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A
ACTUAL CASH VALUE
An amount equivalent to the fair market value of the stolen or damaged property immediately preceding the loss. For real property, this
amount can be based on a determination of the fair market value of the property before and after the loss. For vehicles, this amount can be
determined by local area private party sales and dealer quotations for comparable vehicles.
AGENT
A licensed person or organization authorized to sell Insurance by or on behalf of an Insurance company.
ALLOWABLE CHARGE
The maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either
a reasonable or customary charge.
B
BENEFIT
Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to others.
Benefit Period
The maximum length of time for which benefits will be paid.
Brand Name Drug(s)
Those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under
patent protection, meaning the manufacturer is the sole source for the product.
BROKER
A licensed person or organization paid by you to look for Insurance on your behalf.
C
CANCELLATION
The Termination of Insurance coverage during the policy period. Flat cancellation is the cancellation of a policy as of its effective date, without
any premium charge.
CLAIM
A request for payment for benefits received or services rendered. A billing record as generated and submitted by a provider or subscriber
using paper or electronic media.
(COBRA) Consolidated Omnibus Budget Reconciliation Act of 1985
The federal law that requires employers with more than 20 employees to extend group health Insurance coverage for up to 36 months after
a qualifying event (e.g. Termination of employment, reduction in hours, divorce). The law contains detail provisions relating, among other
things, to an employer's obligation to provide notice of these rights and the circumstances under which such continuation may end. Some
states, such as California, have similar laws applicable to employers with more than 20 employees.
COINSURANCE
An arrangement under which the covered person pays a fixed percentage of the cost of medical care after the deductible has been paid. For
example, an Insurance plan might pay 80% of the allowable charge, with the insured individual responsible for the remaining 20%, which is
then referred to as the coinsurance amount.
Co payment OR COPAY
A type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but
may also be a dollar amount for specified services. The most common percentage co-payment is 20%.
COVERED MEDICAL EXPENSE
Those expenses payable according to the terms of the member contract. The charges for these services are still subject to any cost sharing
components or limits, such as deductibles, coinsurance, co-payments and maximums, included in the contract.
COVERED SERVICES
Hospital, medical and other health care expenses incurred by the covered person that entitle him/her to benefits under a contract. The term
defines the type and amount of expense, which will be considered in the calculation of benefits.
D
DECLINE
The Company refuses to accept the request for Insurance coverage.
DEDUCTIBLE
The amount of the loss which the insured is responsible to pay before benefits from the Insurance company are payable. You may choose a
higher deductible to lower your premium.
E
EFFECTIVE DATE
The date on which the coverage or a change in coverage of a contract goes into effect at 12:01 a.m.
EMERGENCY
In general, a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe
pain) which the member reasonably perceives could permanently endanger health if medical treatment is not received immediately. More
detailed or slightly different definitions may apply based on applicable law.
EXCLUSION
Certain causes and conditions, listed in the policy, which are not covered.
EXPIRATION DATE
The date on which the policy ends.
H
HEALTH Insurance / HEALTH Insurance
A policy that will pay specifies sums for medical expenses or treatments. Health policies can offer many options and vary in their approaches
to coverage.
Hospital
An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both
surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.
I
ID/IDENTIFICATION CARD
A card issued by a carrier to a covered person, which allows the individual to identify himself or his covered dependents to a provider for
health care services. The card is subsequently used by the provider to determine benefit levels and to prepare billing statement.
IN-NETWORK
Refers to the use of providers who participate in the carrier's provider network. Many benefit plans encourage covered persons to use
participating (in-network) providers to reduce the individual's out of pocket expense.
INSURED
The policyholder - the person(s) protected in case of a loss or claim.
INSURER
The Insurance company.
L
LIFE Insurance
A policy that will pay a specified sum to beneficiaries upon the death of the insured.
LIMIT
Maximum amount a policy will pay either overall or under a particular coverage.
M
MEDICAL PAYMENTS
Will pay reasonable expenses incurred for necessary medical and /or funeral services because of bodily injury caused by accident and
sustained by you or any other person.
