The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan.
The availability of medical care. The quality of one’s access to medical care is determined by location, transportation options, and the type of medical care facilities available in the area, etc..
For health insurance purposes, an accident is an unforeseen, unexpected and unintended event resulting in bodily injury.
The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of a deductible.
Most group health insurance policies state that if an employee is not “actively-at-work” on the day the policy goes into effect, the coverage will not begin until the employee returns to work.
The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
A person professionally trained in the mathematical and statistical aspects of the insurance industry.
Actuaries frequently calculate premium rates, reserves and dividends and assist in estimating the costs and savings of benefit changes.
Typicablly, acupuncture services include services performed by a licensed acupuncturist.
Medical care administered, frequently in a hospital or by nursing professionals, for the treatment of a serious injury or illness or during recovery from surgery. Medical conditions requiring acute care are typically periodic or temporary in nature, rather than chronic.
For insurance purposes, this is the date on which a person’s age changes. Note that this may not correspond with the individual’s actual birthday, but may fall midway between birthdays. An age change may result in an increase in rates.
Ages below and above which an insurance company will not accept applications or renew policies.
ASO (Administrative Services Only) – An arrangement in which an employer hires a third party to deliver administrative services to the employer such as claims processing and billing; the employer bears the risk for claims. This is common in self-insured health care plans
Benefit—the amount payable by the insurance company to a plan member for medical costs.
Benefit level—the maximum amount that a health insurance company has agreed to pay for a covered benefit.
Benefit year—the 12-month period for which health insurance benefits are calculated,not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year.
A license from a governmental agency authorizing an individual or an employer to conduct business.
Claim—a request by a plan member, or a plan member’s health care provider, for the insurance company to pay for medical services.
A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.
Coinsurance—the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
Coordination of benefits—a system used in group health plans to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100% of the claim.
Copayment—one of the ways you share in your medical costs,You pay a flat fee for certain medical expenses (e.g., 10AED for every visit to the doctor), while your insurance company pays the rest.
When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient’s healthcare providers to assist in the management of the patient’s long-term needs, with appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member’s health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible.
In healthcare and insurance terminology, a chronic condition is one that is permanent, recurring or long lasting, as opposed to an acute condition.
Deductible—the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
Dependent—any individual, either spouse or child, that is covered by the primary insured member’s plan.
Drug formulary—a list of prescription medications covered by your plan.
Effective date—the date on which a policyholder’s coverage begins.
Exclusion or limitation—any specific situation, condition, or treatment that a health insurance plan does not cover.
Explanation of benefits—the health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.
Group health insurance—a coverage plan offered by an employer or other organization that covers the individuals in that group and their dependents under a single policy.
General Exclusion-The Exclusions, which are applicable under this Insurance Policy to all Benefits and shown in the General Exclusions List.
Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization.
Typically, hospitalization services include services related to staying at a hospital for either scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child.
Individual health insurance—health insurance plans purchased by individuals to cover themselves and their families. Different from group plans, which are offered by employers to cover all of their employees.
Medicare supplement plans—plans offered by private insurance companies to help fill the “gaps” in Medicare coverage.
Network—the group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.
Out-of-network provider—a health care professional, hospital, or pharmacy that is not part of a health plan’s network of preferred providers. You will generally pay more for services received from out-of-network providers.
Out-of-pocket maximum—the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.
Payer—the health insurance company whose plan pays to help cover the cost of your care. Also known as a carrier.
Pre-existing condition—a health problem that has been diagnosed, or for which you have been treated, before buying a health insurance plan.
Premium—the amount you or your employer pays each month in exchange for insurance coverage.
Provider—any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.
Rider—coverage options that enable you to expand your basic insurance plan for an additional premium. A common example is a maternity rider.
Underwriting—the process by which health insurance companies determine whether to extend coverage to an applicant and/or set the policy’s premium.
Waiting period—the period of time that an employer makes a new employee wait before he or she becomes eligible for coverage under the company’s health plan. Also, the period of time beginning with a policy’s effective date during which a health plan may not pay benefits for certain pre-existing conditions.
A factor employed by insurance companies in the underwriting process, used to determine a group’s risk of incurring medical costs, based on the ages and genders of the persons in that group.
Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization
Any Hospital Confinement, for a minimum of one night, of Medically Necessary Treatment/ observation, of any Non-Excluded Disease or Bodily Injury necessitating specialised medical attention and care in a Hospital before, during and after the Treatment/observation, and which cannot be performed on an Out-of-Hospital basis.Renewal occurs when a member continues coverage under a health insurance plan beyond the original time frame of the contract. At the end of each benefit year, a plan member is generally invited to renew his or her coverage.
The date on which a member’s health insurance plan benefit year renews.
Typically, inpatient maternity services include hospitalization and physician fees associated with the birth of a child.
Typically, outpatient maternity services include OB-GYN office visits during pregnancy and immediately after giving birth.
Maternity coverage means the insurance covers part or all of the medical cost during a woman’s pregnancy. Coverage is broken down into inpatient and outpatient services. Typically, inpatient coverage includes hospitalization and physician fees associated with child birth. Outpatient coverage pays for prenatal and postnatal OB-GYN office visits.
A drug which is exactly the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug’s patent has expired. Generic drugs are usually less expensive than brand name drugs.
A time period after the payment due date, during which insurance coverage remains in force and the policyholder may make a payment without penalty.
Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.
Third party administrator (TPA) – An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance. The TPA is not the policyholder or the insurer.
Legal Dependants-The unmarried children who are under 18 year old, or below 25 if still a full-time university student, and the Spouse(s) of the Enrolled Employee.
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