AOC INSURANCE MEDICAL GLOSSARY
AOC Insurance Glossary: general insurance and medical terms
In collaboration with Dr. Alex Cochez
According to traditional Chinese medicine (TCM) acupuncture deals with the flow of chi through meridians by inserting thin needles into acupuncture points. Acupressure uses physical pressure instead. In health insurance usually covered as a separate benefit.
Sudden injury usually due to a vehicle accident, fall, burn, sports or fight.
Insurance companies will only accept applications or renewals within a certain age range.
Maximum amount of money the insured will be covered for during a one year policy and per member.
The core of a health insurance plan is its table of benefits. Each benefit describes covered prevention, diagnostics and treatment for a set of medical conditions and defines its co-pay, deductibles, limit and exclusions. Examples are dental care and outpatient treatment.
Maximum amount that the insurer will pay for a specific benefit, sometimes during one year or per event as described in the table of benefits. Mainly applied to benefits like dental care, vision care, chronic diseases and maternity.
If the insurer offers direct billing, the insured doesn’t have to pay to receive medical care (in accordance to the policy’s benefits). Only the policy member card has to be shown to the healthcare provider assuming the latter is part of the insurer’s direct billing provider network.
Opposite to Pay and Claim.
Form of manual medicine with focus on musculoskeletal treatment. Legislation may differ by country and as such might be considered as conventional or complementary medicine. In health insurance covered as a separate benefit, usually with a frequency limit.
Diseases which present themselves with one or more of following characteristics: recurrent nature, unidentified cause, difficult to treat, resulting into palliative care or a disabled condition.
Form to reimburse or refund medical costs. Has to be submitted to the insurance company or TPA and is available online.
See Pay and Claim.
Part of expenses the insured must pay every time he or she relies on a specific medical benefit. Either a percentage or fixed amount and defined in the policy’s table of benefits.
Complementary and Alternative Medicine (CAM)
There is a lot of debate but without doubt CAM provides equal and even better results for some medical conditions. However health plans consider all complementary healthcare within separate benefits and not all policies will cover these benefits.
Depending on culture and legislation its definition might vary. However from a health insurance perspective outpatient and inpatient treatment only includes medical care given by registered doctors, nurses and physiotherapists. Other healthcare providers are considered as complementary and alternative medicine.
Country Of Origin
Country for which the insured holds a passport.
Country Of Residence
Country where the insured resides as expatriate. Remind this is from an insurance point of view. Ie. in taxation terminology a slightly different definition might apply.
Critically Ill Patient
These patients typically demand intensive care monitoring and treatment. Mostly due to cardiorespiratory failure.
Total amount of money the insured is supposed to pay before the insurer starts paying all further medical expenses. Deductibles may apply on a per year or on a per condition basis. Deductibles are a key factor affecting the premium cost.
Teeth maintenance. In health plans always covered as a separate benefit and offered with varying levels of coverage from routine dental treatment like polishing and scaling to orthodontics.
Health care practitioner specialized in diagnosis, treatment and prevention of diseases of teeth and mouth. Considered as a conventional healthcare provider.
Dental implants are complete or partial false teeth like bridges, crowns, inlays and onlays.
Most health plans offer a dependent status for family members/significant other.
They have the same benefits as the main insured.
See Cashless Settlement.
Direct Billing Provider Network
Some insurers have an agreement with their medical provider network to act as a direct billing provider and as such the healthcare provider will charge the insurer directly. No upfront cash required. This database is available online.
A sudden, critical condition of a patient’s health which demands immediate, live-saving action. Emergencies involve seriously injured/critically ill patients.
Medical emergency transport (ambulance, airflight) to the nearest medical facility suitable to the needs of a critically ill or seriously injured patient.
Medical condition which is not covered by a health plan.
Somebody temporarily or permanentlly residing in a different country and culture then where they were raised.
Full Medical Underwriting (FMU)
In-depth risk analysis of the applicant’s medical history, provided in the medical questionnaire.
Opposite to Moratorium Underwriting.
Registered doctors. However legislation might differ by country. In some countries they are specialized doctors and work as family doctors. Other countries consider every medical graduate without further specialty training as a general practisioner.
Geographical Area Of Cover
Set of countries where the insured is entitled to undergo medical treatment. Scope might vary from a local region to worldwide coverage in accordance to the chosen expat health plan and is a key factor affecting the premium cost.
Good Medical Practise
Core ethical guideline reflecting the principles and values healthcare professionals should be concerned about.
Guarantee Of Payment (GOP)
When the insurer or TPA approves a pre-certification form, they will send a letter of guarantee to the healthcare provider which counts as proof of cover for upcoming diagnostic tests or medical treatment and defines benefit details like co-pay and limits.
Hazardous Sports Cover
Travel insurances cover most sporting activities. However some dangerous sporting activities involve more risk and require extra coverage like scuba diving, rock climbing and paragliding.
See country of origin.
Inpatient Treatment (IP)
When the patient’s medical condition requires an overnight (or longer) stay in a hospital.
Company selling the insurance plan.
Person or entity buying the insurance plan.
See insurance company.
International Health Insurance for Expats
An expat health plan is intended for those who live more than one year abroad. It’s a financial protection in case the insured becomes critically ill/seriously injured. These policies offer a varying set of medical benefits, annual limits and geographical areas.
Letter Of Guarantee (LOG)
See guarantee of payment.
Level Of Cover
Health policies offer different level of covers. Mainly each plan has a different set of benefits, limits and exclusions. Basic policies usually cover inpatient treatment and exclude outpatient and particular benefits.
