Health

ERISA
See Employee Retirement Income Security Act.

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
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.

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.

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.

Entire Contract Clause
A provision in an insurance contract stating that the entire agreement between the insured and the insurer is contained in the contract, including the application if it is attached, declarations, insuring agreements, exclusions, conditions and endorsements.

Evidence of Coverage
See Certificate of Coverage.

Evidence of Insurability
The statement of information needed for the underwriting of an insurance policy.

Examination
The medical examination of an applicant for Life or Health insurance.

Examined Business
Coverage written on an applicant who has been examined and who has signed the application but has paid no premium.

Examiner
A physician appointed by the medical director of a Life or Health insurer to examine applicants.

Excepted Period
See Probationary Period.

Excluded Period
See Probationary Period.

Exclusive Provider Organization (EPO)
A type of preferred provider organization where individual members use particular preferred providers rather than having a choice of a variety of preferred providers. EPOs are characterized by a primary physician who monitors care and makes referrals to a network of providers.

Expected Claims
The estimated claims for a person or group for a contract year based usually on actuarial statistics.

Expected Morbidity
The expected incidence of sickness or injury within a given group during a given period of time as shown on a morbidity table.

Expense
A policy's share of the company's operating costs, fees for medical examinations and inspection reports, underwriting, printing costs, commissions, advertising, agency expenses, premium taxes, salaries, rent, etc. Such costs are important in determining dividends and premium rates.

Experimental or Unproven Procedures
Any health care services, supplies, procedures, therapies, or devices that the health plan determines regarding coverage for a particular case to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.

Explanation of Benefits (EOB)
The statement sent to a participant in a health plan listing services, amounts paid by the plan, and total amount billed to the patient.

Explanation of Medicare Benefits
A notice which is sent to the Medicare patient which provides information designed to explain how the claim is to be paid.

Extended Care Facility
A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care may be provided--skilled, intermediate, custodial, or any combination.

Extended Coverage
A provision in certain Health policies, usually Group, to allow the insured to receive benefits for specified losses sustained after the termination of coverage, such a maternity expense benefits incurred for a pregnancy in progress at the time of the termination.

Extension of Benefits
A condition in the insurance policy which allows coverage to continue beyond the expiration date of the policy in the case of employees who are not actively at work or dependents who are hospitalized on that date. The extended coverage applies only where the employee or dependent is disabled as of that date and continues only until the employee returns to work or the dependent leaves the hospital.