Diccionario de Seguros Medicos y
Seguros de Vida


Informacion y  Cotizacion de Planes Medicos de la Reforma de Salud. Reciba ayuda de Agentes Oficiales de OBAMACARE

Tipo de Seguro:
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HMO O PPO    

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DICCIONARIO EN ESPANOL

Terminos y Conceptos de Seguros Medicos y Seguros de Vida.

 

Glosario de Terminos de Seguros  Medicos y Seguros de Vida 

 
A


AGENTE / AGENT                                                            
 Existen dos tipos de Agentes de Seguros Medicos

- El Agente independiente autorizado a vender y proveer servicios de todas las Companias contratadas.
- El Agente cautivo de una Compania de Seguros que se limita a ofrecer los productos de esta Compania.

Alergista
Médico especializado en afecciones alérgicas

Asegurado/ Insured
Persona que esta cubierta por un seguro medico.

Asistencia médica a Domicilio
Es el cuidado que le permite que una persona necesidades especiales pueda permanecer en su casa. Pueden ser personas mayores, pacientes que se recuperan de cirugías, personas discapacitadas o enfermos crónicos. Los servicios de atención médica a domicilio pueden ofrecer los siguientes beneficios:

-
Cuidados personales, como ayuda al bañarse, el lavado del cabello o vestirse
-
Tareas del hogar, como la limpieza y lavado de la ropa
-
Cocinar o Servicios de entregar comidas a su domicilio
-
Cuidado de la salud, como tener una persona que cuide de su salud en la comodidad de su casa

Anestesiología
Es la especialidad medica que se dedica a la atencion de pacientes primariamente durante intervenciones quirurgicas, aunque tambien se ocupa de aliviar el dolor de causas que no son quirurgicas,como para mujeres a la hora de un parto.

Apelación
Solicitud formal de un miembro o un proveedor de asistencia médica para que se reconsidere una decisión acerca de un servicio, el pago de un beneficio o una acción administrativa.

Asistencia Primaria
Asistencia médica básica o general, usualmente provista por los médicos de cabeceras , pediatras, los médicos de familia, los especialistas en medicina interna entre otros .

Audiología
Es la especialidad que se encarga de diagnosticar y prevenir los problemas auditivos en los seres humanos. Además de la rehabilitación de discapacidades auditivas, ya sea mediante la adaptación de audioprótesis, mediante terapias de rehabilitación (principalmente en casos de acúfenos) y, en colaboración con otras disciplinas, mediante los implantes cocleares


Agent 
A person licensed to sell insurance on behalf of an insurance company.


Accidental Death Benefit

An optional supplement to a life insurance policy that provides an extra payment if the insured’s death resulted from an accident.

Actual Cash Value
An amount equivalent to the fair market value of an item or property at the time of loss, less any allowance for depreciation.

Annuitization
To convert a deferred annuity contract’s account balance to income payments.

Atuary 
A mathematical and statistical expert who calculates risks, forecasts and other financial values for the insurance industry.

Automobile Liability Insurance
Protection for the insured against liability claims arising from their ownership or use of automobiles

Adjustable Rate 
An interest rate that varies based current market rates.

Adjuster
A person who investigates and settles insurance claims.

Admitted Assets
An insurance company’s assets that have met state law guidelines as being easily converted to cash.

Aggregate Limit 
The maximum dollar amount of all claims that will be paid during a policy’s contract period.

Annuity 
A contract where the buyer deposits money initially and later receives payments at regular intervals, usually for life.

Assets 
All of the property owned by a business or individual that has a present market value or worth


Annual limit: A yearly cap on the dollar amount or types of benefits. Above the cap, you pay the full cost of care for the rest of the year. The health reform law now prohibits most employer and individual plans from imposing a yearly cap below $750,000. The cap will rise to $1.25 million as of September 23 of this year. 
 

B


Benefit Period 
The amount of time on a contract that insurance coverage is effective and benefits will be paid.

Broker 
An insurance salesperson that searches the marketplace, in the interest of clients, to find the best policy.

Broker–Agent 
An insurance salesperson who acts both as an agent representing insurance companies and as a broker working in the best interests of clients.

C

Cardiologia
La medicina que se ocupa de las afecciones del corazón y del aparato circulatorio.

