1. Welcome to Jeddah Community College King Abdul Aziz University

2. Lecture By Asif Ahmed Qureshi Masters in Economics Chartered Insurer- U.K. aahmedqureshi@yahoo.com

3. Basic Terms of Insurance

4. Insurance: risk transfer mechanism. Insurance: risk transfer mechanism.

5. Definitions  Insurance company/insurer: the providers of insurance.  Insured / Policyholder" ‑ the individual / employer or other defined or otherwise legally constituted group to whom the insurance Policy is issued.

6. Definitions  Insured persons: person listed in the policy schedule.  Policy: An evidence of the insurance which contract contained all the terms and conditions applicable to the contract.  Endorsement: A document issued by insurance company effecting some kind of amendments to the policy.

7. Definitions  Underwriter: company or person involved in the process of underwriting.  Underwriting: process of accepting or rejecting a risk.  Coverage or cover ” the entitlement by a covered person to health services provided under the Policy or the insurance provided by the policy. benefitsbenefits

8. Definitions  Insurance period: the date from which the insurance starts to the date it expires.  Indemnity: to place the insured in exactly the same position as he was in before the loss.

9. Definitions Limits of cover or sum insured: the maximum benefit available under the policy. bnefits bnefits Policy conditions: condition incorporated in the policy breach of which may give right to the insurer to decline a particular claim. Extensions: additional cover not available in the standard policy.

10. Definitions Addition/Deletion: additions means inclusion of inured member and deletion means the removal of insured person from cover. Geographical limits: the places/countries to which the cover is restricted.

11.  Premium: the fee or charges for the insurance policy/cover.

12. Definitions Pro-rata premium: Charging premium for the period. Rate: calculating premium factor e.g. percentage, per mille, flat. Claims: request for settlement of covered losses suffered by insured.

13. Definitions Deductible: The first amount insured agree to bear in any claim. Outstanding claims: insured losses/claims not yet settled. Specific Exclusions: non-covered services or benefits which are specific to the Covered Person being insured.

14. Definitions General Exclusion: exclusions normally appear in all form of insurance e.g. war, invasion, civil war, radioactive contamination, treatment for the use of drugs etc. General Exclusion: exclusions normally appear in all form of insurance e.g. war, invasion, civil war, radioactive contamination, treatment for the use of drugs etc.

15. Cancellation: discontinuation of policy prematurely. Subrogation: Subrogation refers to the process an insurance company uses to seek reimbursement from the responsible party for a claim it has already paid.

16. Definitions Arbitration: condition in the policy to refer the disputed matters related to claims to an independent body. Forfeiture: Any fraud and concealment by the insured render the contract null and void.

17. Basic Terms of Health Basic Terms of Health Insurance Insurance

18. Definitions  Basic cover: inpatient and outpatient cover  Inpatient ” - Hospital confinement requiring an overnight stay.

19. Benefits ” – the extent or degree of service Covered Persons are entitled to receive based on their contract with the Company. Benefits ” – the extent or degree of service Covered Persons are entitled to receive based on their contract with the Company. benefits benefitsbenefits

20. Definitions In-patient Benefits”- hospitalization or day treatment or observation / treatment in an emergency room / facility which cannot be carried out on out patient basis. Census: In group medical insurance census is used to identify the number of spouse, children and the insured.

21. Definitions "Confinement" and "Confined" an uninterrupted overnight stay following formal admission to a Hospital. “Day Treatment” – medical treatment which must be provided in the Hospital, but which does not require a Confinement.

22. DEFINITIONS "Accident ” – a sudden, unexpected, violent external event causing a severe physical bodily Injury, which is usually visually identifiable, and is documented by a competent authority such as a law enforcement officer or Physician. "Accident ” – a sudden, unexpected, violent external event causing a severe physical bodily Injury, which is usually visually identifiable, and is documented by a competent authority such as a law enforcement officer or Physician.

