This term comes into play largely in connection with long-term disability. (See Long- Term Disability [LTD]). Many, if not most, LTD contracts recognize that for social, moral and economic reasons, the disabled should be encouraged to get back into the mainstream of life through such things as learning to cope with disability or develop a different occupation. The rehabilitation clause enables the claimant to receive some benefits even while seeking reemployment and retraining.
Most medical care insurance is on a reimbursement basis. That is, benefits are based on actual charges made and no more. In many instances, this rules out treatment in governmental facilities that do not require that the patient pay for care.
Many major medical contracts provide that when portions of the maximum benefit have been exhausted in prior claims, they will be reinstated following a specified period during which no benefits are paid out.
To achieve certain limits of coverage, a carrier will frequently award part of the coverage to another insurer. In some instances, this could impose additional requirements for you, but you will be advised on a per case basis of these needs.
Relative Value Schedule
In an attempt to keep dental allowances current with prevailing surgeon’s fees, surgical procedures are rated on a scale of difficulty. Thus, an appendectomy may be six times more complicated than a tonsillectomy and the allowance-is-graded accordingly.
You will probably hear this term in connection with the year-end analysis of the experience of the pool or of the risk itself. The carrier must maintain certain legal reserves (plus amounts for incurred but unknown claims).
Ordinarily the term “retention” will not come up within the context of small-group plans. In large-group cases, retention is the amount after claims that the carrier feels is needed to run the plan, pay taxes, etc. Some carriers include commissions as retention items.
Some carriers apply a risk charge in computing renewal rates, thereby assessing each account with a proportionate share of the overall experience of a class of business.
Room and Board
Extended health care plans usually provide reimbursement for semi- private or private room rates.