CHAPTER 10 : LEGAL ASPECTS OF GROUP INSURANCE UNDERWRITING

 PART 3: UNDERWRITING GROUP LIFE AND HEALTH INSURANCE 

(LIFE AND HEALTH INSURANCE UNDERWRITING 2ND EDITION)

CHAPTER 10 : 

LEGAL ASPECTS OF GROUP INSURANCE UNDERWRITING 

In reviewing applications for group insurance, the underwriter's goal is to approve applications of groups that meet certain conditions, but without investigating (except in rare case ) the insurability of the individuals who comprise the group. (dalam meninjau kembali pengajuan untuk group insurance, tujuan underwriter adalah untuk menyetujui pengajuan-pengajuan group sesuai dengan kondisi tertentu, tetapi tanpa investigasi insurability individu-individu yang membentuk group (kecuali dalam kasus yang langka) 

Because the group underwriter focuses on characteristics of the group rather than on the individual members of the group, people who otherwise would be uninsurable risks often are able to obtain coverage under a group insurance contract. (karena group underwriter fokus pada karakteristik group dari pada individual member dari group, individu yang seharusnya uninsurable risk seringkali memperoleh coverage dibawah group insurance contract)

In this chapter, we describe the legal and regulatory compliance issue that affect the underwriting of group life and health insurance. (dalam chapter ini, akan dijelaskan permasalahan masalah legal dan regulatory complience yang mempengaruhi underwriting group life dan health insurance)

Although many types of group coverage exist, we focus on group life insurance, group medical expense insurance and group disability income insurance. (meskipun ada banyak jenis coverage untuk group, chapter ini lebih difokuskan untuk group asuransi jiwa, group asuransi biaya pengobatan dan group asuransi kehilangan pendapatan akibat cacat) 

THE GROUP INSURANCE CONTRACT

Much of the life and health insurance in force the US and Canada is provided under group insurance contracts, which insure a number of people under one contract, called a master group insurance contract. (sebagian besar life and and health insurance yang berlaku di  US dan Canada berada dibawah group insurance contract, yang mengasuransikan sejumlah orang dalam satu kontrak dan disebut master group insurance)

The parties to a master group or organization are the insurance company and the group policyholder, which is the person or organization that: (para pihak dalam master group or organization terdiri dari insurance company dan group policyholder yaitu orang atau organisasi yang:

1. decide what types of group insurance coverage to purchase for the group members (memutuskan jenis group insurance coverage yang dibeli untuk group members)
2. negotiates the terms of the group insurance contract with the insurer, and (menegosiasi terms group insurance contract dengan insurer)
3. enters into the group insurance contract with the insurer  (mempertemukan group insurance contract dengan insurer)

In the US and Canada, the group policyholder is likely to be an employer that purchases the group insurance for the benefit of tis employees. (di US dan Canada, group policyholder  adalah pemberi kerja yang membeli insurance untuk benefit pekerjanya ) 

We use the terms group prospect or proposed group to refer to a group that has applied for, but has not yet been approved for,  group coverage from an insurance company (kita menggunakan terms group prospect or proposed group untuk menunjukkan group yang mengajukan jaminan dari perusahaan asuransi, tetapi belum disetujui)

We refer to the individuals covered by a group insurance policy as the group insured. (mengacu pada individu-individu yang dijamin oleh group insurance policy sebagai group insured)

Often, individuals who are members of an insured group and their spouses and dependent children are eligible for coverage under a group insurance contract.

We use the terms group member or covered employee to refer to an individual who a member of the insured group and to distinguish such individuals from those people who are insured as spouses or dependent children.

We refer to coverage on spouses and dependent children of insured group members as dependent coverage.

Group insureds are not parties to a master group insurance contract, do not participate in the formation of the contract, and do not receive individual copies of the master group insurance contract. (group insured bukanlah pihak dalam master group insurance contract, tidak berpartispasi dalam pembentukan kontrak, dan tidak menerima salinan kontrak asuransi)

Insurance laws typically require the insurer to provide the group policyholder then delivers a copy of the written description to each group member. (insurance law biasanya mewajibkan insurer memberikan group policyholder kemudian mengirimkan salinannya kepada setiap group member)

The document knows as the certificate of insurance, describes: (Document yang dikenal dengan certificate of insurance, menjelaskan:

1. the coverage that the group insurance contract provides and (coverage yang diberikan oleh group insurance contract)
2. the group insured's rights under the contract (hak-hak group insured dibawah contract)

NEGOTIATION OF THE CONTRACT 

Typically, the terms of a group insurance contract are subject to much more negotiation than the terms of an individual insurance contract.  (biasanya , terms of a group insurance contract lebih banyak tunduk pada negosiasi daripada terms of an individual contract)

Whereas individual insurance contracts are standardized documents that the policyowner must purchase as written by the insurer, group contracts often are tailored to the needs of the group prospect. (sedangkan individual insurance contracts adalah dokumen standar yang harus dimiliki oleh policyholder seperti yang ditulis oleh perusahaan asuansi dan group contract seringkali disesuaikan dengan kebutuhan dari group prospect)

Like individual insurance underwriting, group insurance underwriting begins in the field. (seperti individual insurance underwriting, group insurance underwriting dimulai dari field/lapangan)

Insurance producers sometimes solicit the sale of group life and health insurance products. (insurance producers kadang meminta penjualan produk group life and health insurance)

Group insurance also is marketed by group representatives, who are salaried insurance company employees specially trained in marketing and servicing group insurance products and who deal solely with the distribution of group insurance products. (group insurance juga dipasarkan oleh group representatives, pegawai perusahaan asuransi yang digaji khususnya dilatih marketing dan melayani group insurance product dan menangani distribusi group insurance products)

