Glossary · 90 entries
Senior Care Coverage Glossary. Read line by line.
The terms that decide a senior care claim: whether defense erodes the limit, how far the abuse and assault sublimits sit below the real one, retroactive dates, retention mechanics, regulatory and survey defense, resident trust funds, and the contractual wording landlords and lenders require. For each: what the policy language actually says, what it actually means, and whether it is negotiable.
90 of 90 entries
Limits
Defense Costs Inside the Limit (Eroding Limits)
There are two ways a liability policy can handle the cost of defending you. Defense outside the limit means the insurer pays lawyers in addi…
Limits
Per Occurrence and Annual Aggregate Limits
The per-occurrence limit is the most the policy pays for any one claim. The annual aggregate is the most it pays for all claims in the polic…
Limits
Shared Aggregate versus Per Location Aggregate
A multi-building operator can carry one aggregate shared across the whole portfolio, or a separate aggregate for each location. The differen…
Limits
Claims-Made versus Occurrence Coverage
An occurrence policy responds to injuries that happen during the policy period, whenever the claim is eventually made. A claims-made policy …
Limits
Retroactive Date
On a claims-made policy, the retroactive date is the earliest incident date the policy will respond to. Anything that happened before it is …
Limits
Extended Reporting Period (Tail Coverage)
A tail, formally an extended reporting period, lets you report claims after a claims-made policy ends, for incidents that happened while it …
Limits
Self-Insured Retention and Deductible
A retention is the amount you pay on each claim before the insurer pays anything. A deductible is similar but the insurer typically pays fir…
Limits
Whether Defense Costs Erode the Retention
Separate from whether defense erodes the policy limit, there is the question of whether defense spend counts toward satisfying your retentio…
Limits
Who Controls Defense Within the Retention
When a retention applies, someone has to decide who defends the claim and which law firm does it. Some programs give that control to the ope…
Indemnity
Consent to Settle and the Hammer Clause
A consent-to-settle provision requires the insurer to get your agreement before settling. A hammer clause is the counterweight: if you refus…
Limits
Umbrella and Excess Liability Towers
An umbrella or excess policy sits above the primary layers and pays after they are exhausted. In senior care the tower is often built from s…
Specialty
Sexual Abuse and Molestation (SAM) Sublimit
Abuse and molestation coverage responds to allegations that a resident was sexually abused, whether by staff, by a contractor, by a visitor,…
Specialty
Whether Abuse Coverage Has Its Own Aggregate
Beyond the size of the abuse sublimit, there is the question of whether abuse claims draw on their own annual aggregate or on the same aggre…
Specialty
Assault and Battery Sublimit or Exclusion
Assault and battery provisions respond to physical altercations. In senior care they matter for a reason unique to the setting: residents wi…
Specialty
Punitive Damages Wrap
Some states permit insurance for punitive damages and some hold it void as against public policy. A punitive wrap is a structure that places…
Specialty
Communicable Disease Exclusion
Broad communicable disease exclusions became widespread across liability forms after 2020 and remain on many senior care programs. The langu…
Specialty
Vicarious Liability for Agency and Contract Staff
When a facility uses agency nurses or contract therapists, two coverage questions arise. First, does the facility policy cover the facility …
Specialty
Medical Director Professional Liability
Skilled nursing facilities are required to have a medical director, and the role is defined largely in administrative terms: oversight of cl…
Specialty
Elopement and Wandering Claims
Elopement is a resident leaving a secured area unsupervised. It is not a separate coverage grant in most programs; it is a professional liab…
Specialty
Resident Fall Claims
Falls are the highest-frequency serious claim in every senior care setting. They sit at the boundary between general liability, which handle…
Specialty
Pressure Injury and Wound Care Claims
Pressure injuries, historically called pressure ulcers or bedsores, are staged wounds that develop from sustained pressure on tissue. They a…
Specialty
Medication Error Claims
Medication errors span omitted doses, wrong doses, wrong residents, and failures to monitor for adverse effects. In assisted living, where m…
Specialty
Resident on Resident Altercation
When one resident injures another, the claim against the facility is about assessment, placement, supervision, and whether known behavioral …
Specialty
Wrongful Death and Survival Actions
When a resident dies, two distinct claims can arise. A survival action is the claim the resident would have had, carried on by the estate, c…
Compliance
Regulatory and Survey Defense Coverage
Regulatory defense coverage pays legal and consultant costs of responding to a government proceeding: a survey deficiency, a plan of correct…
Compliance
Billing Errors and Omissions and Audit Defense
Facilities participating in Medicare and Medicaid are subject to post-payment review by government contractors. A billing errors and omissio…
Compliance
Loss of License Coverage
Loss of license coverage responds to income lost when a licensing agency suspends, revokes, or conditions the license to operate. Some forms…
Compliance
Directors and Officers Liability