Cirugía oral o Maxilofacial
Diagnóstico y tratamiento de los trastornos de la boca, los dientes, los maxilares y las estructuras faciales, incluyendo la corrección quirúrgica de las deformidades y fracturas faciales.

Catastrophic coverage: Pays for care above a high deductible (below), generally several thousand dollars or more. Most services below the deductible are not covered, but the law requires policies issued after September 23, 2010, to pay for certain preventive services, such as immunizations and screening for high blood pressure and depression.

Coinsurance: How much you have to pay for care after meeting your deductible (below). A plan may pay 75 or 80 percent of the bill for services. The remainder is your coinsurance.

How much you have to pay for care after meeting your deductible (below). A plan may pay 75 or 80 percent of the bill for services. The remainder is your coinsurance.

Copay: A set fee you pay each time you receive care—$25 whenever you visit the doctor, for example. Your plan pays the rest.

A set fee you pay each time you receive care—$25 whenever you visit the doctor, for example. Your plan pays the rest.

 

Cirugía Oral
La odontología se ocupa de la cirugía de la boca y sus estructuras relacionadas.

Cirugía Ortopédica
Rama de la medicina que incluye el tratamiento quirúrgico de las deformidades y lesiones del esqueleto.

Cirugía Plastica
Procedimientos reconstructivos, que incluyen la recuperación de la forma, y en muchos casos de la función, de las partes del cuerpo que son anormales debido a una lesión, una enfermedad o a defectos congénitos, y los procedimientos cosméticos, que se realizan para mejorar la apariencia de las partes del cuerpo que están dentro del rango normal de apariencia y funcionamiento.

Copago / Copayment
Pago, generalmente de un monto fijo, que usted realiza por sus servicios.

Coaseguro / Coinsurance
El porcentaje de costos de asistencia médica que un miembro es renposable de pagar.

Costos Elegibles
Servicios cubiertos por un Seguro Medico segun lo estipulado con el contrato del plan de salud.

Condición Pre-Existente
Esta es una condición sobre la cual, la persona asegurada ha recibido tratamiento o ha demostrado síntomas claros de una enfermedad antes de obtener un Seguro Medico.

Costos de los Asegurados
Parte de los pagos de asistencia médica por los que un asegurado es responsable. Incluye copagos, coaseguro, deducibles y servicios no cubiertos por su seguro medico.

Commission
A percentage of the policy premium paid to an agent or insurance salesperson as compensation for services.

Capital
Equity of shareholders for a publicly traded insurance company.

Casualty
A liability or loss resulting from an accident.

Commercial Lines
Property and liability policies written specifically for businesses.

Casualty Insurance 
Insurance that is primarily concerned with legal liability for personal injuries or damage to the property of others.

Claim 
Contact made to an insurance company alerting them that payment of the benefit is due under the policy’s contract terms.

Coinsurance
Where the insured shares in the cost of covered services on a percentage basis.

Collision Insurance
Optional coverage that pays for damages due to the insured’s car striking another object.

Comprehensive Insurance 
An optional auto insurance coverage that covers damage to the policyholder’s car caused by fire, theft, vandalism, falling objects and other dangers.

Copayment 
Part of a cost–sharing policy where the insured pays a set amount before receiving a specified service.

Cost–of–Living Adjustment 
An annual adjustment in wages that corresponds with a change in the cost of living.

Coverage
 The total amount of protection provided under an insurance contract.

Coverage Area
The geographic area where an insured is protected under their policy.


D


Deducibles / Deductibles
Cantidad de dinero que es responsable el asegurado antes que el Seguro empieze a cubrir.

Dermatología
Diagnóstico y tratamiento de las enfermedades de la piel.

Death Benefit 
The payment made to a beneficiary upon the death of an insured person.

Deductible
The amount which a policyholder agrees to pay toward the total amount of an insured loss. How much you have to pay out of pocket before coverage kicks in.

Dividend 
A return of part of the annual premium to the policyholder based on the insurance company’s earnings.

