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Chapter – 1 LIFE & HEALTH INSURANCE I NSURANCE Insurance Definition:
It is a system whereby contributions are received from the insuring public and pool of money is created from where the claims are paid to a few unfortunate persons who died during the insurance period. What Is Life Assurance?
Whereby a policy is issued on the life of the person, it is normally called assurance and where the policy is issued for any object it is called insurance. Life Assured:
A person on whose life assurance policy has been issued is called life assured. Assurance Contract:
This is an agreement between the person proposing for insurance and the life insurer. The contract is complete when the following three conditions are fulfilled; •
Proposal form is submitted.
•
It is accepted
•
Premium is paid.
It is not necessary that for completion of the contract any written form of agreement is requir required. ed. The contra contract ct is comple complete te and enforceab enforceable le at law immedi immediatel ately y the above above three three conditions are met. Mortality Ratios:
Rate of deaths per year of the persons within the same age group are called mortality mortality ratios. Mortality ratios are basic themes for life insurance. All plans of insurance are based on mortality ratios. Mortgagee:
Mortgagee is a person whose property has been mortgaged. Mortgager:
Mortgager is a person who mortgages the property for advancing a certain amount of loan to the mortgagee. These terms are used for the persons who are involved in advancing and receiving loan against the security of a tangible property.
2 Life insurance policy is considered as good as a tangible property for the purposes of loan transactions.
Actuary:
Actuary is a person who calculates the mortality ratios and life insurance premium rates based on actual experiences of very wide and larger data with total professional background. Law in Pakistan requires every life insurance company to have an appointed actuary. The appointed actuary is responsible for submitting certain statistical reports directly to the SECP (Secur (Security ity Exchan Exchange ge Commis Commissio sion n of Pakist Pakistan) an) ¸which ¸which is regula regulator tory y body body to monito monitorr the solvency of the insurance companies. Unlike any other employee and officer of the company the services of an appointed actuary can not be terminated without prior intimation of reasons to the SECP. Assignments:
When life assured transfers the rights and liabilities under a policy to another person in a lawful manner it is called assignment. Subject Matter of Assurance:
Subject matter of assurance is always life of a person for the purpose of life assurance. Insurable Interest:
Insurable interest means somebody’s pecuniary stake or interest in the subject matter of insurance. As far as life assurance is concerned, a person has an unlimited insurable interest in his/her life or in the life of his/her spouse. However, the sum assured which is the amount of assurance is regulated and determined by the average yearly income of the person on whose life the policy is being taken. Proximate Cause:
A cause or happening that sets in motion a chain of events which brings about a result without intervention of a new and independent cause. Indemnity:
To place the insured in the same financial status which he or she was enjoying prior to the happening of the event which causes loss? Normally life insurance contracts are not purely contracts of indemnity. Utmost Good Faith:
2 Life insurance policy is considered as good as a tangible property for the purposes of loan transactions.
Actuary:
Actuary is a person who calculates the mortality ratios and life insurance premium rates based on actual experiences of very wide and larger data with total professional background. Law in Pakistan requires every life insurance company to have an appointed actuary. The appointed actuary is responsible for submitting certain statistical reports directly to the SECP (Secur (Security ity Exchan Exchange ge Commis Commissio sion n of Pakist Pakistan) an) ¸which ¸which is regula regulator tory y body body to monito monitorr the solvency of the insurance companies. Unlike any other employee and officer of the company the services of an appointed actuary can not be terminated without prior intimation of reasons to the SECP. Assignments:
When life assured transfers the rights and liabilities under a policy to another person in a lawful manner it is called assignment. Subject Matter of Assurance:
Subject matter of assurance is always life of a person for the purpose of life assurance. Insurable Interest:
Insurable interest means somebody’s pecuniary stake or interest in the subject matter of insurance. As far as life assurance is concerned, a person has an unlimited insurable interest in his/her life or in the life of his/her spouse. However, the sum assured which is the amount of assurance is regulated and determined by the average yearly income of the person on whose life the policy is being taken. Proximate Cause:
A cause or happening that sets in motion a chain of events which brings about a result without intervention of a new and independent cause. Indemnity:
To place the insured in the same financial status which he or she was enjoying prior to the happening of the event which causes loss? Normally life insurance contracts are not purely contracts of indemnity. Utmost Good Faith:
3 Utmost Utmost good faith faith means means that that both both parties parties to the insuranc insurancee i.e. i.e. insure insured d and insurer insurer are requir required ed to disclo disclose se the comple complete te inform informati ation on about about the facts facts which which may influe influence nce the decision of each party for entering or issuing the insurance contract. Each Each part party y plac places es a tota totall relia relianc ncee from from the the stat statem emen ents ts made made by the the othe otherr part party. y. The The prospective prospective insured is required required by the insurer to answer answer specific specific questions questions put to him/her him/her in entering to extract material information necessary for the consideration of insurance proposal by the underw underwrit riter. er. Any concealme concealment nt of materi material al facts facts or missta misstatem tement ent shall shall cause cause the contract to be made violable by the insurers. Proposer:
Proposer is the person who puts forward a proposal for insurance on his/her life or on the life of another person. Life Proposed:
Life proposed is a person on whose life the policy is proposed to be issued Material Information: Information:
Material information means the information about the facts of insurance which may influence the decision of either party to give or take insurance. For example, if an insurer or any functi functiona onary ry of insure insurerr gives gives false false inform informatio ation n to the prospe prospectiv ctivee insure insured d which which induce inducess him/her to take out the insurance policy, the insured will be entitled to make the contract void, and claim the refund of amounts paid along with appropriate damages, if any to the tune the court may deem fit. Similarly, if the prospective insured misstates his/her health or financial position, the insurer would be entitled to deny any claim whatsoever made under the policy. Offer:
When a person fills in a proposal form designed by an insurer and submits that form to the insurer for underwriting consideration, that form constitutes an offer from he proposer for insurance. Counter Offer:
The offer made by the proposer through the proposal form is evaluated and judged by the insurer’s underwriter’s vis-à-vis its underwriting parameters. If the offer does not fit into those parameters, the underwriters have two options; •
To apply special terms such as increased rate of premium or reduction in sum assured and term of the policy or both.
4 •
To decline the offer.
In case of underwriters decide to increase the premium or apply other terms that is called counter offer and if it is accepted by the proposer in writing, the policy is issued on those modified terms.