Maternity Care
The care of women before and during childbirth as well as the care of newborn babies.
N
NEGOTIATED RATE
The amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge.
Negotiated rates are determined by Participating Provider Agreements.
NETWORK
The doctors, clinics, hospitals and other medical providers that a carrier contracts with to provide health care to its covered persons.
Individuals are generally limited to network providers for full coverage of their health costs.
O
OUT-OF-NETWORK
The use of health care providers who have not contracted with the carrier to provide services.
OUT-OF-POCKET MAXIMUM
Refers to the maximum amount that a covered person will have to pay for expenses covered under the plan. It is a sum of deductible and
coinsurance amounts.
P
PLAN BENEFIT MAXIMUM
Maximum amount the carrier will pay toward an individual's coverage. The amount varies depending on the type of coverage the individual
carries.
POLICY
The written contract of Insurance.
POLICY LIMIT
The maximum amount a policy will pay, either overall or under a particular coverage.
PRE-CERTIFICATION
Refers to certifying the medical necessity and level of care in advance. Pre-certification does not guarantee that contract benefits will be
available.
PRE-EXISTING CONDITION
A health condition or medical problem that was diagnosed or treated before enrollment in a new health plan or Insurance policy. Some
pre-existing conditions may be excluded from coverage.
PREMIUM
The amount of money an Insurance company charges for Insurance coverage.
Q
QUOTE
An estimate of the cost of Insurance, based on information supplied to the Insurance company by the applicant.
U
UNDERWRITING
The process of selecting applicants for Insurance and classifying them according to their degrees of insurability so that the appropriate
premium rates may be charged. The process includes rejection of unacceptable risks.
URGENT CARE
The services received for a sudden, serious, or unexpected illness, injury or condition, other than one which is life threatening, that requires
immediate care for the relief of severe pain or diagnosis and treatment of such condition.
ACTUAL CASH VALUE
An amount equivalent to the fair market value of the stolen or damaged property immediately preceding the loss. For real property, this
amount can be based on a determination of the fair market value of the property before and after the loss. For vehicles, this amount can be
determined by local area private party sales and dealer quotations for comparable vehicles.
AGENT
A licensed person or organization authorized to sell Insurance by or on behalf of an Insurance company.
ALLOWABLE CHARGE
The maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either
a reasonable or customary charge.
B
BENEFIT
Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to others.
Benefit Period
The maximum length of time for which benefits will be paid.
Brand Name Drug(s)
Those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under
patent protection, meaning the manufacturer is the sole source for the product.
BROKER
A licensed person or organization paid by you to look for Insurance on your behalf.
C
CANCELLATION
The Termination of Insurance coverage during the policy period. Flat cancellation is the cancellation of a policy as of its effective date, without
any premium charge.
CLAIM
A request for payment for benefits received or services rendered. A billing record as generated and submitted by a provider or subscriber
using paper or electronic media.
(COBRA) Consolidated Omnibus Budget Reconciliation Act of 1985
The federal law that requires employers with more than 20 employees to extend group health Insurance coverage for up to 36 months after
a qualifying event (e.g. Termination of employment, reduction in hours, divorce). The law contains detail provisions relating, among other
things, to an employer's obligation to provide notice of these rights and the circumstances under which such continuation may end. Some
states, such as California, have similar laws applicable to employers with more than 20 employees.
COINSURANCE
An arrangement under which the covered person pays a fixed percentage of the cost of medical care after the deductible has been paid. For
example, an Insurance plan might pay 80% of the allowable charge, with the insured individual responsible for the remaining 20%, which is
then referred to as the coinsurance amount.
Co payment OR COPAY
A type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but
may also be a dollar amount for specified services. The most common percentage co-payment is 20%.
COVERED MEDICAL EXPENSE
Those expenses payable according to the terms of the member contract. The charges for these services are still subject to any cost sharing
components or limits, such as deductibles, coinsurance, co-payments and maximums, included in the contract.
