Insurance Terms Dictionary
Accident means a sudden, unexpected and unintended event.
Accidental Bodily Injury means an injury that resulted from an
accident only.
Accidental Death & Dismemberment (AD&D) means an additional
cash benefit to be paid to the insured person or his beneficiaries (usually family
members) if an accident causes either the death of the insured or causes the insured
to lose body parts, as stated in the policy.
Co-Insurance means the ratio (%) of splitting the bill between
the insurance company and you. 80% co-insurance means you are responsible to pay
20% of the covered expenses. Example: 80% for the first $5,000 means the insurance
company will pay $4,000 and you are responsible for the remaining $1,000. Also look
under "Coverage In/Out PPO Network" for further clarification.
Co-pay means the fee you pay for certain medical services or for
each prescription (drugs). For example, you may pay $10 to fill a prescription and
the health plan covers the balance of the charges.
Coverage in /out PPO Network means the health insurance plan allows
you to use any qualified medical service provider, but offer you to save money by
using the PPO network the insurance plan is affiliated with. You will usually save
money by getting higher benefits, or you Co-Insurance will be lower, if you use
PPO service providers. Example, 90%/70% co-insurance for in/out of network means
you are responsible to pay 10% of the covered expenses if you use the PPO or 30%
if you use a medical service provider which is not affiliated with the network.
Covered Person means any Insured and Dependent who enrolls for
coverage and for whom the required premium is paid.
Deductible means a flat dollar amount of covered expenses that
you are responsible to pay before the policy will provide any benefits. It could
either be per visit or per event - sickness or injury. Per event means you pay your
deductible once for all the different services you received. So in case your doctor
requires you to return for a second check of your condition due to the same sickness,
you will not pay the deductible again.
Dependent means the person's immediate family members: his wife
or husband and their children. A dependent is a person for whom the insured has
some legal obligation to. For most plans, it is the insured's spouse and/or children.
Some plans also allow non-traditional spousal relationships (significant other,
life-partner, etc.) to be considered a dependent.
Effective Date is the specified date of when the health insurance
policy is to begin.
Emergency care - most plans cover emergency care in a hospital
emergency room if it is an extremely urgent medical emergency, even if the hospital
you are taken to is not in the plan's network.
Generic Medications - when a new drug is put on the market, the
pharmaceutical company patents it under a brand name. The company has the exclusive
right to sell the drug under this name, but once its patent expires, other companies
can sell the same drug under its chemical, or generic, name. Generic drugs are typically
cheaper than brand-name drugs.
Insured Person is the person who purchased the insurance, whose
name appears on the certificate of insurance or medical insurance ID card. It might
include his dependents, if added to the policy.
Lifetime Maximum is the maximum amount of money a plan will pay
towards healthcare services over the course of the insured's lifetime.
Maximum Life Time Medical Benefits means the total amount payable
by the insurance company for covered medical expenses for injury or sickness per
policy lifetime.
Maximum per injury or Sickness means the total amount payable by
the insurance company for covered medical expenses for injury or sickness per medical
event.
Medical Evacuation means transferring the insured person to the
nearest hospital or medical facility in case of an emergency injury or sickness
or back to his home country.
Medical Service Provider / Health Care Provider - a doctor, hospital,
laboratory, nurse or anyone else who delivers medical or health-related care.
Outpatient Treatment means all medical services you will be getting
either out of the hospital or in hospital but without being hospitalized. Doctor
visits, clinics, x-rays and laboratories are the common such treatments.
Physician means a licensed doctor.
PPO or
Preferred Provider Organization is a network
of doctors, clinics, hospitals and related medical service providers who are organized
under the PPO to provide health care at a discounted or negotiated rate. Most PPOs
will allow you to seek care outside of the PPO network; however, the benefits are
usually reduced and the insured has a greater co-insurance expense.
Pre-Existing Condition - an injury that occurred or a sickness
that first appeared or manifested itself before the policy was issued. Most plans
will exclude coverage for pre-existing conditions, or will specify a wait period
for coverage to begin for these conditions.
Premium means a specified amount of money that the insurer receives
in exchange for its promise to provide health insurance to an individual or a group.
Prescription Drug Coverage (Rx) is a type of specified expense
coverage that provides benefits for the purchase of drugs and medicines prescribed
by a physician and not available over-the-counter. Often a plan will provide a prescription
drug card that allows the insured to obtain medications by simply paying a co-pay
at a participating pharmacy.
Qualified Service Providers means a licensed doctor or hospital.
Many plans will limit you to a list of doctors and hospitals organized under PPO.
The reason is saving money, getting lower rates per service, in exchange for referring
insured to the PPO. The better plan will allow you to also go out-of-network and
seek treatment at any licensed doctor or hospital.
Repatriation means transporting the remains of an insured person
who died to his family and/or home country. Sickness means an illness, disease or
condition of the Covered Person that causes a loss for which a Covered Person incurs
medical expenses while covered under the Policy. All related conditions and recurrent
symptoms of the same or similar condition will be considered one Sickness.
Usual and Customary Charges means the amount normally charged by
the provider for similar services and supplies and do not exceed the amount ordinarily
charged by most providers of comparable services and supplies in the locality where
the services or supplies are received.
Underwriter (carrier) means the insurance company, the Insurer.
The party to an insurance arrangement who undertakes to indemnify for losses, provide
pecuniary benefits, or render services.