Acceptance:
If the original offer falls into the standard parameters of underwriting, the underwriters accept the proposal as it is, which is called simple acceptance. If the policy is issued after acceptance of the counter offer then it is called acceptance with loading. Consideration
Consideration is an insurance term for the amount of premium which the insured has to pay to the insurer as per agreed terms. Natural Premium:
The premiums for life assurance are collected and charged according to the age of the life assured. Higher the age higher the premium. Insurers maintain a pool of fund in which the insuring public contributes equitably. The younger people have to pay lesser rate of premium as compared to the older people. With the progress in age of a person year by year, he/she becomes nearer and nearer to death. The system of natural premiums is very complicated and as such it is very difficult for the insurers and insuring public alike to receive or pay the premiums on increased rates every year. To overcome this difficulty the actuaries have developed, on scientific basis, the system of level premium. The level premium means that when a person takes out a policy say for 20 years’ term, he/she will pay the same amount of premium every year which has been calculated on average basis. Actuarial Principles:
Actuarial principles include the following factors in determining the rate of premium; •
Expenses of the office
•
Margin of profit of the insurance company.
•
Provision for commission to the insurance agents of the insurance company
•
The study of trends in the rate of mortality.
•
The expected investment income of the insurance company.
Economic Principles:
5 •
The life insurance plays a vital but invisible role in the overall economy of a country especially in the social sector where there is no financial support for the widows and orphans on the government level.
•
It reduces the mental tension of an individual caused by the future financial worries like old-age or well-being of the family.
•
It ensures for the continued education of the children.
•
It also reduces financial stress in case the breadwinner of the family has hirepurchased any property or goods like house, motor car or any household goods.
Legal Principles:
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Chapter – 2 LIFE ASSURANCE CONTRACTS CLASSIFICATIONS In This Chapter: Term insurance Whole life insurance Endowment insurance TERM INSURANCE
It is a type of contract in which sum assured is payable only on death of the life assured within the term of insurance. There is no maturity value and surrender and loan facilities available. WHOLE LIFE INSURANCE
In this type of insurance there are two sub-divisions; •
Whole life insurance by limited payment of premiums which mean that a specific term is selected for payment of premiums and after the expiry of that term the premium ceased to be paid but the sum assured shall be payable on death only.
•
Whole life insurance where the premium is continues to be paid till death of the assured. This type of insurance has further sub class whereby the sum assured is payable either on death or on attaining the age of 85 years.
ENDOWMENT INSURANCE
This is a type of life insurance whereby a specific term is selected and premiums are payable throughout that term or earlier death. If the life assured survives that term the sum assured along with accrued bonuses is paid as maturity value. This class of insurance carries surrender and loan values provided the policy has been enforced for at least two consecutive years.
CLASSIFICATION OF ENDOWMENT INSURANCE
1. Simple Endowment
2. Anticipated Endowment
3. Joint Life Endowment Assurance
4. Progressive Endowment
5. Children Endowment
6. Single Premium Endowment
7. Family Pension Endowment
8. Optional Maturity Endowment
7 9. Mortgage Protection Endowment
10. Personal Pension Endowment
11. Annuities Endowment
12. Unbundled Endowment Insurance
1) Simple Endowment
This class of assurance provides for the benefits to be payable at the end of the term of assurance. Or earlier death equal to the sum assured plus accrued bonuses. 2) Anticipated Endowment
In this plan the insurance is issued for a term which is usually dividable by three periods i.e. 12 year, 15 years and 18 years. At the end of 1/3 rd period and 2/3 rd period sum assured is paid proportionately. Companies give second option whereby the sum assured is paid as 1/4 th at the end of the first broken term and another 1/4 th at the end of 2 nd broken term and remaining 50% of the sum-assured along with accrued bonuses is paid at the end of full term of the assurance. In case of earlier death the full sum assured along with bonuses is payable. If the death occurs within the first broken period the full sum assured will be paid. After the 1 st broken period when the assured has already received a portion of the sum assured even then the full sum assured along with accrued bonuses shall be payable and so will be the case where second installment had also been received by the assured. 3) Joint Life Endowment Assurance
This type of policy is issued on the join lives of two persons which are usually husband and wife wherein one sum assured is involved and accordingly one annual premium is payable. There are two types of covers are available; Simple Jeevan Sathi Simple
In simple joint life assurance the sum assured is payable if both partners survive to the end of the term of the policy or on earlier death of anyone of the partners to the contract. Jeevan Sathi
In Jeevan Sathi plan the maturity benefits are similar to joint life simple policy but in case of death of anyone partner full sum assured without bonuses are paid to the surviving partner. The subsequent premiums ceased to be paid and the policy continues till maturity date or earlier death of the second partner whereby sum assured along with accrued bonuses shall become payable. 4) Progressive Endowment
8 In this type of assurance the policy holder is given an option to increase the sum-assured without giving health requirement after a certain period say five years. However, premium will increase accordingly. 5) Children Endowment
Child endowment policy can be issued independently on the life of the child or jointly with the parents. In child independent policy the premium is paid by the parent and similar is the case with joint with the parent policy. The sum assured is payable along with accrued bonuses on completion of term of the policy that is maturity date or on earlier death of the child. In case of child joint life policy an annuity also becomes payable at an agreed date of sum assured for the remaining term of the policy in case of death of the parent. 6) Single Premium Endowment
In this case or plan, policy can be obtained for any number of years by payment of a single premium at the outset. The sum assured is usually greater than the single premium and is payable on maturity date or earlier death along with accrued bonuses. 7) Family Pension Endowment
In case of death of the assured, sum assured along with accrued bonuses is paid and a pension is started at a pre-agreed rate as mentioned in the policy document for the remaining period of the policy. This rate may range from 10% to 50% of the sum assured. Pension will be payable annually or in monthly installments if the claimant so wishes. 8) Optional Maturity Endowment
In this type of assurance, the assured is given an option to get an early maturity claim instead of completing the full term. This option is usually exercisable after the policy has completed 20 years. 9) Mortgage Protection Endowment
When a person avails any amount of loan from any financial institution against the security of a tangible property he or she is usually required by that financial institution to have a life insurance policy affected on his or her life for a sum assured equal or at greater than the amount of loan. That policy has to be assigned to that financial institution. Such a policy is arranged under Mortgage Protection plan, which has been designed by the insurance companies for this specific purpose. This plan provides for the sum assured to be reduced
9 gradually as the loan amount reduces by payment of loan installments. As the sum insured reduces so is the case with premium and at the end of the term both amounts are zero.