Directors and officers coverage protects individuals who govern the organization, and in most forms the organization itself, against claims …
Compliance
Fiduciary Liability (ERISA)
Fiduciary liability covers people who administer employee benefit plans against claims that they breached their duties under ERISA. It is di…
Compliance
Crime and Employee Dishonesty
A crime policy covers theft of the organization's money and property, most commonly by employees, and typically extends to forgery, funds tr…
Compliance
Resident Trust Fund Coverage
Facilities frequently hold personal funds on behalf of residents in a trust account. CMS requirements at 42 CFR Part 483 govern how those fu…
Compliance
Employment Practices Liability
Employment practices liability covers claims by employees and applicants alleging discrimination, harassment, retaliation, or wrongful termi…
Compliance
Wage and Hour Defense Sublimit
Most employment practices policies exclude wage and hour claims outright, then give back a small sublimit for defense costs only. Damages, m…
Compliance
Cyber Liability and HIPAA Breach Response
Cyber coverage in a healthcare setting splits into first-party costs, meaning your own breach response, forensics, notification, and busines…
Endorsements
Replacement Cost versus Actual Cash Value
Replacement cost pays what it takes to rebuild with materials of like kind and quality. Actual cash value pays replacement cost less depreci…
Endorsements
Ordinance or Law Coverage
Ordinance or law coverage pays the extra cost created when a building code forces you to rebuild differently than what was there. It comes i…
Endorsements
Business Income and Extra Expense
Business income coverage replaces lost earnings while damaged property is repaired. Extra expense pays the added costs of continuing to oper…
Endorsements
Named Storm and Wind Percentage Deductible
In coastal and wind-exposed states, wind and named storm losses carry a percentage deductible calculated on insured value rather than a flat…
Endorsements
Flood Coverage
Flood is excluded from standard property policies and has to be bought separately, either through the National Flood Insurance Program or th…
Endorsements
Equipment Breakdown
Equipment breakdown covers mechanical and electrical failure of building systems: boilers, chillers, elevators, emergency generators, refrig…
Endorsements
Resident Transportation and Non-Owned Auto
Auto liability in senior care covers facility vehicles used for resident outings and medical appointments, vehicles hired for that purpose, …
Compliance
Workers Compensation and the Experience Modifier
Workers compensation pays medical costs and lost wages for employees injured at work, on a no-fault basis. Employers liability, the second h…
Indemnity
Additional Insured Status
An additional insured endorsement extends your liability coverage to another party for claims arising out of your operations. Landlords, len…
Indemnity
Waiver of Subrogation
Subrogation is an insurer right to step into your shoes and recover from whoever caused a loss it paid. A waiver of subrogation gives up tha…
Indemnity
Primary and Non-Contributory Wording
Primary and non-contributory wording settles whose policy pays first when two policies could both respond. Without it, both insurers may tre…
Compliance
Certificate and Insurance Exhibit Compliance
The insurance exhibit to a lease, a management agreement, or a loan document is the schedule listing every coverage, limit, and endorsement …
Compliance
Admitted versus Surplus Lines Coverage
An admitted carrier is licensed by the state, files its forms and rates with the Department of Insurance, and is backed by the state guarant…
Compliance
Risk Retention Groups
A risk retention group is a liability insurer owned by its policyholders, formed under the federal Liability Risk Retention Act, and license…
Compliance
Captives and Group Captives
A captive is an insurance company owned by the operator, or by a group of operators, that formally insures their own risk. A single-parent c…
Limits
Per Bed Rating and Loss-Rated Pricing
Senior care liability is usually priced per bed or per occupied unit rather than on revenue, with rates varying enormously by state, level o…
Compliance
State Licensure Minimum Liability Limits
Many states require a licensed assisted living or skilled nursing facility to carry liability insurance as a condition of holding the licens…
Compliance
HUD Section 232 Insurance Requirements
Section 232 of the National Housing Act authorizes FHA mortgage insurance for residential care facilities, including skilled nursing, assist…
Endorsements
Hammer Clause
A hammer clause is the price attached to your right to refuse a settlement. If the insurer recommends settling, the claimant agrees, and you…
Limits
Related Claims Provision
A related claims provision collapses several claims arising from the same conduct into one claim, attached to the earliest policy year. That…
Limits
Notice of Circumstance
A notice of circumstance is a report of an incident that has not yet become a claim. Once accepted, it locks that incident into the policy i…
Limits
Prior Acts Coverage
Prior acts coverage means an incoming carrier accepts your existing retroactive date rather than resetting it to the inception of its own po…
Endorsements
Severability of Interests
Severability treats each insured as if it held its own policy for the purpose of applying exclusions and conditions. Without it, the miscond…
Limits
Other Insurance Clause
The other insurance clause decides what happens when more than one policy covers the same loss. The usual outcomes are that the policies sha…
Limits
Follow-Form Excess
