An exclusion in English v. Western (1940) 2 All ER 515 was construed by the Court of Appeal as meaning any member of a household of which the insured is head’. The exclusion did not apply when a sister sued her brother for injuries. They were members of the same household but the brother was not its head. The Court applied the contra proferentem rule.
Tag: RAW
Any one accident/event/cause/occurrence
The definition of the conditions under which a reinsurer or insurer becomes liable for a loss or multiple related losses under an excess of loss treaty or underlying policy. Most definitions provide for the aggregation of individual losses arising from the same event or originating cause to be treated as a single claim so that the (re)insured bears only one deductible. Where weatherrelated losses persist over a period the hours clause defines the loss occurrence. Latent disease liability claims may produce multiple claims over a period due to continued exposure of workers to the same harmful working conditions. Insurers may seek (perhaps with difficulty) to define the continuing working conditions as the single event or originating cause. See CLAIMS SERIES CLAUSE.
Any one occurrence
See: Any One Accident/Event, etc.
Any willing provider (AWP) laws
Multiple state laws that establish policies for managed care agreements that require a provider network must enroll any provider who meets the network’s plan provisions.
AOE/COE
See: arise out of employment and in the course of employment (AOE/COE).
AP
1. See anteroposterior (AP). 2. HCPCS Level II modifier that may be used with CPT or HCPCS Level II codes indicating there was no determination of refractive state during an eye examination. Use of this modifier does not affect payment.
APF Exemptions
See: Authorised Professional Firm Exemptions.
Apparent authority
The perceived ability of an agent to bind an insurance contract to an insurance company. If an agent or agency holds themselves out as representing a particular company it is reasonable for the public to assume that such authority is established contractually, even if it is not.
Appeal
1. Request for a review of an insurance claim that has been underpaid or denied by an insurance company to receive additional payment. Such requests are made to the health plan by the patient who is represented by the physician or provider who submitted the original insurance claim. Appeals to self-insured plans are submitted to the employer or U.S. Department of Labor. In some cases, an appeal may be submitted to the Department of Insurance of the state where the plan is located. 2. Redetermination process whereby the provider and/or beneficiary (or representative) exercises the right to request a review of a contractor’s decision to deny Medicare coverage or payment for a service in full or in part. Also called postservice appeals. See also preservice appeal and expedited appeal.
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The right of a party who has received an adverse decision to take the case to a higher court for review.
Appeal process
In the Medicare program, a course of action used by a patient (beneficiary) if he or she disagrees with any decision about the health care services received. Now referred to as redetermination process.