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Primary Care Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine.
Primary Care Network (PCN) This is a group of primary care physicians who provide care to those members of a particular health plan.
Primary Care Physician Some health insurance plans require members to select and seek treatment from a primary physican who either renders treatment or refers the member to an appropriate specialist within the approved health care network.
Primary Coverage This is the coverage which pays expenses first, without consideration whether or not there is any other coverage. See also Coordination of Benefits.
Primary Insurance The insurance policy providing the first layer of coverage that will respond first to any loss exceeding the deductible.
Prior Authorization A cost containment measure which provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.
Pro Rata Clause A provision in a property policy which states that the insurance which has been written "blanket," or as one amount covering several items, shall be limited on each item to the proportionate amount which the value of the particular item bears to the total value of all insured items.
Probable Maximum Loss (PML) The anticipated maximum property fire loss that could result, given the normal functioning of protective features (firewalls, sprinklers, and a responsive fire department, among others), as opposed to maximum foreseeable loss which is a similar valuation, but on a worst-case basis with respect to the functioning of the protective features. Underwriting decisions would typically be influenced by PML evaluations, and the amount of reinsurance ceded on a risk would normally be predicated on the PML valuation.
Probationary Period A period of time between the effective date of a Health Insurance policy, and the date coverage begins for all or certain physical conditions.
Product Recall Insurance Pays the expense associated with government dictated recall of a product suspected of being defective and dangerous to consumers. Pharmaceutical, automobile and aircraft manufacturers are types of risks that often are affected. This expense is not covered by the standard general liability policy.
Professional Review Organization An organization of physicians which reviews services to determine if they are medically necessary.
Property Insurance "First-party" Insurance of real and personal property against physical loss or damage, not to be confused with property damage liability insurance.
Proration of Benefits The adjustment of Health Insurance policy benefits by reason of the existence of other insurance covering the same contingency.
Prospective Payment System A system of Medicare reimbursement for Part A benefits which bases most hospital payments on the patient's diagnosis at the time of hospital admission.
Prospective Reimbursement A system where hospitals or other health care providers are paid annually according to rate of payment which have been established ahead of time.
Prospective Reserve A Life or Health Insurance reserve which it is estimated will be sufficient to pay future claims when probable future premiums, interest, and survivorship benefits are added to it.
Protective Safeguards Clause In property insurance, a clause or provision that clarifies that coverage was granted or a premium credit given based on the existance of, continual maintenance of, and operation of a specified protective device by the insured. The insurer has the right in some jurisdictions, to void the coverage should a loss occur as a direct result of the lack of maintenance or operation of the specified device. Common examples are sprinkler systems and fire or theft alarms.
Provider Any person or entity providing health care services, including hospitals, physicians, home health agencies and nursing homes. Usually licensed by the state.
Proximate Cause That which brings about a result without the intervention of any other force. Important in insurance since it establishes which policy(ies) will pay for a loss, i.e., the one(s) insuring the peril which was the proximate cause of the loss.
Proximate Cause That which brings about a result without the intervention of any other force. Important in insurance since it establishes which policy(ies) will pay for a loss, i.e., the one(s) insuring the peril which was the proximate cause of the loss.
Punitive Damages Damages awarded separately and in addition to compensatory damages, usually on account of malicious or wanton misconduct, to serve as a punishment for the wrongdoer and, possibly, as a deterrent to others. Sometimes referred to as "exemplary damages" when intended to "make an example" of the wrongdoer.
Qualified Medicare Beneficiary (QMB) This is a person whose income is below the federal poverty guidelines. In these cases, the state is required to pay the Medicare Part B premiums, plus any deductibles or copayments.
Qualifying Event An occurrence (such as death, termination of employment, divorce, etc.) that triggers an insured's protection under COBRA, which requires continuation of benefits under a group insurance plan for former employees and their families who would otherwise lose health care coverage.
Quality Assurance Activities involving a review of quality of services and the taking of any corrective actions to remove any deficiencies.
Quarantine Benefit A benefit paid for loss of time resulting from the quarantining of an insured by health authorities.
Quarantine Indemnity See Quarantine Benefit.