Doughnut hole: A coverage gap in Medicare Part D, the federal prescription drug program for adults age 65 and older. The program pays 75 percent of drug costs up to the doughnut hole—the point at which the total paid by the enrollee and the program reaches $2,800. The enrollee must pay the next $1,750 out of pocket before program coverage resumes. As of 2011, the cost of brand-name drugs for enrollees in the doughnut hole are discounted by 50 percent.

A coverage gap in Medicare Part D, the federal prescription drug program for adults age 65 and older. The program pays 75 percent of drug costs up to the doughnut hole—the point at which the total paid by the enrollee and the program reaches $2,800. The enrollee must pay the next $1,750 out of pocket before program coverage resumes. As of 2011, the cost of brand-name drugs for enrollees in the doughnut hole are discounted by 50 percent.

 

E



Elegibilidad
Son los requisitos que debe cumplir una persona para estar cubierta por el contrato del plan de salud.

Endocrinología
Especialidad Medica que trata las glándulas endocrinas, las cuales producen secreciones que ayudan a controlar la actividad metabólica.

Enfermedades Preexistentes / Preexisting Conditions
Afección, lesión o enfermedad considerada como una afección que requiere tratamiento médico, que existía antes de la fecha de entrada en vigencia del contrato del plan de salud. Si la enfermedad es preexistente, puede no estar cubierta por un período de tiempo específico según algunos contratos. El periodo de espera par la cobertura de una enfermedad pre existente es de dos Anos.

Emergencias
Problemas medicos que requieren de atencion medica inmediata y en la mayoria de los casos Hospitalizacion

Equipamiento médico no desechable
Equipamiento médico que puede tener uso repetido y que se utiliza principalmente para fines médicos. Algunos de ellos son las sillas de ruedas, las muletas y las camas. No es el equipamiento que sería útil a una persona que no esté enferma o que podría de otra forma ser útil en el hogar del paciente.

Especialista
Médico Especializado es aquel que se encarga de los problemas en los órganos internos, basado casi por completo en tratamientos no quirúrgicos.

Explicación de los Servicios y beneficios
Notificación enviada por el plan de salud al miembro, en la que se describe la resolución de una aplicacion. Incluye los servicios brindados, el monto facturado, el pago realizado y cualquier costo que sea responsabilidad del miembro.


Earned Premium 
The portion of an insurance premium that falls under the expired part of the policy period.

Elimination Period
The amount of time a policyholder must be insured before he or she is eligible to receive benefits.

Employers Liability Insurance 
Coverage that protects against liability that may be imposed on an employer outside the constraints of a workers’ compensation law.

Exclusions 
Specified conditions or risks that a policy does not cover.

Expense Ratio 
The calculation of an insurance company’s operating expenses to premiums.
 

Exclusions: Conditions and treatments and other services that a health plan or policy will not cover. They must be clearly spelled out in the plan's literature

 Exposure 
The possibility of risk or loss that an insurance company accepts from its policyholder in exchange for the premium.

Extended Replacement Cost 
Pays an additional amount beyond the policy limit to replace a damaged home.


F



Fisiatría
Diagnóstico, tratamiento y prevención de la enfermedad . La fisiatría se concentra en la medicina de rehabilitación.

Fisioterapia
Son tratamientos de los malestares corporales y las funciones musculares a través de varios medios físicos y sin medicamentos.

Fuera de la red / Outside the Network
La libertad que ofrecen algunos Seguros Medicos de consultar a Doctores que no tienen un contrato con el Seguro de salud. Cuando los planes de beneficio incluyen esta opción, los miembros comparten una mayor parte de los costos cuando reciben asistencia de los proveedores que están fuera de la red. Normalmente esta opcion la ofrecen los Seguros PPO.

Formulary: A list of the medications a policy or health plan will cover entirely or in part.

A list of the medications a policy or health plan will cover entirely or in part.

Floater
An insurance policy that covers moveable property under the terms and provisions of a policy covering property at a fixed location, such as a homeowner’s policy.
 

Fee for service: Coverage that offers total freedom in choosing healthcare providers. Generally, you or your doctor will submit a claim for services provided and get reimbursed by the insurer.

Flexible spending arrangements: Accounts set up by employees to tap during the year to pay qualified medical expenses. They reduce taxes because the funds are subtracted from earnings before they are taxed. Anything left over at the end of the year is forfeited.

