Insurance coverage that becomes effective when an employer who has self-insurance has its total group medical insurance claims reach a specific threshold chosen by the employer. This threshold is a percentage of its yearly predicted group health claim costs.
Insurance Encyclopedia
Aggregated Diagnosis Groups (ADGs)
Under a system developed by Johns Hopkins University called adjusted clinical groups (ACGs) , ACGs are a comprehensive family of measurement tools designed to help explain and predict how health care resources are delivered and consumed. ACGs are based on building blocks called aggregated diagnosis groups (ADGs). ADGs are a grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence of the health condition over time. There are two categories of ADGs, ambulatory diagnostic groups–major diagnostic category (ADG-MDC) and ambulatory diagnostic groups–hospital dominant (ADG-HosDom).
Aggregation clause
See: Claims Series Clause.
Aging accounts receivable (A/R) report
Document used to determine outstanding balances from each patient’s account showing status of 30, 60, 90, or 120 days from the date of insurance claim submission. It can be generated by using the date an insurance claim was filed to assess the age of the claim in days. Sometimes referred to as an aging report.
Aging report
1. Document that reports the status of insurance claims to the provider of the medical services and identifies individual transactions that need to be followed up (e.g., appeal or resubmit a corrected a claim). 2. See aging accounts receivable (A/R) report.
Agony of the moment / the principle of alternative danger
Where the defendant pleads contributory negligence, the claimant’s contribution to the accident may be excused if he acted ‘in the agony of the moment’. In Jones v. Boyce (1816) the claimant, fearing that a fast-driven coach would overturn, broke his leg when jumping for safety. The coach did not overturn but his action was justified. The principle of ‘alternative danger’ applies to emergencies generally and may apply even when property is under threat.
Agreed Amount
An agreed amount endorsement waives the coinsurance clause on the insured property. Thus, there is no coinsurance penalty at the time of the claim. While there is no allowance for depreciation, there is also usually no allowance forappreciation. This endorsement is often used for property that cannot be replaced with like kind and quality. For example, very old homes or historical buildings are often insured under an agreed amount. This is also known as a “valued policy.” (See Valued Policy).
Agreed amount clause
An agreement between underwriter and insured whereby, in exchange for the purchase of coverage in an amount specified by the underwriter, the insured is protected from a coinsurance penalty.
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A clause that stipulates that the amount of insurance will automatically meet the coinsurance clause.
Agreed Amount Endorsement
Property Policy provision under which the insured and the Insurer agree that the amount of Insurance specified in an endorsement will automatically satisfy the co-Insurance clause. An agreed amount endorsement eliminates the necessity of determining whether the Insurance carried is at least equal to the stated percentage of the value indicated in the co-Insurance clause. Refer “Co-Insurance.”
Agreed Bank Clause (Agreed Mortgagee Clause)
A provision in the Insurance contract under which the Insurer obligates itself to pay the mortgagee even if the owner breaches some contract condition so long as the breaches was not within the control or knowledge of the mortgagee. Also refer “mortgagee Clause.”