A follow-form excess policy adopts the wording of the underlying policy it sits above, so it responds to the same claims on the same terms a…
Limits
Quota Share Participation
A quota share layer is one excess layer whose limit is split among several carriers by percentage. Each pays its own share of a loss in that…
Limits
Attachment and Exhaustion
Attachment language says exactly what has to happen before the excess layer starts paying. The dangerous formulation is exhaustion by paymen…
Limits
Drop-Down Coverage
Drop-down is what happens to your excess layers when an underlying carrier fails to pay. The wording above is the common position: the exces…
Compliance
Reservation of Rights
A reservation of rights letter means the carrier will defend you while preserving its right to deny coverage later. Carriers send them becau…
Limits
Duty to Defend versus Duty to Indemnify
The duty to defend is the obligation to provide and pay for a lawyer. The duty to indemnify is the obligation to pay a judgment or settlemen…
Limits
Allocation of Defense Costs
Allocation is how a defense bill gets split when a case includes some claims the policy covers and some it does not, or some defendants who …
Specialty
Collateral and Letters of Credit
On a large retention or deductible program the carrier pays claims first and bills you back for the amounts inside your retention. Collatera…
Specialty
Fronting Arrangement
A fronting arrangement is where a licensed carrier issues the policy and then cedes the risk, usually to your own captive. The front provide…
Specialty
Third-Party Claims Administrator
A third-party administrator handles claims that fall inside your retention, where the carrier is not yet paying. It investigates, sets reser…
Specialty
Loss Portfolio Transfer
A loss portfolio transfer moves responsibility for a defined block of existing open claims to an insurer for a single premium. It converts a…
Specialty
Loss Development and IBNR
Loss development is how the incurred value of a policy year changes as claims mature. IBNR is the actuarial provision for claims that have h…
Specialty
Corporate Negligence
Corporate negligence is a claim against the organization for its own conduct rather than for what a caregiver did. It reaches staffing level…
Indemnity
Vicarious Liability and the Borrowed Servant
Vicarious liability makes an employer responsible for the negligence of its employee. The borrowed servant doctrine extends that to someone …
Specialty
Life Care Plan
A life care plan is the plaintiff expert report that prices every future need caused by the injury. Each item gets a unit cost, a frequency …
Specialty
Nuclear Verdict
A nuclear verdict is the industry term for a jury award far above what the facts of the injury alone would suggest, driven by anger at the d…
Specialty
Reptile Theory
Reptile theory is a plaintiff trial strategy that reframes a case from an individual injury into a question of community safety, inviting ju…
Specialty
Third-Party Litigation Funding
Litigation funding is outside capital advanced to a plaintiff or a plaintiff firm to carry a case, repaid from the recovery. The funder take…
Compliance
Spoliation and the Litigation Hold
A litigation hold suspends the routine destruction of records once litigation is reasonably anticipated. Spoliation is what a court calls th…
Compliance
Resident Arbitration Agreement
A resident arbitration agreement moves disputes out of court and in front of an arbitrator. It does not reduce the average value of a claim …
Compliance
Apology Statute
An apology statute makes expressions of sympathy after an adverse event inadmissible in a later civil action. A majority of states have one.…
Compliance
Peer Review and QAPI Privilege
Most states protect the deliberations of a quality assurance or peer review committee from civil discovery, and federal law restricts disclo…
Compliance
Mandatory Reporter Obligation
Care staff in every state are mandatory reporters of suspected abuse, neglect and exploitation, on timelines set by state law and by federal…
Compliance
Immediate Jeopardy
Immediate jeopardy is the most serious survey finding available. It triggers an accelerated removal timeline, discretionary and mandatory re…
Compliance
Plan of Correction
A plan of correction is the facility written response to a statement of deficiencies. Its structure is prescribed: fix the affected resident…
Compliance
Denial of Payment for New Admissions
Denial of payment for new admissions is an intermediate enforcement remedy. The building stays open and keeps caring for existing residents,…
Compliance
Payroll-Based Journal Staffing Data
Payroll-based journal is the federal requirement that skilled nursing facilities submit auditable, payroll-derived direct care staffing data…
Compliance
Acuity-Based Staffing
Acuity-based staffing means setting the staffing level from the assessed needs of the residents actually in the building rather than from a …
Compliance
Special Focus Facility Program
The special focus facility program identifies facilities with a persistent pattern of poor survey performance, subjects them to more frequen…
Compliance
Change of Ownership
On a change of ownership in a certified facility, the provider agreement is generally assigned to the buyer along with its history, includin…
Compliance
Certificate of Insurance
A certificate of insurance is a summary issued for information. The disclaimer above is printed on the standard form and it is enforced: if …
Specialty
Total Cost of Risk
Total cost of risk is the whole number rather than the premium line. It adds retained losses, collateral cost, claims administration and int…
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