10) Personal Pension Endowment
Under Personal Pension Endowment policy different insurance companies have their separate practices. However, there are certain common points. This policy is normally issued for a period of six years. Total amount of premium for all those six years is received in lump sum in advance and at the end of sixth years the pension amount starts to be paid to the insured at the prescribed pre-agreed rate and it continues for the remaining tem of the policy or earlier death of the insured. In this sort of insurance the insurer do not call for any health requirements. 11) Annuities Endowment
Annuities plans are also issued by the life insurance companies but annuities processes are reverse picture of the conventional endowment life insurance. Under annuity policy premium is received in lump sum at the outset and an annuity payment by an insurance company is started after an agreed number of years e.g. 10 years. The annuity policy has two classifications; •
Annuity certain
•
Annuity simple
Annuity certain Under this plan the annuity payments are continuously to be made for an agreed number of years e.g. 20 years irrespective of whether the insured is living or not. Annuity simple In this case the annuity payments stop immediately after the death of annuitant. 12) Unbundled Endowment Insurance
Unbundled policies are endowment life insurance policies give the insured an option to increase the sum-assured and of course the premium by an agreed percentage on yearly basis. This increasing option starts from the third year of the policy. Once an option to increase the sum assured has been exercised by the insured there is no compulsion on him or her to continue to increase the sum assured continuously every year. However if the insured does not exercise the option for 3 consecutive years when he will be barred to increase.
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Chapter - 3(A) Riders or Supplementary Contracts
Accidental Indemnity Benefits (AIB):
This type of supplementary contract provides for the payment of an additional sum assured in case the death of the insured is caused by an accident. Also insured is indemnify at a prescribed rate for the expenses which he or she may incur for the treatment of injuries received by him or her as a result of an accident.
Accidental Death Benefits (ADB):
Under this supplementary contract an additional sum assured is paid in case of death by an accident. For this contract additional premium will be charged by the Underwriter.
Family Income Benefit Rider (FIBR):
Under this supplementary contract an amount equal to an agreed percentage of the sum assured becomes payable to the family of the decease insured for the remaining term of the policy. The percentage may vary between 10 to 50%.
Guaranteed Insurability Rider (GIR):
This supplementary contract provides for the insured to avail a further insurance within given number of years say 10 years without any health requirements.
Hospital and Surgical Rider (H & SR):
This type of contract ensures that in case the life insured has to be admitted into the hospital for treatment of any disease for which he is suffering or for any surgical procedure the insurance company will pay the relevant expenses that is room rent and treatment cost at a rate of sum assured which is usually pre-agreed.
Refund of Premium Rider (RP)
In case of death of insured the premium received by the insurer up to the date of death are also refunded along with the claim amount.
Term Insurance Rider (TIR):
In case of death double of the sum assured is paid even death occurs by any cause.
Waiver of Premium Rider (WPR):
11 Under this supplementary contract if a person is incapacitated on his or her livelihood as a result of any disease or accident. Further premiums under his or her policy are waived and policy continues till maturity date or earlier death. Important note:
All the supplementary contracts have no maturity value, loan value or surrender value.
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Chapter – 3 (B) Life Assurance Contracts There are two parties in life assurance contract; The Proposer The Insured The Proposer
The Proposer (Applicant) who subsequently becomes the insured if the proposal is accepted by the insurer Proposer can’t’ always be the life insured. The Insured
The Proposer and the life proposed is not always the same person. For example a policy is being taken out by a parent on the life his/her child, the parent will be the Proposer and the child life proposed. This process starts with the completion of the proposal form containing a number of questions designed to have complete information about the health condition and financial status of propose.
PROPOSAL FORM The proposal form consists of 3 important portions as under; A.
Personal statement: This contains the information about the; Name Father’s Name Date of birth Disease the proposer may have suffered, Details of accidents, if any Treatment details, Vaccination details Employment details Land ownership Family history with ages of family members, if any Family member died with dates and cause of death and other details etc.
13 B.
Declaration: Declaration is signed by the proposer to the effect that the statements
made by him/her are true to every effect and he/she has not concealed any material information while answering the relevant questions. The proposer also declares that if any concealment is found after issuance of the policy, the insurer may make the contract void and forfeit the premiums paid by the proposer. The proposer also authorizes the insurer to contact any doctor or hospital from where he may have taken the treatment and obtain the treatment record.
AGENT’S REPORT The agent is said to be the 1 st Underwriter of the consumer. He has to report to the insurer about his knowledge of the proposer’s health, his monthly income and the value of his assets and agent also reports the period for which proposer is known to him. After the proposal form, there are 3 steps: Offer Acceptance Consideration Counter offer
A.
Offer: The proposal/applicant form constitutes an offer for getting insurance from the
insurer by the proposer. B.
Acceptance: When the insurance company/insurer receives a complete proposal form
duly signed and witnessed, it is examined by its underwriter. If the offer falls within underwriting parameters it will be accepted and then it is called acceptance. C.
Consideration: After acceptance the proposer has to pay be premium as calculated by
the underwriter and that payment of premium is called consideration. D.
Counter offer: If that proposal does not fall in the parameter of underwriting, the
underwriter will make a counter offer to the Proposer. This counter offer is made in writing by the insurer to the proposer. The proposer may accept this counter offer or may not. If he accepts he will sign this counter offer as a token of his acceptance and pay the premium i.e. consideration to complete the contract. In both situations after payment of consideration the contract will be completed. Acceptance on ordinary rates/terms
The simple process of the acceptance of offer is called acceptance on ordinary rates/terms.
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Acceptance with loading
When the insurer issues the contract after the acceptance of counter offer, it is called acceptance with loading. Decline
In declined cases the underwriter finds extraordinary abnormalities in the life proposed health conditions or in his/her occupation or financial status. Therefore, he will decline the offer treating it as uninsurable. However, certain insurance companies in the world including Pakistan insure such declined lives on special terms under their non-decline nature schemes. One such scheme for example is that if the insured person dies within the 1 st year of insurance no claim what so ever is payable and if insured dies within 2 nd year of the policy the 2 nd year premium will only be refunded. However, if death occurs due to an accident during these two years the full claim will be payable whether the death occurs by accident or true sickness, meaning thereby that both the deaths whether through accident or material cause shall be covered. The insured will have to pay an extra premium every year.
TYPES OF PREMIUMS A.
Natural Premium
Life insurance companies basically charge the premium at a rate as applicable to different ages as the age of person increases so the chances of his death increase accordingly. The older people have to pay the premium at the rate greater than the younger people. This system is called the system of payment of natural premium. Example is; AGE
PREMIUM @ Rs.1000/-
20 years
Rs. 19.10
21 years
Rs. 19.15
22 years
Rs. 19.20
60 years
Rs. 45.50
But it is very difficult from the administrative point of view for the insurance companies to bill and charge the premium on different rates every year. Due to this difficulty the actuaries on the basis of study and analysis of a large number of world wide data of deaths on v various ages, developed a system whereby it was made possible for the insurance companies to charge the same premium from an insured every year throughout the term of the policy. This system is called level premium. This level premium is actually in average amount per year of the natural premium throughout the policy term. This means that the insured will have to pay
15 an extra amount in the early years and a lesser amount in the later years. In this system insurance companies develop their reserves in the early years which are used to offset the claims tendency in later years. B.