23. Definitions Sickness" ‑ physical illness or disease. The term "Sickness" does not include Mental Illness or substance abuse, regardless of the cause or origin of the Mental Illness or substance abuse Sickness" ‑ physical illness or disease. The term "Sickness" does not include Mental Illness or substance abuse, regardless of the cause or origin of the Mental Illness or substance abuse

24. Definitions  Injury ” – bodily damage other than Sickness including all related conditions and recurrent symptoms

25. Definitions Active at Work ” – an employee who is Active at Work ” – an employee who is (1) employed on a full-time basis by the Policyholder and is currently being paid a full-time salary, or (1) employed on a full-time basis by the Policyholder and is currently being paid a full-time salary, or (2) is on formal paid or unpaid leave from the Policyholder.

26. Definitions " Dependents" (1) the Primary Insured ’ s legal spouse or (2) an unmarried dependent child of the primary Insured or the primary Insured ’ s spouse (including a natural child, stepchild, a legally adopted child, or a child placed for adoption).

27. Definitions "Network" ‑ when used to describe a Provider of Health Services. NETWORKSNETWORKS Physician" ‑ any practitioner of medicine who is duly licensed and qualified under the laws of the country in which treatment is received.

28. Definitions “Pre-Hospitalization Form” – A form that must be completed by the attending Physician of the Covered Person and approved by the Company prior to hospitalization.

29. Definitions Prosthetic Device ” – An artificial device, either external or implanted, that substitutes for or supplements a missing or defective part of the body, e.g. artificial limbs and pacemakers. Prosthetic Device ” – An artificial device, either external or implanted, that substitutes for or supplements a missing or defective part of the body, e.g. artificial limbs and pacemakers.

30.  Repatriation" - In case an Insured member has passed away the Mortal Remains will be repatriated to country of origin.  Territory of Occurrence ” – The country where the claimed expenses are incurred.

31. Definitions  SOAP ” – A form which must be completed by the attending Physician in order for the Covered Person to obtain Coverage for outpatient Benefits.  Specific Exclusions ” – non-Covered services or Benefits which are specific to the Covered Person being insured.

32. Congenital cases ” – including Birth defects, Congenital diseases, anomalies &/or Deformities, which may or may not be evident at birth but can appear at a later age. Congenital cases ” – including Birth defects, Congenital diseases, anomalies &/or Deformities, which may or may not be evident at birth but can appear at a later age.

33.  Pre-existing condition: in group health insurance generally a immediately prior to condition for which an individual received medical care during the three months the effective date of coverage

34. Chronic conditions: Chronic disease simply means persistent or recurring disease, usually affecting a person for three months or longer. A chronic disease is generally one that is hereditary or one that is the result of factors such as poor diet and living conditions, using tobacco or other harmful substances, or a sedentary lifestyle The term chronic disease commonly applies to conditions that can be treated but not necessarily cured.

35. Reasonable and customary charges: Reasonable and customary charges: medical Expenses which conforms to the level of most of the physician and hospitals in the country. medical Expenses which conforms to the level of most of the physician and hospitals in the country. Free access: free access allows you treatment in any of the participating network provider network provider Free access: free access allows you treatment in any of the participating network provider network providernetwork providernetwork provider

36. Medical expenses: Means a) Medical, surgical, or specialist ’ s fee b) Hospital, Nursing home, nursing attendance, local ambulance charges ambulance charges c) Physiotherapy, massage and manipulative treatment cost. d) Cost of medicines or surgical or medical requisites

37. Definitions Hospitalization Class. Classes of hospitalization are defined below: Hospitalization Class. Classes of hospitalization are defined below: Class VIP : Standard Suite Class VIP : Standard Suite Class A :Private Room Class A :Private Room Class B :Semi-Private Class B :Semi-Private Class C :Shared Room Class C :Shared Room

38. Definitions Room category: Standard Suite, Private room, Semi Pvt. Room, Shared room Access card: A personalized card issued in the name of each Insured, facilitating his/her access to the Healthcare Service.

39. Definitions Direct billing: Free Access guaranteed at Network (National and International). Co-insurance ” – the percentage of Eligible Expenses in addition to the Premium, which Covered Persons are required to pay for certain Health Services provided under the Policy

40. Age limits: 65 years

41. Thanks Thanks