Insurance Glossary
Explanation of basic insurance terms
A
Accident
Accident is an external, sudden, short-term, unintentional, not being a result of a disease or its treatment, unforeseen concourse of circumstances, which occurred during the policy period, where against the will of an insured person his/her health is damaged or he/she dies. Accidents among other things include but are not limited to the following: illegal actions of third parties (including terrorist attacks), attempts of rescuing people or freight in peril; inhalation of gas or vapor, as well as absorption of poisonous or aggressive substances; muscle lacerations and injuries resulting from sharp movement; frostbite; drowning.
B
Baggage Loss / Theft
Benefits are provided for the Accidental loss or theft to luggage, clothing and personal effects owned by (not hired, loaned, or entrusted to) the Plan Participant. Coverage is secondary to the common carrier settlement and no claims will be accepted until after the Plan Participant has filed and received settlement from the common carrier.
Conditions: a. If the common carrier used weight as a maximum compensation, then this Plan of Insurance will reimburse up to 2 times that of the common carrier reimbursement, subject to the limits shown on the Schedule of Benefits. b. Benefits will be calculated using the Insurer’s estimate of the market value of the item less deduction for age, wear, tear and depreciation, or the cost of repair, whichever is less. c. Any amount paid by a common carrier in settlement toward the loss will be deducted from the reimbursement made by the Insurer. d. The Plan Participant must observe ordinary proper care in the supervision of the insured property and in all cases of loss. e. In the event of a claim in respect to a pair or set of items, the Insurer shall only be liable in respect of the value of that part of the pair or set which is lost, stolen, or damaged. f. Claims will not be considered unless proof of ownership and evidence of value is provided. g. Any amount paid for temporary loss of baggage will be deducted from the final claim settlement if baggage proves to be permanently lost.
Exclusions: The Insurer shall not be liable for: a. Damage to baggage of any kind and or its contents; b. Any loss or theft, or suspected theft not reported to the Police within 24 hours of discovery and a written report obtained; c. Any damage or loss or theft of property in transit (or in possession of the Plan Participant), which has not been reported to the carrier and written report obtained; d. Loss of theft of any property left unattended in a public place; e. Any theft from an unattended motor vehicle unless the property is in a locked/covered luggage area, and there is evidence of forced entry which has been verified by a Police Report; f. Any loss from motor vehicles left unattended at any time between the hours of 10:00 p.m. and 8:00 a.m.; g. Loss, damage or theft of valuables and money packed in suitcases or other receptacles while travelling. h. Loss or damage caused by decay, wear and tear, moth, vermin, or atmospheric conditions’ i. Deterioration or mechanical derangement of any kind; j. Loss due to confiscation or detention by Customs or other authority; k. Damage to sports equipment while in use or loss of jewelry while swimming (other than wedding rings); l. Breakage of or damage to fragile articles and any consequence thereof. m. Property not covered by this Plan includes but is not limited to; unset precious stones, contact or corneal lenses, spectacles or accessories; stamps, documents, deeds, manuscripts or securities of any kind; items of a perishable nature; business goods, samples, tools of trade or motor accessories; household goods and home contents.
Conditions: a. If the common carrier used weight as a maximum compensation, then this Plan of Insurance will reimburse up to 2 times that of the common carrier reimbursement, subject to the limits shown on the Schedule of Benefits. b. Benefits will be calculated using the Insurer’s estimate of the market value of the item less deduction for age, wear, tear and depreciation, or the cost of repair, whichever is less. c. Any amount paid by a common carrier in settlement toward the loss will be deducted from the reimbursement made by the Insurer. d. The Plan Participant must observe ordinary proper care in the supervision of the insured property and in all cases of loss. e. In the event of a claim in respect to a pair or set of items, the Insurer shall only be liable in respect of the value of that part of the pair or set which is lost, stolen, or damaged. f. Claims will not be considered unless proof of ownership and evidence of value is provided. g. Any amount paid for temporary loss of baggage will be deducted from the final claim settlement if baggage proves to be permanently lost.
Exclusions: The Insurer shall not be liable for: a. Damage to baggage of any kind and or its contents; b. Any loss or theft, or suspected theft not reported to the Police within 24 hours of discovery and a written report obtained; c. Any damage or loss or theft of property in transit (or in possession of the Plan Participant), which has not been reported to the carrier and written report obtained; d. Loss of theft of any property left unattended in a public place; e. Any theft from an unattended motor vehicle unless the property is in a locked/covered luggage area, and there is evidence of forced entry which has been verified by a Police Report; f. Any loss from motor vehicles left unattended at any time between the hours of 10:00 p.m. and 8:00 a.m.; g. Loss, damage or theft of valuables and money packed in suitcases or other receptacles while travelling. h. Loss or damage caused by decay, wear and tear, moth, vermin, or atmospheric conditions’ i. Deterioration or mechanical derangement of any kind; j. Loss due to confiscation or detention by Customs or other authority; k. Damage to sports equipment while in use or loss of jewelry while swimming (other than wedding rings); l. Breakage of or damage to fragile articles and any consequence thereof. m. Property not covered by this Plan includes but is not limited to; unset precious stones, contact or corneal lenses, spectacles or accessories; stamps, documents, deeds, manuscripts or securities of any kind; items of a perishable nature; business goods, samples, tools of trade or motor accessories; household goods and home contents.
Baggage Delay
Benefits are provided for reimbursement for the replacement of necessities in the event of baggage being temporarily lost in transit during the outward journey for longer than 12 hours.
Conditions: a. Proof of a Missing Bag Report must be filed with the common carrier.