Accounts set up by employees to tap during the year to pay qualified medical expenses. They reduce taxes because the funds are subtracted from earnings before they are taxed. Anything left over at the end of the year is forfeited.

Formulary: A list of the medications a policy or health plan will cover entirely or in part.

 


G



Gastroenterología
Diagnóstico y tratamiento de las enfermedades del estómago, el intestino, el hígado y el páncreas.

Ginecología
Especialidad médica y quirúrgica que trata las enfermedades del sistema reproductor femenino, utero, ovarios, y la vagina.

General Account
An undivided account in which insurers maintain funds that support contractual obligations for guaranteed products and annuities.

General Liability Insurance 
Coverage protecting businesses from most liability risks other than automobile and professional liability.

Grace Period 
Period of time after the due date of a premium during which the policy remains active without penalty.

Guaranteed Renewable 
A policy that the insurer is required to renew until the policyholder reaches a certain age, as long as premiums are paid on time.

Grandfathered plan: Any plan that existed on or before March 23, 2010, when health reform became law. Such policies are exempt from some of its provisions.

Group Health Insurance: Coverage available through employers or "affinity groups" such as a union or student organization.



H
 

 

Hospicio
Brinda asistencia de apoyo para las personas que padecen una enfermedad terminal.

 Hazard
Something that affects the likelihood of a loss occurring.

HMO
Prepaid insurance plans that provide comprehensive health care to its members.

Health Savings Account
Tax–free savings account used solely for health care expenditures.

Hurricane Deductible 
An amount added to a homeowner’s insurance policy to limit an insurer’s loss from hurricane damages.

Health maintenance organization: A form of managed care in which you receive all of your care from participating providers. You usually must obtain a referral from your primary-care physician before you can see a specialist.

A form of managed care in which you receive all of your care from participating providers. You usually must obtain a referral from your primary-care physician before you can see a specialist.

Health reimbursement arrangement: Accounts set up by employers to pay employees' medical expenses. Only the employer can contribute to the account.

Accounts set up by employers to pay employees' medical expenses. Only the employer can contribute to the account.

Health savings account: A special account established by an employer or an individual to save money toward medical expenses. As with flexible spending arrangements, they reduce taxes because the funds are subtracted from earnings before they are taxed. A key difference is that any remaining balance at the end of the year rolls over to the next year.

A special account established by an employer or an individual to save money toward medical expenses. As with flexible spending arrangements, they reduce taxes because the funds are subtracted from earnings before they are taxed. A key difference is that any remaining balance at the end of the year rolls over to the next year.

High-deductible plan: A health plan that provides comprehensive coverage only for costly care such as expensive surgery. It features a high deductible and an annual limit on the total amount paid out by a covered individual or family. Such a plan is usually coupled with a health savings account or a health spending account.

A health plan that provides comprehensive coverage only for costly care such as expensive surgery. It features a high deductible and an annual limit on the total amount paid out by a covered individual or family. Such a plan is usually coupled with a health savings account or a health spending account.

High-risk pool: A state-run program that offers coverage for those who cannot get health insurance from another source because of serious illness

  

I


Inmunología
Estudio de la inmunidad y las respuestas inmunológicas.

Inscripción abierta / Open Enrollment
Plazo de tiempo en el que un empleado puede cambiar su estado de inscripción o plan de beneficios, generalmente sin evidencia de buena salud o períodos de espera.

Indemnity 
The principle by which a policyholder is restored to the same financial position that they were in immediately prior to a loss.

Inflation Protection 
The clause in an insurance policy that increases benefit levels to account for anticipated increases in the cost of covered services.

Insurance Adjuster 
An individual who settles claims brought by policyholders on behalf of an insurance company.

Investment Income 
The money an insurance company received in premiums but has not yet paid out on claims.

Individual health insurance: Coverage purchased by an individual, usually directly from an Insurance Company

Coverage purchased by an individual, usually directly from an Insurance Company

Lifetime limit: Formerly a cap on the total amount paid out by the health insurer over the entire time you are enrolled. Above the cap, you pay the full cost of care. Lifetime limits on most benefits are now prohibited under health reform.