EXTRA MORTALITY (EM)
EM +50 EM +100 EM +200 “EM” the lives proposed or under written by the insurer according to their underwriting principles and parameters. If any proposal does not fit in those parameters especially with regard to the health condition or on account of occupation, he or she is considered. For insurance in consideration of payment of an extra premium the reasons for which the extra premium is charged come within the bracket of extra mortality. Extra mortality is usually charged under any or both of the following headings:
C.
•
“ME” Medical Extra
(e.g. if he is suffering from hypertension)
•
“OE” Occupational Extra
(e.g. he is a Rickshaw Driver)
Medical Extra
If the person is already suffering from any disease, he must have to pay extra premium.
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CHAPTER - 4 LIFE INSURANCE PROPOSALS These fall under two broad categories: Non-Medical Proposal form Medical Proposal form
Non-Medical Proposal Form
In non-medical proposal form the underwriters rely entirely on the statements and information given by the proposer. In other words the contract is issued under utmost good faith.
Medical Proposal Form
It is almost similar to that of non-medical but except that the questions in the personal statement are put to the proposer by he doctor appointed by the insurer. The answers are recorded by the doctor in his/her handwriting. Apart from the physical medical examination of the proposer the insurers get certain clinical and laboratory test made according to the sum assured proposed. Except for occupational extra the extra premium is charged in respect of relevant cases of medical. 1. Loading
In technical terms the premium charged under extra mortality as medical extra or occupational extra is called loading. This means that the ordinary rate of premium has been loaded or increased by the rate applicable to extra mortality. 2. Policy Document
Policy document is an evidence of contract. The policy document is issued after the contract. It has four parts as under: Preamble clause: this clause identifies the parties to the contract and sets forth the rights and
liabilities of the parties. It also refers to the fund to which the policy pertains. Schedule: in schedule all the necessary particulars of the insurance are mentioned. These
particulars include;
Policy number.
Sum assured
Plan of insurance (Table & Term).
Date of commencement of policy or risk.
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Date of maturity.
Name and address of the assured.
Name of guardian (if nominee is minor)
Amount of premium.
Mode of payment (monthly, quarterly, half yearly or annually).
ANF option (Automatic non-forfeiture).
Reference to endorsements, if any.
Terms and conditions
The first term is Grace Period. Different insurance companies have heir own practices but hey usually allow the grace period of 31 days after the premium has become due. If the premium is paid within grace period the policy remains in force, otherwise it lapses. In case death occurs within the grace period and the premium is still unpaid, the insurer will pay the claim by deducting that outstanding premium from the claim amount. 3. Revival: A policy can be revived by payment of outstanding premiums and fulfillment of necessary health requirements. Companies usually place restrictions that a policy remaining lapsed for more than 5 years shall not be revived. 4. Paid-Up Value
If a policy has been enforced for at least two consecutive years by payment of premium, it can be made paid-up for a reduced sum-assured. No further premiums will be payable and the reduced sum assured shall become payable either on maturity or earlier death. Example is. Sum assured
Rs. 1, 00,000
Term
20 years
Paid premium
3 years
Paid up value
= 1, 00, 00 x 3 = 15,000 20
5. Surrender Value
The policy shall acquire a surrender value, after it has been enforced by payment of premium for at least two consecutive years. While calculating the surrender value following payments are not taken into consideration;
First Year Premium (FYP)
Premium of any supplementary contract.
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6. Loan Value The policy holder can obtain a loan against the policy up to an amount equal to the 80% of
surrender value of the policy, which is repayable in easy installments along with an interest as prescribed by the company from time to time. 7. Automatic Non Forfeiture (ANF): This class is incorporated in he policy contracts by the insurance companies to comply with the provisions of section 93 of the Insurance Ordinance, 2000. This has two sub-sections;
APU – Automatic Paid-up. This means that if the policy has run for at least two consecutive years by payment of premiums and any subsequent premiums have not been paid and in response to a notice for payment of premium, the policy holder instead of paying the premium opts to discontinue the policy he can select this option whereby the policy will be made paid-up for a reduced sum assured. 8. API – Automatic Premium Loan: If The Policy Holder Selects This Option Then the Policy Will be kept in force by applying surrender value to the outstanding premiums, till such time the surrender value is exhausted. Once he surrender value is exhausted the policy is treated as having been automatically surrendered and as such carry no claims value whatsoever. 9. Evidence Of Age:
This condition states no benefits under this policy what so ever, shall be paid until and unless the age of the life assured is got admitted on the basis of a valid documentary evidence. 10. Suicide Clause: If the life assured commits suicide within 13 months of the issuance of the policy, no claims shall be payable. 11. Currency And Payment Of Premium: The premiums will be paid under Pakistan currency and at the prescribed offices of the insurance company. 12. Supplementary Benefits
Any supplementary contracts are attached to this policy and those will be regulated as per terms and conditions contained in the enclosed relevant documents.
19 13. Premium Notices: The policy holder has to pay the premium as and when they fall due. There is no obligation on the insurance company to issue premium notices. However, the companies do issue premium notices invariably as a business courtesy. 14. Incontestability Clause: This clause states that answers to questions and any statement made by the proposer in the proposal form shall not be contested after two years of the issuance of policy, unless a fraudulent intension of the assured is proved. 15. Travel, Residence And Occupation: This policy is free from travel, residence and occupation. 16. Free Look Period: This condition or privilege has been incorporated in the policy documents by the insurance companies, as a result of insurance rules issued by the DECP. The rule states that the policy holder can get the policy cancel and have the refund of premium without any deduction, except the medical expenses if any, within fourteen days of the issuance thereof. 17. Liquidated Damages: The Insurance Ordinance, 2000 makes it compulsory to pay the liquidated damages at a rate 5% above the bank rate if the insurance company delays the payment of the claim beyond 90 days of the submission of all the claims requirements by the claimant.
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CHAPTER - 5 CLAIMS Injury Claims Maturity Claims Surrender Claims Death Claims
A.
Surrender claims:
When a policy acquires a surrender value the policy holder can get its cash value payment by surrendering him original policy document. Surrender value or cash value is calculated according to the surrender value factors developed by the actuaries of the concerned insurance company. However, while calculating the surrender value following types of payment are excluded:
Premium for any supplementary contract
Premium for any occupational extra or medical extra
Premium for 1st year
For obtaining the surrender value payments, the policy holder have to apply in writing to the insurance company and have to sign a pre-receipt discharge voucher which contains the amount of cash value, bank account number of the policy holder and name and address of the branch of the bank. The discharge voucher has to be got witnessed. After completion of these requirements and submission thereof along with the original policy document, the company makes the payment of the amount of surrender value. After payment of surrender value no claim what so ever lies against the insurance company. As per Zakat and Usher Ordinance, 1980, Zakat has to be deducted at prescribed rate from the surrender value and deposited with the Government treasury. The policy holder who does not want to get the Zakat deducted will have to submit a Zakat declaration affidavit. B.