Producers and group representatives are responsible for: (producer dan group representative bertanggung jawab untuk)

1. finding group prospects (mencari group prospect)
2. designing requests for proposals and submitting applications to insurers, and (mendesign proposal dan mengirim permohonan kepada insurer
3. installing the group plan (menetapkan rencana group)

Group plan installation includes all the activities that occur from the time a prospect decides to purchase a group insurance policy to the time the coverage is explained to the group members and the master contract and individual certificated are issued. (grup plan installation meliputi semua aktivitas yang terjadi mulai saat suatu prospek memutuskan untuk membeli polis asuransi sampai dengan jaminan dijelaskan kepada anggota serta penerbitan master contract dan individual certificate)

FORMATION OF THE CONTRACT

A create a valid insurance contract the parties to the contract must

• Mutually (saling) agree to the contract's terms
• Both have contractual capacity
• Exchange legally adequate consideration 
• Form the contract for a lawful (sah) purpose

The parties to a group contract meet these requirement in much the same way as the parties to an individual contract. (para pihak dalam group contract memenuhi persyaratan ini sama seperti para pihak pada individual contract)

The primary difference is in how the lawful purpose requirement is met. (perbedaan utamanya adalah bagaimana persyaratan tujuan yang sah terpenuhi)

The lawful purpose requirement is met for an individual insurance contract by the presence of insurable interest. (persyaratan tujuan yang sah dipenuhi individual insurance contract dengan adanya insurable interest)

Group life and health insurance contract are not required to meet the insurable interest requirement because the group policyholder's interest in the contract does not induce wagering as does a policyowner's interest in an individual insurance contract. (group life and health insurance contract tidak disyaratkan untuk memenuhi persyaratan insurable interest karena kepentingan group policyholder dalam kontak tidak menimbulkan taruhan seperti kepentingan policyowner dalam individual insurance contract)

The lawful purpose requirement for a group insurance contract is met if the group policyholder purchases the coverage to provide a benefit to covered group members. (persyaratan tujuan yang sah untuk group insurance contract dipenuhi jika group policyholder membeli coverage untuk member agar mendapatkan benefit)

REGULATORY COMPLIANCE ISSUES AFFECTING GROUP INSURANCE UNDERWRITING (Isu-isu regulatory compliance yang mempengaruhi group insurance underwriting)

As we describe in Chapter 3, individual life and health underwriters in the US must comply with privacy and nondiscrimination requirements, and group underwriters also must  comply with those requirements. (Individual life and health underwriters di US harus mematuhi persyaratan privacy dan nondiscrimination)

In addition, group life and health insurance underwriters are subject to a range and federal regulatory requirements that are specific to group insurance. (selain itu, group life and health insurance underwriter patuh pada persyaratana peraturan federal yang lebih khusus untuk group insurance)

We describe such state and federal requirements in this section. (di section ini akan dijelasakan persyaratan negara dan federal)

STATE REGULATORY REQUIREMENTS (persyaratan peraturan negara)

State regulation of group life insurance is relatively uniform across the US because most states have enacted laws based on the NAIC Group Life Insurance Definition and Group Life Insurance Standard Provisions Model Act (Group Life Insurance Model Act).

Laws based on the model act define the types of groups that are eligible for group life insurance and specify standard provisions that group life insurance policies must include.

The NAIC also has adopted the Group Health Insurance Definition and Group Health Insurance Standard Provisions Model Act (Group Health Insurance Model Act), which defines the groups that are eligible for group health insurance and specifies standards contract provisions.

Because only about one-fourth of the states have enacted laws based on the Group Health Insurance is much less uniform than state regulation of group life insurance.

Eligible Groups (grup yang memenuhi syarat)

• Single-Employer Group (kelompok Majikan Tunggal)
• A single-employer group, commonly referred to as an employer-employee group, consists of the employees of one employer. (single-employer group merujuk pada kelompok majikan pekerja, yang terdiri dari pekerja-pekerja dari satu majikan)
• The policyholder is the employer or a trust fund established by the employer. (policyholder adalah majikan atau trust fund yang ditetapkan oleh majikan)
• A trust is a fiduciary relationship in which a person, known as a trustee, hold legal title to property - known as the trust property or trust fund - for the benefit of to another person. 
• Debtor-Creditor Group (kelompok Debitur Kreditur)
• A debtor-creditor group consists of individuals who have borrowed money from a specific lender (debtor-creditor group terdiri dari individu-individu yang meminjam uang dari peminjam)
• Group coverage issued to a debtor-creditor group is referred to as group creditor insurance. 
• Labor Union Group (kelompok persatuan pekerja)
• A labor union group consists of workers who are members of a labor union, which is an association that promotes the welfare, interest, and rights of its members. (Labor union group terdiri dari pekerja-pekerja yang menjadi anggota persatuan pekerja/buruh, yaitu asosiasi yang mendukung kesejahteraan, kepentingan dan hak-hak anggotanya)
• Multiple-Employer Group
• A multiple-employer group consists of the employees of:
1. two or more employers in the same industry (
2. two or more labor unions, or
3. one or more employers and one or more labor unions.
• Association Group 
• An association group consists of members of an association, which is an organization of employers or individuals formed for a purpose other than to obtain insurance. (association group terdiri dari anggota-anggota asosiasi yang dibentuk untuk maksud lain dari memperoleh asuransi)
• Credit Union Group 
• A credit union group consists of the members of the members of one or more credit unions, which are cooperative associations that pool the savings of their members and use those funds to make loans to members. 
• Discretionary Group (kelompok pembuat kebijakan)
• A discretionary group is any other type of group that qualifies for group insurance coverage according to applicable state insurance laws