§ 51 Actions on insurance policies
§ 52 Ad damnum clause
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Terms Used In Maine Revised Statutes > Title 14 > Part 1 > Chapter 3 - Pleadings

  • Allegation: something that someone says happened.
  • Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
  • Attorney-in-fact: A person who, acting as an agent, is given written authorization by another person to transact business for him (her) out of court.
  • Basic health care services: means health care services that an enrolled population might reasonably require in order to be maintained in good health and includes, at a minimum, emergency care, inpatient hospital care, inpatient physician services, outpatient physician services, ancillary services such as x-ray services and laboratory services and all benefits mandated by statute and mandated by rule applicable to health maintenance organizations. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Capitated basis: means fixed per-member, per-month payments or percentage-of-premium payments pursuant to which the provider assumes full risk for the cost of contracted services without regard to the type, value or frequency of services provided. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Carrier: means a health maintenance organization, an insurer, a nonprofit hospital, a medical service corporation or any other entity responsible for the payment of benefits or provision of services under a group contract. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Commissioner: means the Commissioner of Health and Human Services. See Maine Revised Statutes Title 22 Sec. 1-A
  • Common law: The legal system that originated in England and is now in use in the United States. It is based on judicial decisions rather than legislative action.
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Copayment: means an amount an enrollee must pay in order to receive a specific service that is not fully prepaid. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Deductible: means the amount an enrollee is responsible to pay out of pocket before a health maintenance organization begins to pay the costs associated with treatment. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Department: means the Department of Health and Human Services. See Maine Revised Statutes Title 22 Sec. 1-A
  • Enrollee: means an individual who is enrolled in a health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Group contract holder: means an entity or person that has purchased coverage from a health maintenance organization that provides, at a minimum, basic health care services to enrollees. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Health care services: means any services included in the furnishing of medical care, dental care or hospitalization to an individual, or any services incident to the furnishing of that care or hospitalization, as well as the furnishing of any other services to an individual to prevent, alleviate, cure or heal human illness or injury. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • health insurance: means insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto, including provision for the mental and emotional welfare of human beings by defraying the costs of legal services only to the extent provided for in chapter 38. See Maine Revised Statutes Title 24-A Sec. 704
  • Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • In-plan covered services: includes emergency services. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Lien: A claim against real or personal property in satisfaction of a debt.
  • NCQA accreditation survey report: means the unpublished, detailed survey report to a health maintenance organization by the National Committee for Quality Assurance upon completion of NCQA's accreditation survey of the health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Nonprofit hospital or medical service organization: means any organization defined in and authorized to act under Title 24, chapter 19. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Obligor: means an individual who receives an overpayment or an adult individual who is a member of an assistance unit that receives an overpayment. See Maine Revised Statutes Title 22 Sec. 3811
  • Out-of-plan covered services: means nonemergency, covered health care services obtained without a referral from providers who are not otherwise employed by, under contract with or otherwise affiliated with the health maintenance organization or from affiliated specialists. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Overpayment: means program benefits that exceed the amount of program benefits for which an individual or assistance unit is eligible when the department or a court has determined that the benefits were provided as a result of an intentional program violation, an unintentional error by the individual or household or an error by the department. See Maine Revised Statutes Title 22 Sec. 3811
  • Participating provider: means a provider as defined in subsection 18 that, under an express or implied contract with a health maintenance organization, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment, directly or indirectly from the health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Person: means an individual, firm, partnership, corporation, association, syndicate, organization, society, business trust, attorney-in-fact or any legal entity. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Pleadings: Written statements of the parties in a civil case of their positions. In the federal courts, the principal pleadings are the complaint and the answer.
  • Point-of-service option: means a health maintenance organization product that allows an enrollee to select either the comprehensive health care benefits of the health maintenance organization or care from a provider of the enrollee's choice outside the health maintenance organization network with traditional indemnity benefits. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Point-of-service product: means a product that includes both in-plan covered services and out-of-plan covered services. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Provider: means a physician, hospital or person that is licensed or otherwise authorized in this State to furnish health care services. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
  • Statute: A law passed by a legislature.
  • Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Uncovered expenditures: means costs to a health maintenance organization for health care services that are the obligation of the health maintenance organization for which an enrollee may also be liable. See Maine Revised Statutes Title 24-A Sec. 4202-A