CARD T011
Claim
A claim is a request for benefits under an insurance policy.
How it works
A claimant reports the event and supplies information needed for the insurer to evaluate benefits. For health insurance, a provider often submits the claim; for life insurance, the beneficiary typically submits the death claim. Filing is not the same as approval. Missing information can require follow-up, and a denial should explain its basis and any available review process. [1] [3]
After a covered person dies, the named beneficiary sends a claim form and requested proof of death. Those documents ask the insurer to evaluate and pay death proceeds; sending them is not itself the payment.
Keep claim, coverage, and benefit separate: request, protection, and payment or service. Specific claim deadlines belong to the applicable policy and law.
CARD T012
Exclusion
An exclusion identifies a specified loss, condition, or service that a policy does not cover.
How it works
An exclusion differs from a deductible, which allocates part of a covered expense to the insured, and from a waiting period, which delays eligibility for a particular benefit. Read the exclusion’s exact wording and any exceptions or riders affecting it. Exclusions must also comply with applicable law; an example in one policy is not a rule for every product. [3]
Assume a policy validly excludes a particular elective service. Paying the deductible does not turn that excluded service into a covered one.
An excluded item is not simply a covered item with a larger out-of-pocket share.
CARD T013
Rider
A rider is an addition to a policy that changes its terms or benefits.
How it works
A rider can add protection, restrict protection, or otherwise modify a provision. Some riders cost extra, while others are included; the document determines what changes and any separate conditions. Read a rider alongside the base policy. Adding an accidental-death benefit, for example, does not mean every death qualifies for that extra payment. [5]
A life policy includes an accidental-death rider. A qualifying accidental death may trigger an additional payment, but the rider’s definition and exclusions still have to be satisfied.
Do not assume that every rider expands coverage or that every rider applies to every claim.
APPLY THE TERMS
Practice questions
Select an answer, then check it to see why each option is right or wrong.
T011 · Claim
0 of 3 answered
T012 · Exclusion
0 of 3 answered
T013 · Rider
0 of 3 answered
Sources & further reading
Original explanations and practice scenarios informed by the following regulator resources. State examples are not presented as nationwide deadlines or requirements.