Exclusions and Limitations: The Insurer shall not be liable for:
a. Any items purchased after the return of the baggage will not be covered.
b. Benefit does not apply to the return or homeward journey.
Conditions: a. Proof of a Missing Bag Report must be filed with the common carrier.
Exclusions and Limitations: The Insurer shall not be liable for:
a. Any items purchased after the return of the baggage will not be covered.
b. Benefit does not apply to the return or homeward journey.
C
Copay
A copay is a fixed amount for a covered service that the Insured person is responsible to pay directly to the medical provider. This payment is usually made at the time of service. The Insured is not refunded for the amount of the Co-Payment.
Coinsurance
Coinsurance is the percentage of the Eligible Expenses for which the Insurance Company is responsible to pay. The remainder is paid by the Insured. The Coinsurance amount for Eligible Expenses is only paid after the Deductible has been met or the Co-Payment has been paid.
D
Deductible
The amounts of covered Allowable Charges payable by the Plan Participant during each Period of Insurance before the Plan benefits are applied. Such amount will not be reimbursed under the Plan. The Deductible is not considered part of the Out-Of-Pocket Maximum.
E
EOB
EOB = Explanation of Benefits. It's a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
ER
ER = Emergency Room - the department of a hospital that provides immediate treatment for acute illnesses and trauma. Emergency rooms are the most expensive places to receive care therefore should be used only for true emergencies.
F
First Health Network PPO
First Health Network PPO is the Preferred Provider Organization which your Policy utilizes. If you visit a First Health medical provider, your expenses are paid at the “Preferred Allowance”. It is always in your best financial interest to go to a First Health network medical provider.
F1 Visa
An F1 visa is a nonimmigrant visa for those wishing to study in the U.S. You must file an F1 visa application if you plan on entering the US to attend a university or college, high school, private elementary school, seminary, conservatory, language training program, or other academic institution.
H
Healthcare Network
A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members.
I
Injury / Illness
Illness is a physical sickness, disease, pregnancy and complications of pregnancy of a Plan Participant. This does not include Mental Illness. Injury is defined as an accidental bodily harm sustained by a Plan Participant that results directly and independently from all other causes from a covered Accident.
In-Network
In-Network doctors, other health care providers, and hospitals that contract with the healthcare network that you are a member of.
J
J-1 Visa
A J-1 visa is a non-immigrant visa issued by the United States to research scholars, professors and exchange visitors participating in programs that promote cultural exchange, especially to obtain medical or business training within the U.S.
M
Medical Evacuation
Medical Evacuation is the timely and efficient movement and en route care provided by medical personnel to injured patients being evacuated from the scene of an accident to receiving medical facilities, or to patients at a rural hospital requiring urgent care at a better-equipped facility using medically equipped ground vehicles (ambulances) or aircraft (air ambulances).
Medical Repatriation
Benefits are provided for either repatriation of mortal remains, or local burial is included in this Plan. This benefit excludes fees for return of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest expenses and similar person burial preferences.
MVA
MVA means Motor Vehicle Accident
N
Network
A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members.
P
Provider
The organization or person performing or supplying treatment, services, supplies or medications.
Pre-Existing Condition
Any Illness or Injury, physical or mental condition, for which a Plan Participant received any diagnosis, medical advice or treatment, or had taken any prescribed medication, or where distinct symptoms were evident prior to the Effective Date.
Preventive Care
Healthcare services that include check-ups, patient counseling and screenings to prevent illness, disease and other health-related problems.
S
Schedule of Benefits
The summary description of the benefits, payment levels and maximum benefits, provided under this Plan.
Student Health Center
Student Health Center means an ambulatory care facility affiliated or contracted with a Participating School that, at a minimum, maintains a staff consisting of a nurse director/nurse practitioner, staff Nurses, and either a staff Physician or an arrangement with a Physician to perform office visits. In the event a Participating School does not otherwise have a Student Health Center, the Participating School may request permission from the Program Manager to designate a Walk-In Pharmacy Clinic to be treated as a Student Health Center for the purposes of the policy.
T
Telemedicine
Telemedicine involves the remote distribution of health-related services and information via telephone and video. It allows long distance patient/clinician contact and care, advice, reminders, education, intervention, monitoring and remote admissions.
U
Urgent Care
Urgent care is a category of walk-in clinic focused on the delivery of same-day medical care in a dedicated medical facility outside of a traditional emergency department (emergency room). It is not intended to provide care of life threatening conditions!
URC
Usual Reasonable and Customary Charge: The lower of: 1) the Provider’s usual charge for furnishing the treatment, service or supply; or 2) the charge determined by the Insurer to be the general rate charged by the others who render or furnish such treatments, services or supplies to persons: 1) who reside in the same geographical area; and 2) whose Injury or Illness is comparable in nature and severity.
The Usual, Customary, and Reasonable charge for a treatment, service or supply that is unusual, or not often provided in the area, or that is provided by only a small number of Providers in the area, will be determined by the Insurer. The Insurer will consider such factors as: 1) complexity; 2) degree of skill needed; 3) type of specialist required; 4) range of services or supplies provided by a facility; and 5) the prevailing charge in other areas.
The Usual, Customary, and Reasonable charge for a treatment, service or supply that is unusual, or not often provided in the area, or that is provided by only a small number of Providers in the area, will be determined by the Insurer. The Insurer will consider such factors as: 1) complexity; 2) degree of skill needed; 3) type of specialist required; 4) range of services or supplies provided by a facility; and 5) the prevailing charge in other areas.