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Drug Price Review (DPR) A procedure used to determine drug price maximums. It involves determining wholesale drug prices based on the American Druggist Blue Book.
Drug Utilization Review (DUR) A method for evaluating or reviewing the use of drugs in order to determine the appropriateness of the drug therapy.
Dual Choice The federal requirement that employers having 25 or more employees who are within the service area of a federally qualified HMO, who are paying at least minimum wage and offer a health plan to their employees, must offer HMO coverage as well as an indemnity plan.
Duplicate Coverage Inquiry (DCI) A request to determine whether or not other coverage exists. Used to apply the coordination of benefits provisions where two or more insurance companies are involved.
Duplication of Benefits A situation where identical or overlapping coverage exists between two or more insurance companies or service organizations.
Duty to Defend A provision in commercial and personal liability insurance policies where the insurer has the right and duty to defend lawsuits against the insured, even when those suits are considered false, groundless, or fraudulent.
Dwelling A house in which people live, as distinguished from a store, factory or any other building.
Earned Premium The portion of the policy premium allocable to the expired portion of the policy term.
Earth Movement Exclusion A provision to exclude coverage for loss caused by settlement of earth, creep or slide of soil, or other instability of the earth.
Earthquake Vibrations of the earth's crust caused by pressures from within the earth.
Effective Date The day upon which a policy first becomes elegible to pay covered losses.
Effective date The date that a person is eligible for benefits.
Effects Personal property, goods, chattels, clothes, and documents.
Egilibility Period Once an employee has become elegible for company benefits such as life and health insurance, the employee is usually given a limited period of time to decide which benefits to subscribe to without having to go through physical examinations and prove insurability. This is called the eligibility period. Once the eligibility period has expired, should the employee decide to purchase or subscribe to the insurance benefit programs, proof of insurability is normally required and the insurer may reject the employee's request.
Elective Benefits Lump sum payments which the insured may generally choose in lieu of periodic payments for certain injuries, such as fractures and dislocations.
Elective Indemnities See Elective Benefits.
Eligibility Date The date that a person is eligible for benefits.
Eligibility Period 1) The period of time during which potential members of a Group Life or Health program may enroll without providing evidence of insurability. (2) The period of time under a Major Medical policy during which reimbursable expenses may be accrued.
Eligibility Requirements Requirements imposed for eligibility for coverage, usually in a group insurance or pension plan.
Eligible Dependent A dependent of an insured person who is eligible for coverage according to the requirements set forth in the contract.
Eligible Employee An employee who is eligible based on the requirements as indicated in the group contract.
Eligible Expenses Expenses as defined in the health plan as being eligible for coverage. This could involve specified health services fees or "customary and reasonable charges."
Eligible Person Similar to eligible employee except it could be a contract covering people who are not employees of a specified employer. An example might be members of an association, union, etc.
Elimination Period In health insurance, an amount of time after the occurrence of a disability during which no indemnities are payable, as provided in the policy. An elimination period can apply to accident, sickness, or to both. Commonly referred to as the waiting period. Also used in boiler and machinery business interruption insurance.
Elimination Period A loosely used term, sometimes designating the probationary period, but most often designating the waiting period in a Health Insurance policy. See also Probationary Period and Waiting Period.
Embezzlement Fraud in using money for yourself that has been entrusted by another. A similar term, conversion, applies to property instead of money.
Emergency An injury or disease which happens suddenly and requires treatment within 24 hours.
Emergency Accident Benefit A group medical benefit which reimburses the insured for expenses incurred for emergency treatment of accidents.
Emergi-Center See Freestanding Emergency Medical Services Center.
Employee Benefit Program Benefits offered an employee at his place of work by his employer, covering such contingencies as medical expenses, disability, retirement, and death, usually paid for wholly or in part by the employer. These benefits are usually insured.
Employee Certificate of Insurance The employee's evidence of participation in a group insurance plan, consisting of a brief summary of plan benefits. The employee is provided with a certificate of insurance rather than the actual insurance policy.
Employee Contribution The employee's share of the premium costs.
Employer Contribution The portion of the cost of a health insurance plan which is borne by the employer.
Encounter Each time a person meets with a health care provider to receive services, is a separate "encounter."
Encounters Per Member Per Year The total number of encounters per year divided by the total number of members per year.
Endorsement A document with language attached to and becoming part of a basic policy for the purpose of amplifying or modifying it, either at its inception or during its term. Any such modification can become effective only with the agreement of the insured, unless clearly made soley for the benefit of the insured.
Enrollee An eligible individual who is enrolled in a health plan _ does not include an eligible dependent.
Enrolling Unit The organization (such as an employer) that contracts for participation in a health insurance plan.
Enrollment Used to describe the total number of enrollees in a health plan. It may also be used to refer to the process of enrolling people in a health plan.
Enrollment Period The amount of time an employee has to sign up for a contributory health plan.
ERISA See Employee Retirement Income Security Act.
ERISA-Employee Retirement Income Security Act of 1974 Sometimes called the "pension reform act." One of the pruposes of this act is to force employers to protect the assets of the business that have been designated as employee pension benefits.
Errors & Omissions Clause Obligatory reinsurance treaties contain a provision to clarify that because of the nature of the treaty, should an error or omission occur in the process of recording or describing of the ceded risk, if the risk is otherwise covered by the treaty, the reinsurer will still respond despite the error or omission.
Estoppel The prevention of one party from asserting rights which might otherwise have existed, by reason of that party's inequitable conduct. Waiver is a term sometimes used interchangeably.
Evidence of Insurability In life and health policies, a statement on the application that provides proof of an individual's occupation and/or physical condition. Used to help determine that individual's acceptability for insurance.
Examination The medical examination of an applicant for Life or Health insurance.
Examiner A physician appointed by the medical director of a Life or Health insurer to examine applicants.
Excess Insurance An amount of protection which bears all or a portion of a loss after the loss exceeds an agreed amount. This amount may or may not be insured elsewhere by the company issuing the policy. Excess policies are not subject to the basic principle of contribution with non-excess policies, although they may contribute or share the loss with other excess policies.
Excess Line A line of insurance provided by insurers not licensed in the states where the risks are located and placed under the surplus lines laws of the various states. Before such placements can be made through specially licensed surplus lines agents and brokers, state laws generally require evidence that placements could not readily be made in licensed insurers--or broadly referred to as being all lines of insurance placed with nonadmitted insurers.
Excluded Period See Probationary Period.

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