Insurance Terms                                                  



The beneficiary is enrolled in a health insurance plan and receives benefits through those policies.


Benefit refers to the amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.

Certificate of Insurance:

The certificate of insurance is printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. It discloses what is covered, what is not, and dollar amounts.


A claim is a request by an individual (or his or her provider) to an individual’s insurance company for the insurance company to pay for services obtained from a health care professional.


Coinsurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called “co-payment.”  Coinsurance is often specified by a percentage, i.e. the employee pays 20% toward the charges for a service and the employer or insurance company pays 80%.


The deductible is the amount an individual pays for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.

Denial of Claim:

Denial of claim is the refusal of an insurance company or carrier to honor a request by an individual (or is or her provider) to pay for health care services obtained from health care professional.


A dependent is a person or persons relying on the policy holder for support, may include the spouse and/or unmarried children (whether natural, adopted or step) of an insured.

Effective Date:

The date requested by an employer for insurance coverage to begin.


Exclusions are expenses which are not covered under an insurance plan. These are listed in the Certificate Booklet/Policy.

Explanation of Benefits:

An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the client must pay. The document is sometimes accompanied by a benefits check.

Guaranteed Issue:

Guaranteed issue refers to health insurance coverage that is guaranteed to be issued to applicants regardless of their health status, age, income-and guarantees that the policy will be renewed as long as the policy holder continues to pay the policy premium.


Health Insurance Portability & Accountability Act of 1996, P.L. 104-91. This law relates to underwriting, pre-existing limitations, guaranteed renewal, COBRA and certification requirements in the event someone terminates from the plan.

Individual Health Insurance:

Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan.

Lifetime Maximum Benefit:

The maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.


A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.

Maximum Dollar Amount:

The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period.  Maximum dollar limits vary greatly. They may be based on or specified in the terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.

Out-of-Pocket Maximum:

A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100% for an individual’s health care expenses.


Agreed upon fees paid for coverage of medical benefits for a defined benefit period. Premiums can be paid by employers, unions, employees, or shared by both the insured and individual and the plan sponsor.

Pre-Existing Condition:

A pre-existing condition is a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.


Provider is a term used for health professional who provide health care services. Sometimes, the term refers to only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapist, and others offering specialized health care services.


Within many managed care plans, transfer to specialty physician or specialty care by a primary care physician.


The company that assumes responsibility for the risk, issues insurance policies and receives premiums.

Worker’s Compensation Insurance:

Insurance coverage for work-related illness and injury. All states require employers to carry insurance.




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