Maturity claims
A maturity claim becomes payable after completion of term of the policy. Maturity value is calculated by adding accrued bonuses to the sum-assured. For obtaining payment of the maturity value the policyholder has to submit the following documents;
Pre-receipt discharge voucher
Attested copy of NIC
Original policy document
21 C.
Injury claims
Policies which carry AIB rider are eligible for claims under this heading. If a policy holder receives accidental injuries, he can claim an indemnity as per schedule given in the endorsement of AIB contract. This schedule may differ from company to company. However an example could be as follows; •
Loss of both eyes (indemnity is full sum assured)
•
Loss of one eye and one limb (full sum assured)
•
Loss of one eye (half of the sum assured will be paid)
•
Loss of one limb (half of the sum assured will be paid)
•
Loss of thumb and index finger (1/4 th of the sum assured will be paid)
•
For other in juries by which the insured is totally and temporarily disable to perform any duties for wage or profit (Rs. 5/- per thousand of sum assured per week)
•
If the insured is partially disabled, he will receive 1/4th of the weekly disability.
When a policy holder receives disability payment under both the previous headings for 52 weeks continuously and he still disabled the payment will be switched to an annuity which equals to 10% of the sum assured. The period during which the annuity is being paid the subsequent premiums under the policy following due in that period shall be waived and policy will continue as enforced. If the annuity is paid for 10 years which is the maximum period all the subsequent premiums will also be waived. D.
Death claims:
Death claims fall under these two sub-divisions; Early death claims Non-early death claims
Early Death Claims
Those claims which occur within the incontestability period which are, within two years of the issue of the policy. Process
1. When death of a policy holder occurs the claimant under the policy informs the life insurer of the fact along with proof of death i.e. a
22 copy of the death certificate is attached with the information letter. This process is called intimation. 2. Immediately on receipt of the intimation of death the claims manager of the insurer checks the policy status and if it is found enforce, he will issue the claim forms. If the policy is lapsed he would issue a regret letter informing the claimant that nothing is payable under the policy being lapsed. The claim forms include the following;
Claimant’s statement
Attending doctor’s report
Certificate of identity
Employer’s statement, if the policy holder was employed
The claimant has to get these forms filled in, attested and submitted to the insurer. On receipt of claims forms duly completed he claims manager will get the case investigated to confirm as to whether the statements made in the proposal form and the information disclosed thereby are correct or not. If any concealment or misstatement found with its documentary evidence like any sort of treatment of a sickness, which was material to disclose in the pre-insurance period it will be substantiated with the relevant treatment documents which may be in the shape of written prescriptions of any attending physicians and or hospital admission record. If he evidence of concealment of pre-insurance ailment is strong the claims manager shall be constraint to repudiate the claim and inform the claimant accordingly. In case everything goes all right the claims manager shall accept the claim and issue a re-receipt discharge voucher. On completion of this pre-receipt discharge voucher the insurer would issue the claims cheque. Non-early Death Claims
In non-early death claims he process is almost same as that of early claims except that investigation is not mandatory and is only carried out in a very few cases where there is a genuine doubt about any foul play. The employers statement form is also not required under the non-early death claims.
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CHAPTER - 7 GROUP LIFE INSURANCE As the name denotes group life insurance caters for the needs of a group of people working together or having he same kind of profession. It is a sort of term insurance. No surrender, loan or maturity values are available there under.
Recent trends: There has been rapid growth in him transaction of group insurance for the last one decade. About 45% of life insurance business in Pakistan is now been transacted under the group life portfolio. The insurance companies have evolved new plans and types of group insurance coverage. A market of group life insurance is very competitive and the insurance companies have to win the group life insurance business on the basis of their efficient services and competitive rates. For this purpose they have made and are continuing to make substantial modifications in heir plans and designs of the policy. Rather the companies have adopted a flexible approach whereby they could make decisions according to nature of each group individually.
Basic Principles: The group insurance contract is between the employer and the insurer for the benefit of the employees. This means that the parties to the contract are employer and the insurer. The employee is only the beneficiary. The claim is to be paid by the insured heirs. This is called a master contract. Although an employee is not the party to the contract, the insurers do issue certificate of group insurance to individual employee. That certificate is a proof of insurance on the basis of which he heirs of the deceased employee can claim he sum insured. In group insurance contracts an element of anti-selection is not there (i.e. person takes insurance by concealing his illness) because in most of group insurance contracts proposal forms are not
24 used. The sum insured for each employee or class of employee is always selected by the employer. The employer is the policyholder not the employee. The premium is always paid by the policy holder.
Nature of the groups: Groups can be of various natures some of which are mentioned below; Employer: The employer having he authority of hire and fire can affect the
composition of that group frequently. Single employer groups: These groups consist of employees who were employed by a single employer and their terms and conditions of the service are controlled and regulated by that Multiple employer groups: In various cases the employees of different employers
make out a group e.g. some companies may take up a project combined under a consortium for common purpose e.g. joint venture. Trade Associations: Association of engineers of the Pakistan or Association of
officers of any institution is the example. Labor unions: The members of the labor unions can be termed as a group for
insurance purposes. Affinity groups: The people having the same profession are called affinity
professionals e.g. lawyers, doctors. Affinity groups having the same profession like doctors, engineers, lawyers, accountants etc. Debtor/creditor groups: The persons obtaining loans from financial institutions form
the group of this sort.
Size of the group: When the group insurance was started a minimum number of
members of the group were hundred. However as the competition grew this number has been reduced to 10 now a days. There is no limitation on maximum number of group membership. The underwriters view the smaller groups with more underwriting attention and would like to ask for evidence of insurability from each member.
Flow of members: Those groups in which older members retire and younger members are inducted on a prescribed basis are called stable groups from the underwriting point of view because the age distribution is stable. The groups where there are excessive changes are not generally like by the underwriters. There are certain groups whose job on average is hazardous therefore; such
25 groups are insured on extra mortality while some groups like workers of coal mines etc. are not at all insurable.
Risk classification: Ordinary groups/standard: These groups are insured by charging usual ordinary
premium as applicable to the standard lives. Sub-standard groups: The groups are those whose members are involved in
hazardous and risky profession and are accordingly charged with an occupational extra premium. Declined groups: The groups which are not insurable fall into this category.
Eligibility of group members: The members become eligible for group insurance under two separate schemes;
Non-contributory scheme: This means that the premium is being paid by the employer
and the employee do not have to pay anything on that account. In this scheme the participation of the members must be 100%.
