Common Health Insurance Terms

These are some commonly used insurance terms. Call the health insurance office at 803-777-1916 if you need more clarification.

Accident An unexpected event that causes injury.

Basic medical plan Insurance coverage that pays agreed-on medical expenses up to a relatively low maximum. For example, an insurance maximum may be $50,000 lifetime benefit for each injury or sickness.

Benefits The money the insurance company pays a healthcare provider for medical services if you become ill or injured.

Claim A request by you for payment by the insurance company of medical expenses that are covered under the insurance policy. The provider of a medical service will usually file a claim for you.

Co-insurance You and the insurance company share the cost of medical procedures in a specified proportion. For example: 80% (company) and 20% (you).

Co-payment The set or fixed dollar amount you are required to pay each time a particular medical service is rendered.

Coverage The conditions under which the insurance company will pay.

Deductible The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a $250 deductible, the insurance company pays as agreed after you pay the first $250 for qualifying expenses.

Dependents Your spouse and children. If you are covered under your parents’ insurance, you are their dependent.

Emergency A severe medical condition which may include pain, loss of breathing or consciousness, heart attack, stroke, poisoning, convulsions or severe bleeding.

Exclusions  Conditions under which the insurance company will not pay; for example, cosmetic procedures are exclusions.

Explanation of Benefits (EOB) The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.

Identification Card A card given to you that identifies you as being eligible for benefits. The card must be presented when seeking treatment.

Insurance A system under which individuals, businesses and other organizations, in exchange for a premium, are promised payment for losses resulting from certain dangers as specified in a contract. 

Insurance Company An organization licensed to operate as an insurer.

Insurance Policy The legal document issued by the company to the policyholder which outlines the terms and conditions of the insurance; also called a "contract."

Insured  A person or organization covered by an insurance policy.

Major Medical A plan that provides much broader coverage than the basic medical plan.You may increase your coverage by paying an additional amount over your basic premium.

Out-of-Pocket Costs The total you pay out of your pocket for a policy year. These costs include the deductible, co-insurance and amounts considered by the insurance company to be above the "Usual and Customary charges."

Pharmacy A business where drugs approved by a doctor are legally sold.

Pre-existing Condition A medical condition that required treatment during a fixed period of time, usually 3 or 6 months, before you purchased your insurance policy.

Premium The price you pay for your insurance policy. 

Stop Loss See "Out-of-Pocket Costs."

Usual and Customary Charges (Also called "Reasonable and Customary Charges") The routine charge for a medical service by similar professional medical providers in the same geographical area.