Maternal care during pregnancy. In health policies covered as a separate benefit and offered with varying levels of coverage. Routine prenatal tests conform good medical practise and natural childbirth are usually included with a benefit limit for each pregnancy. C-section delivery and complications are often covered as a separate benefit.
Healthcare practisioner graduated from a medical faculty, licensed by a national board and specialized in diagnosis, treatment and prevention of diseases and injuries and other physical and mental impairments.
Medical Provider Network (MPN)
Partnership between the insurance company and healthcare providers. The MPN database is available online. Some healthcare providers will act as direct billing provider.
List of questions concerning the insured’s medical history and current medical status. Required for full medical underwriting and to be completed by the applicant together with the application form.
Moratorium literally means waiting period. And so in health insurance it represents a 24 month delay of cover for known pre-existing conditions. If during these 24 months the insured shows any specific symptoms or receives medical care for this pre-existing disease, the insurer will not start covering it.
Medical specialty diagnosing and treating cancer.
Dental devices like braces, retainers and invisalign to align teeth more appropriately.
Complementary medicine based on a qualititave and quantitative use of nutritional molecules to diagnose, treat and mainly prevent certain medical conditions. However vitamines and supplements are not considered as prescription drugs and as such not covered.
Form of holistic, manual medicine. Usually focused on musculoskeletal, visceral and cranial manipulation. Legislation may differ by country and as such might be considered as conventional or complementary medicine. In health insurance covered as a separate benefit, usually with a frequency limit.
Over The Counter drugs (OTC)
OTC medication can be purchased without a physician’s prescription. However legislation differs by country. Remind insurers will not reimburse OTC medication.
Opposite to Prescription Drugs.
Out Of Pocket
Part of expenses the insured has to pay directly to the health care provider, without getting reimbursed. Typically for co-pay and deductibles.
Outpatient Daycase Surgery
Usually minor or intermediate surgical procedures under local anesthesia and intended for overall healthy patients. Discharge will occur within the same day. Remind this is not an inpatient treatment as the patient doesn’t stay overnight.
Outpatient Treatment (OP)
Medical care for which the patient doesn’t have to stay overnight in a hospital.
Benefit covering usual, reasonable and customary charges for a parents’ hospital accomodation while their child has been admitted.
Pay And Claim Procedure
The insured will have to pay all medical expenses in advance. Once all invoices received the insured can complete a claim form and have it sent to the insurer or TPA. As a final step the insurer will refund (according to the policy and benefit description).
Opposite to Direct Billing.
Manual therapy discipline and considered as conventional medicine. Therefore prior to treatment a physician’s prescription is required. In healthcare insurance covered as a separate benefit, usually with a frequency limit.
Contract detailing the medical benefits for which the insured will be covered.
Exact offer from the insurer. Containing all details like benefits, limits, exclusions and geographical area of coverage.
See Annual Limit.
Pre-approval - Prior approval
Involves the process of requesting an approval from the insurer or TPA about upcoming medical care or diagnostic tests. Usually required for outpatient daycase surgery, all inpatient treatment, prenatal care and some specific benefits. Pre-certification forms are available online.
Pre-existing medical Conditions
Any medical condition the insured suffered prior to joining a new health plan or upgrading to a higher level of cover.
The annual amount to be paid for a specific insurance. Some factors influencing the premium cost are the insured’s age and medical condition, geographical area of cover, country of residency, deductible, payment frequency, underwriting type.
Medication which is not available without a physician’s prescription. While filing a claim, the physician’s prescription is supposed to be enclosed.
Opposite to Over The Counter Drugs.
Treatment to promote and encourage health and doing so to prevent diseases.
Recovery from a varying range of medical causes and consequently with a varying range of goals and outcome.
Expiring date of a health insurance plan unless renewed. Usually there’s a 1 year time of coverage. Premiums might change due to medical inflation and sometimes it’s useful to compare what other policies have to offer at that moment.
As soon as being declared fit to fly, the insured can be repatriated to his county of origin/residence. Usually by commercial airline flights. Might refer to the transportation of the deceased’s mortal remains as well.
Standard Private Room/Ward
Hospital room with 1 bed. It’s the lowest rate private room available. Accepted costs based on URC.
Hospital room with 3 to 8 bed. It’s the lowest rate room available.
Standard Semi Private Room/Ward
Hospital room with 2 beds.
Seriously Injured Patient
Due to acute trauma these emergency patients require rapid assesment of their injuries and live-saving treatment.
Third Party Assistance Company (TPA)
Office acting as an intermediary between the insured and the insurance company and as such responsible for the medical underwriting, claims/pre-certification handling, the medical provider and direct billing network.
Intended for those who will be travelling less than one year without option for renewal. This plan covers mainly emergency inpatient treatment, lost baggage and missed flight departures.
Second medical opinion
When the insured experiences difficult health circumstances abroad, a medical reassesment or advice by another and unbiased physician can become a valuable and sometimes necessary resource.
Trip Cancellation or Interruption
Benefit refunding trip expenses if cancelled or interrupted due to illness, death or other unpredictable causes.
Risk analysis based on an applicant’s medical condition and sofort his or her eligiblity for a specific health insurance plan. Two types of underwriting are used in expat health insurance: moratorium and full medical underwriting.
Usual, Reasonable and Customary Charges (URC)
Average cost for a specific medical service based on common sense and statistics for a given country. The insured will be reimbursed if the medical expenses are URC compliant.
Everything related to eye care. In health insurance covered as a separate benefit.
See Conventional Medicine.
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2012 - Alex Cochez - Medical Docteur