Below are the definitions of some common insurance terms used in the policy wording. If you have any questions about your policy and coverage, please feel free to contact us at
1-800-578-2111.
Accidental Death and Dismemberment (AD&D) - Accident insurance that pays the insured or beneficiary in case of bodily injury or death due to an accident that is not natural causes.
Calendar Year - The amount of time between January 1 and December 31. The 12 month period beginning January 1 and ending at 12:00 midnight on December 31, the last day of the year.
Certificate of Creditable Coverage (CCC) - A certificate issued by an insurance company that gives written verification of the existence of insurance, dates of coverage, and thus is proof that a person has or has had valid medical insurance.
Claims - The legal maximum allowable amount of money due an insured person from an insurance company to pay for an incurred medical expense. Usually a claim is made in the form of a written notification to the insurance company requesting payment for medical care received, care that is covered under the terms of the insurance policy.
Co-Insurance - A percentage of the medical costs to be shared by the insurer and the insured after the deductible has been met. In an 80/20 to $5000 plan, the insured will pay his deductible (e.g. $500) and also 20 percent (the co-insurance) of the first $5000 of medical costs. Then the insurance company will cover all eligible expenses after the out-of-pocket maximum. Note that co-insurance is not the same as co-pay.
Co-Pay / Co-Payment - A certain amount of money, usually a fixed preset dollar fee, paid by a person who has insurance at the time medical care is received. This fee is in addition to any deductible and co-insurance limits.
Covered Expenses - Medical expenses that the insurance company will cover based on the insurance policy purchased, thus expenses that qualify for reimbursement. A summary of covered expenses is listed in the Schedule of Benefits.
Deductible - The amount of medical costs to be covered by the insured before the company begins to cover costs.
Dependent - Usually a spouse and/or children who are legally dependent on the insured. Depending on the insurance plan, dependents may qualify for insurance coverage on the insured's policy.
Effective Date - The date when the insurance coverage begins. The day when coverage for medical care begins.
Eligible Medical Expenses - A medical expense that an insurance company will cover. For example, many insurance policies will not cover plastic surgery, so it would not be an eligible medical expense.
Explanation of Benefits (commonly referred to as an EOB form) - Is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
Fulfillment Kit - Materials sent to the client after they have been approved for insurance coverage. The kit usually contains the medical ID card, a certificate of coverage, a detailed explanation of the insurance plan, information concerning filing claims, and contact information for the insurance company.
The Health Insurance Portability and Accountability Act (HIPAA) - This is also known as the Kassebaum-Kennedy Act enacted by the US Congress in 1996. It includes basic requirements for health insurance privacy and portability of health insurance, thus avoiding exclusion of coverage for pre-existing medical conditions.
In-Network, Out-of-Network - Medical facilities and practitioners that have contracted with the insurance companies to provide discounted rates. Those facilities that have not contracted are considered Out-of-Network. The insured will save money by using In-Network providers and facilities.
In-Patient - A patient admitted for a 24-hour residence (or at least overnight) in a medical facility where he is being treated.
Insurance Broker - An individual who works as an intermediary between a person wanting insurance and one or more insurance companies to guide them in the purchase of insurance.
Lifetime Maximum - The maximum amount an insurance company will provide for all medical care received. The usual limits are $1,000,000; $3,000,000 or $5,000,000.
Maximum Limit, Maximum Coverage - The maximum amount an insurance company will provide for all medical care received. The usual limits are $1,000,000; $3,000,000 or $5,000,000. (Same as Lifetime Maximum)
Medical Evacuation (MedEvac, medivac) - Timely and efficient evacuation and en-route care of critically ill or injured persons, usually by air transportation, to a place where they can receive adequate medical care.
Online Fulfillment - Electronic communication of medical ID card, certificate or indication of coverage, information on the policy purchased, how to file a claim, and the insurance company's contact information.
Out-Patient - A patient who receives medical treatment at a clinic or hospital, but is not admitted for an overnight stay.
Out-of-Pocket - Direct outlays of cash that will not be reimbursed by the insurance company. This will include deductibles and co-insurance limits.
Policy Year - The amount of time from the effective date of the policy that comprises one full year. For example, if the effective date begins January 14, 2012, the coverage will end at midnight, January 13, 2013.
Pre-Certification - The need to check with the insurance company before receiving medical care, generally for major medical procedures, to confirm if the medical care received will be covered by the insurance company.
Pre-Existing Condition - Any medical condition that the insured has prior to contracting for insurance coverage.
Premium - Payment for insurance, the amount paid by the insured to the insurance company for health insurance coverage.
Preventive Care (Wellness Benefit, Well-Care) - Medical care given in advance of symptoms to prevent illness or injury. Generally includes emphasis on healthy behavior, regular testing, screening for diseases, routine physical examinations and immunizations.
Rider (Waiver) - A formal written statement by the insurance company to the insured amending and modifying coverage, e.g., adding or excluding coverage. It could involve waiving coverage for a certain medical condition like cancer, hepatitis or adding coverage for such conditions.
Schedule of Benefits (SOB) - A list of the benefits, amount of coverage provided in a health insurance policy, usually one or two pages in length.
Trip Cancellation - Provides reimbursement for non-refundable trip payments and deposits if a trip is canceled for illness, death or other specific unforeseen circumstances The trip cancellation benefit covers you in the event you have to cancel prior to your trip due to a covered reason listed in your travel insurance policy prior to your departure date.
Trip Interruption - Trip interruption plans typically reimburse you for pre-paid non-refundable travel expenses if an unexpected crises (e.g., death of a family member, sickness, airline strike, travel supplier bankruptcy, among other crisis) occurs during your trip causing it to be cancelled, interrupted or delayed.
Underwriter - (1) The company that receives the insurance premium and accepts the responsibility to cover medical costs; (2) The employee in an insurance company who decides whether or not the insurance company should assume the risk of offering the insurance to an individual or group; (3) An insurance agent.
Usual, Reasonable u0026amp; Customary (UCR) - The amount an insurance company will pay for a covered medical expense based on the customary charges of all medical providers in a given geographic area for a similar service.
Waiting Period - A period of time the insured must wait before some or all of the coverages offered in an insurance plan begin and the insured can receive benefits.
Waiver (Rider) - A formal written statement by the insurance company to the insured amending and modifying coverage, e.g., adding or excluding coverage. It could involve waiving coverage for a certain medical condition like cancer, hepatitis or adding coverage for such conditions.
Wellness Benefit (Preventive Care, Well-Care) - Medical care given in advance of symptoms to prevent illness or injury. Generally includes emphasis on healthy behavior, regular testing, screening for diseases, routine physical examinations and immunizations.