Railroad Protective Liability The standard commercial general liability policy excludes liability for construction or demolition operations on or near railroad property, such as tracks, trestles, sidetracks,etc. In order to provide coverage for this exposure, the railroad protective liability policy is available to provide protective liability coverage for railroad owners, property owners, or contracts from the vicarious acts of contractors or subcontractors who are working on their behalf. The policy is purchased by the subcontractor or contractor in the name of the party needing protection. For example, a contractor demolishing a building near a railroad track may need to purchase a railroad protective liability policy for the property owner, the railroad, or both.
Railroad Retirement System which provides retirement and other benefits, including eligibility for Medicare, for railroad workers.
Railroad Travel Policy form of Accident Insurance policy sold in railroad stations by ticket agents or by vending machines. See also Travel Accident Insurance.
Rate The price for a unit of insurance; all units in a given policy, multiplied by the rate per unit, produce the premium. In fire insurance, the price per $100 of insurance for one year. The basis for pricing other types of insurance varies greatly; for example, payroll is used in workers compensation insurance, area of retail floor space or sales volume is used in certain types of general liability insurance, and so forth.
Rating Process The steps used to determine a premium rate for a particular group based on the amount of risk that group presents. Items that generally go into the rating process include age, sex, type of industry, benefits, and administrative costs.
Real Property The earth and all attached to it; land and buildings. Also known as real estate.
Reasonable and Customary Charges The charge for medical services which refers to the amount approved by the Medicare Carrier for payment. Customary charges are those which are most often made by a provider for services rendered in that particular area.
Recidivism This term refers to how often a patient returns to an inpatient hospital status for the same reason.
Recipient Anyone designated by Medicaid as being eligible to receive Medicaid benefits.
Recurring Clause. Health Insurance policy provision defining the duration of a period of time during which the recurrence of a condition will be considered a continuation of a prior period of disability or confinement.
Referral Within many managed care plans, transfer to specialty physician or specialty care by a primary care physician.
Referral Provider The person or provider to whom a participating provider has referred a member of the plan.
Registered Nurse (RN) A licensed professional with a four-year nursing degree. Able to provide all levels of nursing care including the adminstration of medication.
Rehabilitation Clause A clause in a Health Insurance policy, particularly a Disability Income policy, that is intended to assist the disabled policyholder in vocational rehabilitation.
Reinstatement 1)Restoration of the amount of insurance depleted from a policy by payment of loss. Most fire policies contain an automatic reinstatement clause. 2)Reinstituting or putting coverage back into effect under a policy in which coverage has been suspended or canceled for a part of the policy term.
Reinsurance 1)The transaction whereby an insurance company(the reinsurer), for a consideration, agrees to endmnify another insurance company known as the ceding company (the reinsured) against all or part of a loss which the latter may sustain under a policy or policies it has issued. 2)When referred to as "a reinsurance," the term means the relationship between reinsured(s) and reinsurer(s).
Reinsurance Treaty A reinsurance agreement between an insurance company and a reinsurer, usually for one year or longer, which may be divided into two broad classifications: 1)The participating type which provides for sharing of risks between the ceding company and the reinsurer; and 2)The excess type which provides for indemnity by the reinsurer only for loss which exceeds some specified predetermined amount.
Relative Value Schedule A surgical schedule which basically compares the value of one surgical procedure to another and establishes the surgical fee to be paid.
Relative Value Unit Sometimes used instead of dollar amounts in a surgical schedule, this number is multiplied by a conversion factor to arrive at the surgical benefit to be paid.
Renewable Term Life Insurance A term life insurance coverage that offers the renewal of the coverage without making the insured take physical exams or otherwise prove insurability.
Renewal A policy issued to replace one which has expired.
Rental Reimbursement Coverage An optional personal auto coverage endorsement to provide reimbursement for the expenses incurred by an insured when a temporary replacement vehicle is needed following a covered accident to the insured's vehicle.
Replacement Cost Insurance Protection which pays the cost to restore or replace damaged or destroyed property without deduction for depreciation. Automatically included in homeowners forms.
Reserve An amount representing a liability of an insurer


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