Contributory group insurance scheme: As the name denotes the members of the group
pay the group insurance premium by contribution among themselves. This scheme can be availed independently or in addition to the non-contributory cover. In contributor scheme the participation of the member must be not less than 75%.
For both these categories a group member to be covered must be actively at work.
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CHAPTER - 8 PREMIUM AND ADMINISTRATION The group insurance premium is calculated basically according to a group morbidity (which shows the rate of injuries in accidents) and mortality but those are not followed strictly because the experience of each individual group differs as such it is a major factor in determining the group insurance premium for a particular group. The other factors involved are the age of the every member of the group and wage of the every member of group. Thus a group insurance premium is calculated taking into account group mortality/morbidity tables, past claims experience of that group and average ages and wages of the group. In case of a new group, the experience of similar groups is considered. The group insurance like other kinds of insurance is regulated by the Insurance Ordinance, 2000 in Pakistan. As compared to individual life insurance the group insurance rates are cheaper. As we have already seen the group insurance contract is between the employer and the insurer, as such it is the employer who has the right to choose the amount of sum assured for each individual member or class of members. The employee can not himself/herself determine the sum assured.
POLICY PROVISIONS Group Insurance Certificate: One policy document is issued as an evidence of the
contract of group insurance between the employer and the insurer. However, insurers do issue group insurance certificate to each individual member of the group. Such a certificate contains brief particular of the insurance like date of commencement, date of expiry, sum assured and name of the nominee etc. Grace period: A grace period to pay the premium is allowed after the due date. The
period differs from insurer to insurer and contract to contract. However, generally 31 days are allowed after the premium has become due. Nominee: In group life insurance the name of nominee is not mentioned in the policy
document. It is recorded separately in the records of the insurer and stated in the certificate. Age admission: Age of each and every member of the group must be declared by the
employer and admitted so by the insurer. Incontestability: Although group insurance contracts are usually issued for a period
of 1` year, there is a provision to renew them every year in such a case any
27 misstatements made in the proposal form by the employer shall not be contestable in any court of law unless a ground of fraudulent intention is proved. Profit commission: Most of the group life insurance contracts contain a provision of
profit commission which means that if that group shows a profit then a percentage of that profit shall be paid back to the employer by the insurer. Such a percentage varies from 70% to 90%. However, if the group shows a loss that has to be borne by the insurer. Conversion into ordinary life: Some of the group insurance policies contain a
provision and if any group member leaves that group then he has a right to convert that policy into individual life insurance by paying the difference of premium. Claims settlement: The claims under group life insurance policy are paid in respect of
deceased/injured (if the accident coverage is obtained) in favor of the employer. It is the employer who then has to pay that claim to the heirs of the deceased or to the injured person.
GROUP LIFE INSURANCE PLANS As we know the group life insurance plans are issued in term of insurance as such all sorts of plans issued under a group life insurance cover only – the death risk or accidental injuries risk wherever such cover has been obtained. The following plans are usually issued in group life insurance; Yearly renewable plan: This plan is issued for one year initially with a provision that
it will be renewable at the option of the employer or policy holder for every subsequent year. However the premium will be charged according to the rate arrived at after taking into account the experience of previous year and the present ages and wages of the members of the group. Survivor income plan: Under this plan a yearly income is guaranteed to the survivors
of the deceased employee for a given number of years. Group permanent plan: Under this plan the insurance companies issue the group
insurance policies for a period as long as the concerned group would like to be covered. The issuance of this plan is very rare even in the western world. It is not at all issued in Pakistan. AIB Rider: This rider can be attached with any of the above plans to provide for an
indemnity for accidental injuries to the group members in addition to the death risk covered under these plans.
GROUP LIFE INSURANCE PREMIUM
28 The factors influencing the group insurance premium rate are as under: Group mortality and morbidity tables Past experience of the group or of similar groups Age of every member of group Wage/sum assured for every member Sex of the group members (2 years relaxation is given to females) Larger group discount. If group is larger than average a premium rate discount is
given The rate will be calculated afresh every year. For certain typical groups where the
correct number of members is not ascertainable some companies provide a blanket cover. An example of such group could be the persons getting loan from financial institutions.
Terms & Conditions Group Insurance Certificate: The insurer will issue group insurance certificate to
every member of the group. Grace period: The policy allows a grace period of say 31 days after the premium has
become due. If the claim occurs during that period, it will be paid after deducting the individual member’s share of the premium of that group. Nominee/Beneficiary: The name of nominee or beneficiary will be mentioned in the
group insurance certificate instead of the main policy document. Age under statement: If any member’s age is found to have been under stated the
arrears of the premium will be charged. Incontestability: The statements made in the proposal form will be incontestable after
the policy has been enforcing for 2 years except where the fraud or fraudulent intension is proved. The onus of proof shall be on the insurer. Group participation: All members of the group which have been mentioned in the list
provided by the employer shall be covered under this policy. Any exits on account of resignations, termination or dismissals etc. shall be communicated to the insurer. Such cases shall be covered only up to the date of exit. Any new inductions shall also be reported along with their usual particulars. The premium for exits and inductions shall be adjusted at the year end. Conversion: The insurance under this group can be converted into individual life
insurance in certain special circumstances on leaving that individual of the group.
29 Settlement option: The claims under this policy shall normally be settled in lump
sum. However, in certain policies an option is given to the nominee to receive the amount of claim in installments along with the accruing profit
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CHAPTER – 9 HEALTH INSURANCE There are two distinct types of health insurance coverage; Medical Expense Coverage Disability Income Coverage
Medical expense coverage provides benefits for the treatment of sickness or injury. Disability income coverage provides income benefits when the insured is unable to work because of sickness or injury. The manner in which health insurance benefits – both medical expense and disability income are provided varies substantially according to the coverage terms specified by the provider.
MEDICAL EXPENSE COVERAGE Medical expense coverage is designed to provide benefits to help the insured pay for the costs of receiving medical treatment for a sickness or an injury. Several types of medical expense coverage are available.
Hospital-Surgical Expense Coverage:
Hospital-surgical expense coverage provides benefits related directly to hospitalization costs and associated medical expenses incurred by an insured for treatment of a sickness or an injury. The specific benefits provided by the hospital-surgical expense coverage are described in a policy or in another document used to define the terms of the coverage. Hospital-surgical expense policies usually specify that the insured must be hospitalized before any benefits are payable, although some such policies provide benefits for certain specified outpatient charges. These policies also specify benefit amount limits for most covered expenses. Although the specific benefit amount limits for most covered expenses. Although the specific benefits available vary from policy to policy and are usually subject to certain limitations and exclusions, most hospital-surgical expense policies cover;
30 1.
