Frequently Used Insurance Terms
Accident: A sudden, unexpected and unintended event
Accidental Death & Dismemberment (AD&D): 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 to lose body parts.
Claim: A formal notice to an insurance company requesting payment of an amount under the terms of a policy.
Co-insurance: The ratio (%) of splitting a bill between the insurance company and you. 80% for the first $5,000 means the insurance company will pay $4,000 and you are responsible for the remaining $1,000.
Co-pay: The fee you pay for certain medical services or prescription drugs. For example, you may pay $10 to fill a prescription and the health plan cover the balance of the charges.
Covered Exenses: Most health insurance plans, whether they are fee-for-service, HMOs or PPOs, do not pay for all health care services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered health care services are those medical procedures the health insurer agrees to pay for. They are listed in the health insurance policy.
Covered Person: Any Insured and Dependent who enrolls for coverage and for whom the required premium is paid.
Customary Fee/Charges: Most health insurance plans will pay only what the call a reasonable and customary fee for a particular health care service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference. This is addition to the deductible and coinsurance you would expected to pay. To avoid this additional cost, ask your doctor to accept your health insurance company's payment as full payment. Or shop around to find a doctor who will. Otherwise you will have to pay the rest yourself.
Deductible: The dollar amount of covered expenses you are responsible to pay the physician or medical facility each year before the policy will pay any benefits. Deductible Per Event means you pay your decutible once for all different services you received per one sickness or accident. So in case your doctor requires you to return for a check of your condition due to the same sickness, you will not pay the deductible again.
Exclusions: Specific conditions or circumstances for which the health insurance policy will not provide benefits.
HMO (Health Maintenance Orgnization): Prepaid health insurance plans. You pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO. Kaiser is an example of a HMO.
Managed Care: Ways to manage costs, use, and quality of the health care system. All HMOs and PPOS have managed care.
Maximum Lifetime Medical Benefits: The total amount payable by the insurance company for covered medical expenses due to injury or sickness per policy lifetime.
Maximum Out-of-Pocket Expenses: The most money you well be required to pay a year for deductibles and coinsureance. It is a stated dollar amount set by the health insurance company, in additioni to regular premiums.
Maximum per Injury or Sickness: The total amount payable by the insurance company for covered medical expenses for injury or sickness per medical event.
Medical Evacuation: Transferring the insured person to the nearest hospital or medical facility in case on an emergency injury or sickness or back to his home country.
PPO (Preferred Provider Organization): 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. You can use other doctors, but at a higher cost than if you used one in the PPO network.
Pre-existing Condition: A health problem (injury or illness) that existed before the date your health insurance became effective.
Premium: The amount you pay in exchange for health insurance coverage.
Primary Care Doctor: Uusally your first contact for health care. This is often a family physicain or internist. A primary care doctor monitors your health and diagnoses adn treats minot health problems, and refers you to specialists if another level of health care is needed. In many insurance plans, health care by specialists is only paid for if you are referred by your primary care doctor. The HMO or insurance company will provide you with a list of doctors fromwhich you will choose your primary care doctor.
Provider: Any person (doctor, nurse, dentist) or institiution (hospital or clinic) taht provides medical care.
Repratriation: Transporting the remains of insured person back to his home country.
Sickness: An illness, disease or condition of the inusred for which he/she 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.
Third-Party Payer: Any payer for health care services other than you. This can be a healther insurance company, an HMO, a PPO, or the Federal Government.