Formerly a cap on the total amount paid out by the health insurer over the entire time you are enrolled. Above the cap, you pay the full cost of care. Lifetime limits on most benefits are now prohibited under health reform. 



 L


Liability 
A legally enforceable obligation.

Liability Insurance 
Coverage designed to protect the policyholder from financial loss due to liability resulting from bodily injuries or property damage.

Licensed
  An agent or insurer who has completed certification in order to operate and conduct business in the insurance industry.

Living Benefits 
Allows terminally ill policyholders to collect part of their life insurance benefits before death to pay for medical expenses.

Loss Ratio 
The percentage of premiums an insurer spends on claims.

Losses Incurred
 The total losses incurred by an insurance company during a particular time period.



M



Máximo en efectivo / Maximo fuera de Bolsillo / Maximun Out of Pocket
Es el máximo que debe pagar un asegurado anualmente por costos de asistencia médica permitidos. Una vez que se llega al máximo de gastos fuera de Bolsillo, el plan de salud paga el 100 por ciento hasta el final del año calendario o del beneficio.

Medicina Familiar / Medicos de Cabeceras
Especialidad médica que se concentra en la asistencia médica de toda la familia, incluyendo la asistencia de obstetricia y los procedimientos quirúrgicos menores.

Medicina Interna
Especialidad médica que se concentra en la prevención, el diagnóstico y el tratamiento de las enfermedades que afectan a los adultos.

Médico
Doctor autorizado con una capacitación completa en práctica médica tradicional. Los médicos son sometidos a una educación médica con una amplia base, a una vasta experiencia en la residencia y a una serie completa de exámenes ante tribunales médicos previo a obtener la autorización.

Médico Generalista
M
édico que no limita su campo de práctica a una especialidad.

Miembro
Persona asegurada por un Seguro Medico.

Monto Permitido
El pago en dólares que un plan de salud determina que es adecuado para un servicio cubierto.



N

Named Perils 
The specific hazards a policy protects you against.

Net Income
The income that a company has after subtracting costs and expenses from the total revenue.

Net Premium
The total policy premium minus commissions and expenses.

Noncancellable 
A policy that guarantees you can receive coverage as long as you make timely premium payments.

Nonstandard Auto (High Risk Auto or Substandard Auto) –
Coverage for drivers who are unable to purchase standard coverage because of a variety of factors including lack of experience, poor driving record, etc.

O


Occurrence –
An accident or exposure to conditions resulting in bodily injury or property damage which occurs during a policy’s term period.

Other Income/Expenses 
Represents income and expenses other than normal business operations.

Out–of–Pocket Limit
The maximum amount an insured will be required to pay for covered services during a specified time period.


P



 

Pediatría
Doctores especializados en prevención, diagnóstico y tratamiento de las enfermedades de los niños desde el nacimiento hasta la adolescencia.

Plan complementario Medicare
Por que Medicare solo paga el 80% de sus gastos Medicos hay Companias que ofrecen Cobertura complementaria, disponible para las personas elegibles para Medicare, para ayudar a pagar los saldos restantes después de que Medicare haya realizado el pago.

Plan de punto de servicio / Point of Service
Tipo de plan de beneficio que permite que el miembro elija los servicios de salud de un proveedor de asistencia primaria que está dentro de la red o de un proveedor de asistencia médica que está fuera de la red al momento en que necesita la asistencia, con diferentes niveles de beneficios.

Planes de acceso libre / Open Access
Planes que ofrecen algunas Companias que permiten a los asegurados visitar a los especialistas de la red para recibir asistencia sin necesidad de referido de otro médico.

Podiatría
Diagnóstico y tratamiento de las enfermedades de los pies.

Protética
Estudio de las extremidades artificiales, su diseño, construcción y colocación en un paciente.

Proveedor
Cualquier individuo o grupo que proporciona un servicio de asistencia médica, tales como los médicos, los hospitales, las agrupaciones de médicos, los hogares para ancianos o las farmacias.

Proveedor de asistencia médica
Hospital, clínica, médico u otra institución que provee servicios de asistencia médica.

Radiología
Especialidad Medica que se ocupa del uso de los rayos X y del radio en el diagnóstico y tratamiento de enfermedades.

