Insurance Terms and Definitions

Co-Payment or Co-Insurance

Is a specific dollar amount that you must pay to a doctor at the time of service. For example, if your insurance will pay 80% of a bill, then your co-pay will be 20%.

Covered Medical Expenses

Means costs for services and supplies included under the policy.

Deductible

A "deductible" is the amount of money you must pay toward a medical bill that the insurance company will not pay . For example, if you have a $20 deductible on a visit to the doctor's office, you must pay $20 and the insurance will begin from that point to pay for covered expenses.

Medical Emergency

Means the occurrence of a sudden, serious and unexpected Sickness or Injury. This condition could result in:

  • Death
  • Serious danger to the person's body
  • Serious danger to the health of a pregnant woman

Medical Necessity

This policy only pays for services and supplies that are a Medical Necessity. No benefits will be paid for expenses that are not a Medical Necessity, including any or all days of Hospital Confinement.

Pre-Existing Condition

The existence of symptoms or signs of illness within the 180 days immediately prior to the date your insurance began.

  • Any condition which begins, is diagnosed, treated or recommended for treatment within the 180 days immediately before the date under the policy. Pre-Existing Conditions will not be covered under this policy until the Insured (you) has been covered by the plan for 180 days.

Prescription Drugs

  • Any medication which a doctor wants you to take - s/he will write it down.
  • Injectable insulin

Provider vs. Non-Provider

A provider is a physician who is in the insurance's network of physicians. Your co-pay for these physicians will be 20% which is your responsibility. For any physician that is not in our network, your co-pay will be 40%, which is your responsibility.

Usual and Customary Charges

Means a reasonable charge which is usual and customary for similar services and supplies. No payment will be made under this policy for any expenses which are more than the Usual and Customary Charges. Let's say that the usual fee, based on an accurate study of doctors' charges, for an anesthesiologist is $500. But he charges you $600. Your insurance will pay its percentage of the $500. You'll pay anything above that percentage of the $500, plus your deductible.