Specific Claims with Reserves

Effective

Policy effective date.

Policyholder

Policy holder name.

Employee

Employee with a relationship to the claimant.

Claimant

Claimant name.

Age

Claimant age.

Diagnosis

Medical diagnosis precipitating the claim.

Incurred From

Date when the claim qualifying event first occurred.

Incurred To

Date when the claim qualifying event ended.

Paid From

Date of initial claim payment.

Paid To

Date of latest claim payment.

TPA Amount Paid

Amount paid by the Third-Party Administrator.

Eligible Claims

Claim amount eligible for reimbursement.

Specific Deductible

Specific coverage deductible amount.

Claim Reimb

Total claim amount reimbursed as of Paid To date.

Amount Outstanding

Claim amount still payable. Equals eligible claim amount less specific deductible and claim reimbursement.

Amount in Reserve

Amount set aside for claim reimbursement.