Hospital charges for room, board and hospital services.
2. Surgeon’s and physician’s fees during a hospital stay. 3. Specified outpatient expenses. 4. Extended care services, such a convalescent or nursing home costs. Any medical expenses incurred by an insured other than the expenses described in the policy are not ‘eligible expenses’, and no policy benefits are payable for those expenses.
BENEFITS: Hospital charges:
The benefit payable for hospital room and board is typically limited to a maximum benefit amount per day. Some hospital-surgical expense policies provide a higher maximum benefit amount per day for room and board charges when he insured must be confined in an intensive care or a cardiac care unit, since these charges are considerably higher than the charge for regular daily hospital room and board. In addition, most policies specify a maximum number of days for which the room and board benefit will be payable during each period of hospital confinement. A separate hospital expense benefit is payable to cover miscellaneous hospital charges, such as X-ray and laboratory fees, medicines, and the use of an operating room. Hospital-surgical expense policies usually specify maximum benefit amount payable for all such hospital services. This amount is often set at a multiple of the maximum room and board benefit amount. Specified outpatient expenses:
Most hospital-surgical expense coverage includes benefits for certain outpatient charges, such as charges for emergency room treatment of an accidental injury. Generally, the treatment must be administered within a specified period of time after the accident, usually 48 to 72 hours, in order for the benefit to be payable. Other outpatient charges currently covered by most hospital-surgical expense policies are those chares incurred for diagnostic tests performed in an adequately equipped doctor’s office or clinic. These tests include X-rays and blood tests, among others. The policy usually states the maximum benefit amount that will be payable for these expenses. Surgeon’s and physician’s fees:
Hospital-surgical expense policies are one of two methods to describe the amount of a surgeon’s fee that the policy will cover. The first method is to include a surgical schedule in the policy. A surgical schedule lists common surgical procedures and describes the maximum benefit amount the insurer will pay for each procedure; the policy also specifies that the
31 insurer reserves the right to determine the maximum benefit payable for surgeon’s fee for any operation not listed on the schedule. In some cases, each procedure is assigned a specified number of benefit units, and the policy describes the benefit amount payable for each unit.
The second method used to
Determine the benefit amount payable for surgeon’s benefits is to specify that such benefits will be based on the ‘reasonable and customary’ or ‘usual and customary’ charges for the procedure performed that is, the prevailing charges made by surgeons of similar expertise for a similar procedure in a particular geographic area. Fees for dental and cosmetic surgery usually are not covered by hospital surgical expense policies unless such surgery is necessary as the result of an accidental injury or medical impairment. A separate benefit is payable to cover fees for services provided by an anesthesiologist during surgery. In addition, some policies cover a physician’s fees for medical services that are not related to surgical procedures if these fees are incurred while the insured is hospitalized. The policy specifies the maximum benefit amount payable for each physician’s visit in the hospital, as well as the maximum number of such visits that will be covered.
Extended-care services:
The extended-care benefit of a hospital-surgical expense policy covers room and board charges, up to a specified maximum amount, when the insured is confined in an extendedcare facility, such as a nursing or convalescent home. The benefit is designed to encourage the use of extended-care facilities by patients who need professional care while recovering from illnesses or surgery but who do not need he full services of a hospital. The insured’s confinement in an extended-care facility must begin within a specified number of days after a hospital stay for the same cause in order for the benefit to be payable. The policy specifies the maximum number of days and the maximum benefit for each day of confinement.
Deductible amounts:
Some hospital-surgical expense policies specify that, before any benefits become payable under the policy, the insured must pay a portion of the eligible medical expenses incurred. The portion that the insured must pay before the insurance company will make any benefit payments is called the deductible amount, commonly shortened to the deductible. The deductible is applied throughout the life of the policy on the basis of a specified deductible period. The most commonly specified deductible period is one year, in which case the deductible is often called a calendar year deductible and applies to any eligible medical expenses incurred by the insured during any one calendar year.
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Exclusions:
Any medical expenses not described in a hospital=surgical expense policy as eligible medical expenses are not covered under the policy. Thus, most such policies do not cover medical expenses incurred through (1) purchasing medicines and drugs, unless those medicines are given during a hospital stay or while obtaining outpatient surgery, (2)employing private-duty nurses, and (3) obtaining routine dental treatments, oral surgery, eye examinations, and corrective lenses, unless such expenses are incurred as the result of an accidental injury. In addition medical expenses that result from any of the following are usually excluded from coverage under hospital-surgical expense policies;
1. Cosmetic surgery, unless such corrective surgery is (1) required due to accidental injury, (2) performed on a newborn to correct a birth defect, or (3) required tgor medical reasons. 2. Treatment for any injury or sickness that occurs while the insured is in military service or that results from an act of war. 3. Treatment for injuries that arfe intentionally self-inflicted or that are the result of attempted suicide. 4. Any hospital-surgical procedures for which expenses are paid by other organizations or which are provided free of charge in government facilities (For example, if the insured is receiving benefits from workers’ compensation for any occupational injury or illness, the insured would not be permitted to collect duplicate benefits under a hospital-surgical expense policy for treatment of the same occupational injury or sickness.)
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CHAPTER – 10 MAJOR MEDICAL COVERAGE Although the benefit amounts available under hospital-surgical policies are high enough to cover the medical expenses caused by most illnesses and injuries, these benefit amounts may be insufficient to cover medical expenses that result from major illnesses or injuries requiring expensive or long-term care. Major medical coverage was designed to meet the need for economic protection in such cases.
Coverage: Major medical coverage, which provides substantial benefits for both hospital expenses and outpatient expenses, is subject to fewer limitations than in hospital-surgical expense coverage. Major medical coverage provides benefits for the same types of medical expenses that are covered by hospital-surgical expense policies. In addition, major medical coverage provides for expenses that may not be covered under basic hospital-surgical plans, including the costs incurred for: Receiving outpatient treatment Employing private-duty nurses renting or purchasing treatment equipment and
medical supplies Purchasing prescribed medicines
Types of Major Medical Coverage Two types of major medical coverage are commonly available: Supplemental, or superimposed, major medical Comprehensive major medical, which is also called comprehensive health insurance
Supplemental major medical policy:
It is issued in conjunction with hospital-surgical expense coverage, and is designed to provide benefit payments for expenses that exceed the benefit levels of the hospital-surgical policy. Comprehensive major medical policy:
It combines into one policy the coverage provided under hospital-surgical expense policies and supplemental major medical policies; thus, comprehensive major medical policies provide complete and substantial medical expense coverage under one policy, and such policies cover most of the medical expenses an insured may incur.
