registration body within the country in which they are resident.


• Sub-Acute Care – Medical care which is somewhat acute, falling between acute and chronic care, but with some acute features.


• Term Life – Term life insurance, which is renewable on an annual basis, pays a death benefit if the covered person dies during the covered term. It generally provides the largest insurance protection per premium dollar. Term life insurance policies are best purchased for temporary life insurance needs such as if premature death should occur, salary replacement, funding of a child's education, or paying off a mortgage or other personal or business debt.


• Terrorism – Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but is not limited to, the actual use of force or violence and/or the threat of such use.


• TieCare International – A division of GBG dedicated to providing insurance products to the international school market niche.


• Third party administrator (TPA) – A company that provides claims and administrative services on behalf of another company or large self-funded groups. GBG’s International Claims Services (ICS) is a TPA.


• Third Country Nationals (TCNs) – A foreign national working in another country other than their home country.


• Transmittal process – Process by which a new account is set up in our system detailing premiums and commissions.


• TravelCare – Supplemental travel medical insurance covering emergency medical treatment while traveling anywhere in the world. This product offers annual worldwide single-trip and multi-trip travel insurance plans for individuals and families or groups. TravelCare annual multi-trip offers unlimited trips during the year with each trip lasting no longer than 90 days. With emergency evacuation benefit, trip cancellation and the option for hazardous sports coverage, TravelCare offers the insurers peace of mind while traveling.


• Treatment – Surgical or medical procedures that have the sole purpose of curing or relieving acute illnesses or injury.


• Treaty – Agreement with an Underwriter that allows GBG to quote certain risks without seeking approval from the Underwriter.


• Temporary total disability (TTD) – Inability to perform any occupation for a limited time


• Underwriter – One who analyzes risks and sets rates or a company that accepts insurance risk.


• Usual and Customary Charges (U&C; UCR) – Average charges for medical treatment in a region or within a defined group of providers. Most policies limit benefits to reasonable, usual, and customary charges.


• Utilization Review Procedures – The process by which GBG reviews the medical necessity of a treatment.


• Voluntary Group – A plan in which any member can opt in or out. This is the opposite of a mandatory plan.


• War and Terrorism coverage (W&T) – Coverage added to any insurance plan for losses resulting from acts of War & Terrorism. Certain exclusions apply.


• WorldCare – A TieCare International medical policy designed for schools.


• World Medical Network (WMN) – Division of GBG, based in India and part of CoreTree, focusing on network development, process workflow management, technology implementation, etc.


• Worldwide Coverage – Medical coverage throughout the world with the exception of “hot spots” unless such coverage is approved by GBG.