A policy provision that eliminates cover in regard to specified property, persons, perils, forms of damage or particular circumstances. The excluded risks may be uninsurable, require special consideration or readily be ‘bought back’ if required. The exclusions may be general, i.e. across all sections of the policy, or section-specific. The insurer must prove that an exception applies unless the exclusion comes in the form of qualifying words in the operative clause. See QUALIFIED PERILS.
Insurance Encyclopedia
Exclusions
Specific conditions or circumstances listed in the policy for which the policy will not provide benefit payments.
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Specific situations, conditions or circumstances that are listed in the contract as being not covered.
Exclusive agency system
A system of insurance sales, in which agents only provide business to one company or give the right of first refusal to a certain company.
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Method of marketing Insurance through agencies which operate as independent business, but which represent only one Insurer.
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See: Captive agent.
Exclusive agent
Insurance agent who works for one insurance company and is not permitted to sell products of other companies. He or she may be salaried or work on a commission basis. Also known as captive agent .
exclusive provider organization (EPO)
Type of managed health care plan that combines features of HMOs and PPOs. It is referred to as exclusive because it is offered to large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws. Such plans are for large clinics to participate in and combine fee-for-service PPO and HMO benefits.
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A plan that requires some or all services to be provided by a very limited number of medical care providers. It is similar to but more restrictive in its provider network than the HMO.
Exclusive provider organization (Health Insurance)
A kind of preferred provider organization in which the insured has a primary care doctor who refers him or her to other providers, instead of the insured having a variety of preferred providers to choose from.
Exclusive Remedy Doctrine
Doctrine in workers compensation insurance which states that workers compensation benefits should be the exclusive or sole source of recovery for workers who have a job related accident or disease; doctrine has been eroded by legal decisions.
Exclusive territory
Under the general agency distribution system, a region in which no person other than the general agent is allowed to sell the insurance company’s products.
Exclusivity
1. Sole right to render a service or benefit. The provider or group may provide certain services and does not have to share the right with other providers or groups. 2. Clause sometimes found in managed care contracts that prohibits contracting with other plans.
Exclusivity clause
Section in a contract that forbids physicians from contracting with more than one managed care plan (e.g., health maintenance organization, preferred provider organization).