Red / Network
Hospitales, médicos y otros profesionales médicos que firman un contrato con un plan de salud para proporcionar asistencia a sus miembros. También denominados proveedores participantes o pertenecientes a la red.

 

Referidos / Referrals
Es la aprobación previa de un doctor primario para que un paciente consulte a un especialista.

Pre–Existing Condition
A physical or mental condition which existed prior to the effective date of an insurance policy

Policy 
A written document that outlines the terms and conditions of the insurance coverage.

Peril 
The cause of a possible loss that an insurance policy covers against.

Personal Injury Protection 
Automobile insurance coverage that typically requires insurance companies to provide first–party coverage without regard to fault.

Personal Lines
Insurance policies that are written specifically for individuals and their property.

Preferred Auto
Coverage offered to drivers who have a clean driving record.

PPO
A network of healthcare providers who give medical care to enrolled persons at a discounted rate.

Premium 
The payment or one of the regular payments made to an insurance company in exchange for protection from risk, as specified on the insurance policy.

Profit 
Gross income minus expenses.



Q


Qualifying Event 
An occurrence that begins the protection for a policyholder.

R

Reinsurance 
Protection that an insurer purchases from another insurance company on a large–risk policy.

Renewal 
Continuing an insurance contract beyond its original term by the insurer’s acceptance of the premium for a new policy term.

Replacement Cost 
The amount needed to replace damaged property without cost to the insured for depreciation.

Risk Management
Controlling the various risks that a company may be subject to.

S


Salud Mental / Dependendencia de Sustancias Quimicas/ Mental Health
La práctica de evaluar y tratar la salud mental, los trastornos por dependencia química, el autismo y otros desórdenes.

Seguro Medigap
Pólizas de seguro privadas que complementan Medicare y cubren la diferencia entre lo que paga Medicare y los costos permitidos para servicios cubiertos y no cubiertos.

 

Servicios de diagnóstico
Servicios de rayos X, laboratorio y patología que ayudan a diagnosticar o tratar una enfermedad o una lesión.

 

Solicitud
Información suministrada por un proveedor de asistencia médica o un miembro para establecer que se han prestado servicios médicos. Los proveedores de la red Blue Cross presentan las solicitudes para sus pacientes.

Solvency 
The ability of an insurance company to pay the claims of its policyholders.

Standard Auto 
Insurance for average drivers with relatively few accidents on their record.

State of Domicile 
The state where an individual or business is permanently residing or doing business.

Stop Loss
The dollar amount on claims when the insurance company begins to pay at 100% per insured individual.

Subrogation
 Gives the insurer full rights to recover damages against the person responsible for the loss.

 

T

 

 
Terapia Ocupacional
Esta parte de la medicina incluye programas de actividades para ayudar a los pacientes a recuperar un grado de independencia o a regresar al trabajo.

Term Life Insurance 
Provides coverage for a specified period of time.

Tort
A wrong or injury caused by one person to another, resulting in legal liability.

Total Loss 
A claim for the maximum amount covered by the insurance policy.

 

U



Urgencia
Cualquier problema medico que no requiera de una Hospitalizacion

Umbrella Policy
Provides for coverage of losses beyond the limit of a regular insurance policy.

Underwriter 
An individual working for an insurance company who determines whether or not that company should accept the risk for a particular policy.

Underwriting 
 The process by which an insurer determines whether or not it will accept the risk for a specific insurance policy.

Unearned Premium
 The portion of an insurance premium that falls under the unexpired part of the policy period.

Uninsured Motorist Coverage
 Insurance that covers a policyholder’s collision with a driver who does not have liability insurance.

Universal Life Insurance 
A flexible policy where excess premiums are invested in interest–yielding accounts.



V



Valuation

The process of estimating the value of an existing insurance policy.

Variable Life Insurance 
A flexible type of coverage whose value depends on how well the investments chosen are performing.

Viator 
The owner of a life insurance policy who sells it to a third party and receives a lump sum cash payment in return.



W


Whole Life Insurance 
A policy that has been kept active with the required payments and which pays a lump sum upon the insured’s death.

Waiting Period 
The number of days that must pass before a policyholder’s benefits start.

Waiver of Premium 
A provision in an insurance policy that waives the collection of premiums should the policyholder become unable to work due to an accident or injury.

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