Glossary

Coinsurance
The amount you are required to pay after you have met your deductible. The coinsurance rate is usually an expressed percentage. Example: If the insurance company pays 80% of the claim. You pay 20%.
Co-payment or Co-pay
Refers to the payment that must be made at the time of service for Physician Office Visits
Deductible
Is a specified dollar amount which must be paid by the covered individual in each deductible accumulation period before payment of benefits will be made by the insurance company.
Emergency Services
Services provided within 48 hour of an injury or medical emergency.
Exclusions
Specific conditions or circumstances for which the policy will not provide benefits.
Medical Emergency
The sudden onset of a medical condition with acute symptoms of severity that the absence of immediate medical condition could result in:A) permanently placing the patients health in jeopardy;
B) causing other serious medical consequences;
C) causing serious impairment to bodily functions;
D) causing serious and permanent dysfunctions to any body part;
Medical Necessary
Describes health care treatments, services or supplies which are appropriate and consistent with the diagnosis and treatment of a medical condition according to generally accepted medical standards.
Out-of-pocket expenses
Refers to the amount a covered person will have to pay “Out of their pocket” in a calendar year.
Pre-existing condition
Condition for which a person received medical care, treatment, services, medication, diagnosis, or consultation 12 months prior to the insured person’s effective date of coverage or a condition that produced symptoms that are distinct and significant enough to establish the onset of a condition or that the condition manifested itself, where a person learned in medicine would be able to diagnose the condition because of those symptoms.
Premium
The amount you pay in exchange for insurance coverage.
Provider
Any person (Doctor, Nurse, Dentist) or institution (hospital or clinic) that provides medical care.