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Expense participation: Both comprehensive and supplemental major medical policies usually specify that the insured must share in the payment of the medical expenses incurred. Sharing in the cost of such medical expenses is called expense participation. Expense participation encourages an insured to keep medical expenses to a minimum and, consequently, enables the health insurance provider to keep the costs of the coverage to a lower level and well. The two expense participation methods most commonly used are deductibles and coinsurance. Deductibles:
The manner in which a deductible is applied in major medical policies depends on whether the policy is a comprehensive major medical policy or a supplemental major medical policy. The deductible included in most comprehensive major medical policies functions in the same manner as does the deductible found in hospital-surgical expense policies; the insured must pay a specified flat amount before any policy benefits are payable. Supplemental major medical policies usually include a corridor deductible. The corridor deductible is an amount that the insured must pay. Co-insurance:
Most major medical policies require that the insured pay a specified percentage of all the eligible medical expenses, in excess of the deductible, which he or she incurs as a result of a sickness or injury. This method of expense participation is called coinsurance, or percentage participation. Exclusions:
Although major medical policies provide benefits for several types of medical expenses not covered by hospital-surgical expense policies, major medical policies do contain some of the same exclusions that are found in hospital-surgical expense plans. Specifically, major medical policies contain the same exclusions that are found in hospital-surgical policies regarding cosmetic surgery, self inflicted injuries, injuries received while in military service or as the result of war, and treatments received free of charge or for which benefits are paid by another organization. In addition, major medical coverage usually does not include benefits for dental treatments and vision care.
Types of coverage: Hospital Confinement Coverage:
35 The coverage provided under hospital confinement policies, which are often called hospital indemnity policies, consists of a predetermined flat benefit amount for each day an insured is hospitalized. The amount of the daily benefit is specified in the policy and does not vary according to the amount of medical expenses the insured incur. Specified Expense Coverage:
Specified expense coverage is medical expense coverage that provides benefits to reimburse the insured for expenses incurred by: Obtaining treatment for an illness that is specified in the policy or Purchasing medical supplies or treatments that are specified in the policy. The most commonly offered forms of specified expense coverage include dread disease coverage, dental expense coverage, prescription drug coverage, and vision coverage. Dread Disease Coverage:
Dread disease coverage is a type of coverage designed to pay benefits for only those medical expenses incurred by an insured that has contracted a specified disease. The most commonly offered type of dread disease coverage is cancer insurance. Such coverage may be purchased to supplement basic hospital-surgical expense coverage and can serve the same purpose as supplemental major medical coverage if the insured should incur medical expenses as a result of contracting the disease named in the policy. However, if the insured incurs medical expenses for the treatment of any illness other than the one specified, no policy benefit will be payable. Dental Expense Coverage:
Hospital-surgical expense coverage and major medical expense coverage do not provide benefits for expenses incurred by obtaining routine dental work and dental treatments. Coverage for such expenses can be provided only through dental expense insurance. Dental expense policies usually provide benefits for routine examinations, preventive work and dental procedures needed to treat tooth decay and diseases of the teeth and jaw. Prescription Drug Coverage:
Prescription drug coverage is designed to provide benefits to the insured for the purchase of prescribed drugs and medicines. Only drugs that cannot be obtained without a prescription are eligible for coverage under prescription drug plans; over-the-counter medicines, such as aspirin, are not covered. Vision Care Coverage:
36 Vision care coverage provides the insured with benefits for expenses incurred obtaining eye examinations and corrective lenses. Most policies that provide such coverage specify that one routine examination of the insured per year will be covered. The maximum amount that will be paid in benefits for eyeglass lenses and for frames is also specified; if the insured purchases contract lenses instead of eyeglasses, the maximum benefit amount is usually equal to the amount that would have been paid for lenses and for frames. Disability Income Coverage:
Disability income coverage provides a specified income benefit when an insured person becomes unable to work because of an illness or an accidental injury. Disability income policies provide no medical expense coverage; they are intended to provide protection from the financial losses that result from a person’s inability to work while disabled. The insured person’s disability must meet the policy’s definition of total disability in order for the insured to receive the income benefit. Definitions of Total Disability:
Each provider of disability income coverage specifies the definition of disability that will be used to determine whether a covered person is entitled to receive disability income benefits. Although a complete listing of every definition of total disability that is or has been used would be impossible to construct, we will describe the definition of disability included in government programs, as well as the other criteria that a disabled individual must meet in order to qualify for benefits under government programs. 1. Total Disability; Any Occupational Absence: At one time, total disability was defined in disability income insurance policies as a disability that prevented an insured from performing the duties of any occupation. Since a strict interpretation of this definition would prevent most people from every qualifying for disability income benefits, most insurers have stopped using this definition. Total Disability; Current Usual Definition:
The usual definition of total disability included in disability income policies today is more liberal than the old definition just described; the newer definition discusses disability in two stages. According to this newer definition, at the start of disability, insureds are considered totally disabled if their disability prevents them from performing the essential duties of their regular occupations. However, at the end of a specified period after the disability has begun, usually two years, insureds are considered totally disabled only if their disabilities prevent them from working at any occupation for which they are reasonably fitted by education,
37 training, or experience. In addition, this definition of total disability usually specified that whenever he insured is working in any gainful occupation, the insured is not considered to be totally disabled. Total disability; “own previous occupation”
Some companies have further liberalized the definition of total disability included in disability income policies that are issued to members of certain professional occupations. According to this definition, an insured is totally disabled if the insured is unable to perform the essential duties of his/her own previous occupation. 2. Total disability; “income loss”
A type of disability income coverage, often called income protection insurance, has gained popularity since the late 1970s primarily in the upper income professional market. This coverage differs from traditional disability income coverage primarily with regard to the definition of disability included in such policies. The definition of disability included in income protection policies specifies that an insured is disabled if that person suffers an income loss caused by the disability. Disability Income Benefits:
The benefit amounts available through disability income coverage are not intended to fully replace an individual’s pre-disability earnings. Instead, these income benefit amounts are limited to amounts that are lower than the individual’s regular earnings when not disabled. Without restrictions on the income amounts available through disability income coverage, a disabled insured could receive as much income as he or she received when working, if such were the situation, as insured who became disabled would have little incentive to return to work and might prolong the period if disability. An insurance company carefully limits the maximum amount of the disability income benefit that a particular applicant can purchase. When determining the maximum amount of disability income available to an applicant, the insurer considers the applicant’s; Usual earned income, before taxes. Unearned income, such as dividends and interest, which will continue during a disability. Additional sources of income available during a disability, such as disability income benefits provided through group disability income coverage and government-sponsored disability income programs. Current income tax bracket, because the applicant’s usual earned income is reduced by taxes while disability income benefits from individual policies are not reduced by taxes.
