Insurance Glossary
Explanation of basic insurance terms
A
Accident
Accident is an external, sudden, short-term, unintentional, not being a result of a disease or its treatment, unforeseen concourse of circumstances, which occurred during the policy period, where against the will of an insured person his/her health is damaged or he/she dies. Accidents among other things include but are not limited to the following: illegal actions of third parties (including terrorist attacks), attempts of rescuing people or freight in peril; inhalation of gas or vapor, as well as absorption of poisonous or aggressive substances; muscle lacerations and injuries resulting from sharp movement; frostbite; drowning.
Aetna Passport
Aetna Passport to Healthcare Network: The Preferred Provider Organization which your Policy utilizes. If you visit an Aetna Passport to Healthcare medical provider, your expenses are paid at the “Preferred Allowance”. It is always in your best financial interest to go to a Aetna Passport to Healthcare network medical provider.
C
Copay
A copay is a fixed amount for a covered service that the Insured person is responsible to pay directly to the medical provider. This payment is usually made at the time of service. The Insured is not refunded for the amount of the Co-Payment.
Coinsurance
Coinsurance is the percentage of the Eligible Expenses for which the Insurance Company is responsible to pay. The remainder is paid by the Insured. The Coinsurance amount for Eligible Expenses is only paid after the Deductible has been met or the Co-Payment has been paid.
D
Deductible
Deductible means the dollar amount of eligible expenses which must be incurred and paid by the insured before benefits are payable under the policy. Such amount will not be reimbursed under the Plan. The Deductible is not considered part of the Out-Of-Pocket Maximum. It applies separately to each insured. Depending on the policy, the deductible may be per accident per sickness or per policy year.
E
EOB
EOB = Explanation of Benefits. It's a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
ER
ER = Emergency Room - the department of a hospital that provides immediate treatment for acute illnesses and trauma. Emergency rooms are the most expensive places to receive care therefore should be used only for true emergencies.
H
Healthcare Network
A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members.
I
Injury
Injury means bodily harm which results independently of disease or bodily infirmity, from an Accident after the effective date of an Insured’s coverage under the Policy, while the Policy is in force as to the person whose Injury is the basis of the claim. All injuries to the same Insured sustained in one Accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury.
In-Network
In-Network doctors, other health care providers, and hospitals that contract with the healthcare network that you are a member of.
Inpatient
Inpatient means an Insured who is confined in an institution and is charged for room and board.
Insurer
Insurer means duly licensed insurance organization indicated in the Policy, who ultimately carries the insurance risk under the Contract.
M
Medical Evacuation
Medical Evacuation is the timely and efficient movement and en-route care provided by medical personnel to ill or injured patients being evacuated from the scene of an accident to receiving medical facilities, or to patients at a rural hospital requiring urgent care at a better-equipped facility using medically equipped ground vehicles (ambulances) or aircraft (air ambulances).
Medical Repatriation
Medical Repatriation is the transportation of a participant with a medical condition back to their home country with some form of medical assistance. Medical Repatriation usually refers to transportation back to the home country for recovery or rehabilitation after emergency services in another country. Medical Repatriation is also appropriate when a medical condition prohibits the Plan Participant from actively participating in the overseas program or assignment.
O
Out-of-pocket maximum
Out-of-Pocket Maximum means the maximum dollar amount the Insured is responsible to pay during a Policy Term. After the Insured has reached the Out-of-Pocket Maximum, the Policy pays 100% of Eligible Expenses for the remainder of the Policy Term. The Out-of-Pocket Maximum is met by accumulated Deductible, Coinsurance and Co-payments. Penalties and amounts above the Usual, Reasonable and Customary Expenses do not count toward the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is shown on the Schedule of Benefits. Not all policies have an Out-of-Pocket maximum.
Outpatient
Outpatient means an Insured who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for a Injury, but who is not confined and is not charged for room and board.
P
Policy
Policy means the policy document, the application of the policyholder and the participating organization and any end endorsements, riders or amendments that will attach during the period of coverage.
Pre-Existing Condition
Pre-Existing Condition means an Injury, Sickness, disease, or other condition during the Look-back period (specified in the Schedule of Benefits), immediately prior to the date the Insured’s coverage is effective for which the Insured 1) received or received a recommendation for a test, examination, or Medical Treatment for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or treatment; or 2) took or received a prescription for drugs or medicine.
Preferred Allowance
Preferred Allowance refers to the amount an in-network provider will accept as payment in full for covered medical expenses.
Preventive Routine Care
Preventive and Routine Care means healthcare services that include check-ups, immunizations, patient counseling and screenings to prevent illness, disease and other health-related problems.
R
Repatriation of Mortal Remains
This is the expense of preparation and the air transportation of the mortal remains of the Plan Participant from the place of death to their Home Country. This benefit is excluded where death occurs in their Home Country. This benefit excludes fees for return of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest expenses and similar person burial preferences.
S
Schedule of Benefits
The schedule of benefits is a summary which specifies the benefits available under the policy, which is subject to the policy definitions, exclusions and benefit limits.
Service Provider
Service provider means a hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, physician, dentist, chiropractor, licensed medical
practitioner, registered nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the insurer approves.
practitioner, registered nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the insurer approves.
Sickness
Sickness means Sickness or disease contracted and causing loss commencing while the Policy is in force as to the Insured whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Insured is being treated or has received Treatment will be considered as part of the original Sickness.
T
Telemedicine
Telemedicine involves the remote distribution of health-related services and information via telephone and video. It allows long distance patient/clinician contact and care, advice, reminders, education, intervention, monitoring and remote admissions.
TPA
TPA = Third Party Administrator. The TPA is usually the organization who is responsible for administering the health insurance policy and is chosen by the Insurer.
U
Urgent Care
Urgent care is a category of walk-in clinic focused on the delivery of same-day medical care in a dedicated medical facility outside of a traditional emergency department (emergency room). It is not intended to provide care of life threatening conditions.
URC
URC = Usual Reasonable and Customary Charge: The lower of: 1) the Provider’s usual charge for furnishing the treatment, service or supply; or 2) the charge determined by the Insurer to be the general rate charged by the others who render or furnish such treatments, services or supplies to persons: 1) who reside in the same geographical area; and 2) whose Injury or Illness is comparable in nature and severity. The Usual, Customary, and Reasonable charge for a treatment, service or supply that is unusual, or not often provided in the area, or that is provided by only a small number of Providers in the area, will be determined by the Insurer. The Insurer will consider such factors as: 1) complexity; 2) degree of skill needed; 3) type of specialist required; 4) range of services or supplies provided by a facility; and 5) the prevailing charge in other areas