COVERED SERVICES
Hospital, medical and other health care expenses incurred by the covered person that entitle him/her to benefits under a contract. The term
defines the type and amount of expense, which will be considered in the calculation of benefits.
D
DECLINE
The Company refuses to accept the request for Insurance coverage.
DEDUCTIBLE
The amount of the loss which the insured is responsible to pay before benefits from the Insurance company are payable. You may choose a
higher deductible to lower your premium.
E
EFFECTIVE DATE
The date on which the coverage or a change in coverage of a contract goes into effect at 12:01 a.m.
EMERGENCY
In general, a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe
pain) which the member reasonably perceives could permanently endanger health if medical treatment is not received immediately. More
detailed or slightly different definitions may apply based on applicable law.
EXCLUSION
Certain causes and conditions, listed in the policy, which are not covered.
EXPIRATION DATE
The date on which the policy ends.
H
HEALTH Insurance / HEALTH Insurance
A policy that will pay specifies sums for medical expenses or treatments. Health policies can offer many options and vary in their approaches
to coverage.
Hospital
An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both
surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.
I
ID/IDENTIFICATION CARD
A card issued by a carrier to a covered person, which allows the individual to identify himself or his covered dependents to a provider for
health care services. The card is subsequently used by the provider to determine benefit levels and to prepare billing statement.
IN-NETWORK
Refers to the use of providers who participate in the carrier's provider network. Many benefit plans encourage covered persons to use
participating (in-network) providers to reduce the individual's out of pocket expense.
INSURED
The policyholder - the person(s) protected in case of a loss or claim.
INSURER
The Insurance company.
L
LIFE Insurance
A policy that will pay a specified sum to beneficiaries upon the death of the insured.
LIMIT
Maximum amount a policy will pay either overall or under a particular coverage.
M
MEDICAL PAYMENTS
Will pay reasonable expenses incurred for necessary medical and /or funeral services because of bodily injury caused by accident and
sustained by you or any other person.
Maternity Care
The care of women before and during childbirth as well as the care of newborn babies.
N
NEGOTIATED RATE
The amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge.
Negotiated rates are determined by Participating Provider Agreements.
NETWORK
The doctors, clinics, hospitals and other medical providers that a carrier contracts with to provide health care to its covered persons.
Individuals are generally limited to network providers for full coverage of their health costs.
O
OUT-OF-NETWORK
The use of health care providers who have not contracted with the carrier to provide services.
OUT-OF-POCKET MAXIMUM
Refers to the maximum amount that a covered person will have to pay for expenses covered under the plan. It is a sum of deductible and
coinsurance amounts.
P
PLAN BENEFIT MAXIMUM
Maximum amount the carrier will pay toward an individual's coverage. The amount varies depending on the type of coverage the individual
carries.
POLICY
The written contract of Insurance.
POLICY LIMIT
The maximum amount a policy will pay, either overall or under a particular coverage.
PRE-CERTIFICATION
Refers to certifying the medical necessity and level of care in advance. Pre-certification does not guarantee that contract benefits will be
available.
PRE-EXISTING CONDITION
A health condition or medical problem that was diagnosed or treated before enrollment in a new health plan or Insurance policy. Some
pre-existing conditions may be excluded from coverage.
PREMIUM
The amount of money an Insurance company charges for Insurance coverage.
Q
QUOTE
An estimate of the cost of Insurance, based on information supplied to the Insurance company by the applicant.
U
UNDERWRITING
The process of selecting applicants for Insurance and classifying them according to their degrees of insurability so that the appropriate
premium rates may be charged. The process includes rejection of unacceptable risks.
URGENT CARE
The services received for a sudden, serious, or unexpected illness, injury or condition, other than one which is life threatening, that requires
immediate care for the relief of severe pain or diagnosis and treatment of such condition.
| Important Disclaimer: As per our knowledge and experience, we have tried to provide answers but there is no guarantee of accuracy of these answers. The exact answers can vary time to time due to the change in Insurance companies policies/rules. Please use this information at your own risk. If you have any question/doubt, we strongly recommend you to contact us. |
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