Medical Insurance Glossary Terms
Allowable Expense: Allowable Expense is any medically necessary, Usual, Customary and Reasonable expense applicable within a geographic area.
Beneficiary: The beneficiary is the person who would receive any insurance benefits in the event that the policyholder dies while being covered on the insurance plan.
Benefits: Monetary payments made by the Insurer to service providers or reimbursement to policyholders for expenses incurred with respect to the coverage under the schedule of benefits and riders included in the specific policy. This applies to dependents that are covered under the plan as well.
Coordination of Benefits: The integration of one policy contract’s benefits with benefits from another policy by following a specific principle.
Coinsurance: Coinsurance is a percentage of what the insurance will pay to cover the Insured’s healthcare cost after the deductibles or co-payments have been satisfied.
Co-Pay: The co-pay (or co-payment) is the amount of money that the Insured is required to pay out of pocket and upfront to the medical provider as a percentage of the eligible expenses. Usually, the co-pay amount should not apply towards the satisfaction of any deductible requirement.
For example: If you have an insurance policy with a 80% coinsurance and a medical bill of $500.00, the insurance will pay 80% or $400.00 and your co-pay would be 20% of the cost or $100.00 (assuming that there is no deductible on the plan).
Coverage: Eligible benefits provided by an insurance policy and its schedule of benefits.
Deductible: The deductible is the amount that the Insured is required to pay out of their own pocket before the insurance company will begin paying towards any covered or eligible expenses. The deductible is usually paid once per policy or calendar year and payment is not required again until the Insured renews for an additional year. The deductible may apply on an Individual and/or Family basis.
Dependent: An employee’s spouse under age 65 and unmarried dependent children under the age of 18, resident in the country where the contract is issued. Coverage can also be extended to children over 18 years but less than 25 years, who are attending an educational institution on a full-time basis.
Eligible Expenses or Covered Medical Expenses: The charges for treatment, supplies or services rendered which are the usual, customary and reasonable charges for those services and which are medically necessary for treatment of injury or illness.
Evidence of Insurability: Written proof, presented by an individual on an application form or through a medical exam, that a person is acceptable for coverage under an insurance policy.
Expenses Incurred: Purchases of supplies, treatment or services received at a point in time.
Maximum benefits: The maximum payable by the Insurer (or insurance company) according to the schedule of benefits.
Medically Necessary: Services or supplies ordered or provided by a hospital, licensed physician or medical facility to treat or diagnose a sickness or injury. The medical services or supplies must be consistent with the diagnosis and treatment of the sickness or injury, not primarily for the convenience of the covered person or the medical provider, and not part of a treatment plan that is considered experimental or for research purposes.
Network Provider: The provider network (also known as an in-network provider or preferred provider) is a group of licensed healthcare providers (medical practitioners, hospitals, specialist clinics and pharmacies) that have contracted with the insurance company to provide medical services. Utilizing an in-network provider could be more cost effective for the Insured as network providers usually accept co-payments from the Insured and coinsurance directly from the Insurer.
Pre-certification: Pre-certification means the approval in advance by the Insurer or insurance company for Medically Necessary and covered services subject to the eligible charges.
Pre-existing Conditions: Pre-existing conditions include any injury or illness that an Insured may have prior to obtaining an insurance plan or policy.
Primary Insured: The named applicant on the application form for health insurance and for whom insurance is in force under the Policy.
Repatriation of Remains: Repatriation of remains covers the cost of returning the Insured’s body back to their home country in the event of death.
Usual, Reasonable and Customary Charges: Usual, Reasonable and Customary (also known as URC Charges) is the average cost for a particular treatment in a particular geographic area. It is the amount that insurance companies use to describe the limit on how much they will pay for covered expenses.
For example, if majority of the medical providers usually charge $3,500 for a particular procedure in Antigua, the insurance company will not pay a doctor $8,000 for the same procedure. Instead, they will limit their payment amount to “Usual, Reasonable and Customary Charges” – in this example, $3,500.
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