Private Medical/Healthcare Insurance is, well insurance!
As such there are a plethora of words and phrases that have specific legal implication that get used during advisory conversations. All the advisers that Sustainable Healthcare recommends strive to speak in plain English. However below you will find a glossary of terms that you may choose to refer to.
Accommodation charges. Charges relating to your hospital room, meals and nursing directly to your treatment
Acupuncture. An ancient system of healing achieved by the insertion of needles into strategic body points.
Acute condition. A medical condition that responds to treatment, which aims to return you to your previous state of health or leads to your full recovery.
Alternative medicine. Treatments such as acupuncture, homeopathy and other complementary treatments.
Allowed Amount - The highest amount we will cover (pay) for a service.
All risks cover provides the broadest form of insurance cover. Such policies do not name the risks covered but list the exclusions and all unnamed risks are automatically covered.
Benefit Period - When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.
Example: You may have a plan with a benefit period of January 1 through December 31 that covers 10 physical therapy visits. The 11th or more session will not be covered.
Benefits. The cover provided by your plan
Birth defect. Any deformity, abnormality or disability, arising during pregnancy, or caused during childbirth.
Bodily injury. Any physical harm or damage to you.
Claim. Any report of an incident in which the policy holder requests a payout or indemnity from the insurer under the conditions of the policy.
Coinsurance - A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay.
Example: Your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance.
Coinsurance Limit (or Maximum) - The most you will pay in coinsurance costs during a benefit period.
Condition - An injury, ailment, disease, illness or disorder.
Contract - The agreement between an insurance company and the policyholder.
Covered Charges - Charges for covered services that your health plan paid for. There may be a limit on covered charges if you receive services from providers outside your plan's network of providers.
Covered Person - Any person covered under the plan.
Covered Service - A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.
Dependent Coverage - Coverage for your dependents who qualify.
Cancer. A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.
Cash benefit. A cash payment which is normally payable when a policyholder or member stays in a non-fee paying hospital.
Chronic. A medical condition which has one or more of the following characteristics:
• needs on-going or long-term monitoring through consultations, examinations, check-ups or tests
• needs on-going or long-term control or relief of symptoms
• requires your rehabilitation or for you to be specially trained to cope with it
• continues indefinitely
• has no known cure
• comes back or is likely to come back
Congenital abnormality. A medical condition that is present at birth or is believed to have been present since birth, whether it is inherited or caused by an environmental factor.
Consultant. Please see specialist.
Continuation of Personal Medical Exclusions. If you transfer from another insurer they may offer to continue the same underwriting terms including any special exclusion which previously applied to you. Upon agreement, you will not be subject to any new personal underwriting terms.
CPME. See Continuation of Personal Medical Exclusions.
Critical. A medical condition which is unstable and serious, where the outcome cannot be medically predicted, prognosis is uncertain and the person may die.
Date of joining. When you first became a member on the plan.
Daycare treatment. Treatment at a hospital or a day-care unit when medical supervision is needed for recovery, but you do not stay overnight.
Dental. That which affects the teeth and gums.
Dependant. A plan holder’s
• husband, wife or partner
• unmarried child, stepchild or legally adopted child under a defined age
• unmarried child under a defined age who is in full-time education
Diagnostic tests and procedures. A medically necessary test or examination to investigate the cause of your symptoms.
Emergency. A sudden, unexpected acute medical condition or an unexpected acute episode of a chronic medical condition that, without treatment within 48 hours of onset, could result in death or serious damage to bodily functions.
Excess. The amount you must pay towards the cost of a covered claim
Exclusion. A medical condition which will not be covered by your policy
Full medical underwriting (FMU). With full medical underwriting, you disclose your entire medical history upfront and the insurer places outright exclusions on most pre-existing conditions. They’ll usually rule out covering any pre-existing conditions, although there may be leeway to negotiate cover for more minor illnesses at your insurer’s discretion.
Hazardous pursuits. Any activity or sport that places you at an increased risk of suffering a medical condition or making an existing medical condition worse.
Hospice. An organisation providing services for patients with terminal illnesses. Hospice care may be received as an in-patient or out-patient, at home, or at a centre for controlling pain and other symptoms.
Hospital. An institution that provides medical, surgical or psychiatric care and treatment for the sick or the injured. Different insurers and their policies offer different hospital access.
Health Assessment - A health survey that measures your current health, health risks and quality of life.
Inpatient Services - Services received when admitted to a hospital and a room and board charge is made.
Institution (Institutional) - A hospital or certain other facility.
Insurance premium tax. A government tax
IPT. See Insurance premium tax.
Long-term Insurance - A type of health insurance that covers certain services over a set amount of time (typically a 12-month period).
Medical Care - Medical services received from a healthcare provider or facility to treat a condition.
Medically Necessary (or Medical Necessity) - Services, supplies or prescription drugs that are needed to diagnose or treat a medical condition. Also, an insurer must decide if this care is:
Medical conditions. Signs or symptoms, injury, illness, sickness or disease.
Medical inflation. The average rate that medical insurance premiums increase annually
MRI scan. Full screening using a magnetic resonance imaging (MRI) scanner.
Moratorium underwriting. Moratorium underwriting excludes most pre-existing conditions you’ve suffered over a set period, usually the last 5 years.
Accepted as standard practice. It can't be experimental or investigational.
Not just for your convenience or the convenience of a provider.
The right amount or level of service that can be given to you.
Example: Inpatient care is medically necessary if your condition can't be treated properly as an outpatient service.
Non-covered Charges - Charges for services and supplies that are not covered under the health plan.
Nursing at home. Services of a registered nurse in your home when prescribed and supervised by a medical practitioner, consultant or specialist and related directly to a medical condition for which you are receiving treatment under the plan.
Outpatient Services - Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic.
Out-of-pocket Cost - Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost. Consult your plan for more information.
Orthodontic. That which affects the structure, function, or development of the teeth, upper or lower jaw or the oral cavity.
Oncology. A branch of medicine that deals with tumours (cancer).
Period of insurance the period of time covered by the policy as shown in the policy schedule and any further period for which the insurer agrees to insure you.
Prescription Drug - Any medicine that may not be given without a prescription because of federal or state law.
Policy is the name sometimes given to your contract of insurance. It refers to the level of cover that you have agreed with your insurer, outlines the terms, and details any particular conditions that you need to be made aware of, or that you need to make your insurer aware of.
Premium - Payments you make to your insurance provider to keep your coverage. The payments are due at certain times.
Provider (Healthcare Provider) - A hospital, facility, physician or other licensed healthcare professional.
Palliative. Treatment aimed to relieve the symptoms, rather than to stop, delay, or reverse progression of the medical condition causing them or provide a cure.
Physiotherapy. A practice to improve a broad range of physical problems associated with different parts of the body.
Plan year. A period of 12 months from the plan start date, as shown on a valid certificate of insurance.
Pre-authorised, pre-authorisation. The process you must follow to get approval from the insurer before receiving or incurring costs for treatment.
Pre-existing. Any medical condition or related medical condition which typically has one or more of the following characteristics:
• was foreseeable
• clearly showed itself
• you had signs or symptoms of
• you asked for advice about
• you received treatment for
• to the best of your knowledge, you were aware you had
Professional sports. Sports which you are being paid to take part in and where any payment is received.
Psychiatric. A medical condition which affects your mind, mental function or emotions whether the cause is organic, traumatic or reactive.
Rehabilitation. Treatment aimed to restore your health or mobility to help you live a more independent life.
Renewal date. The anniversary of the start date of the plan as shown on a valid certificate of insurance.
Routine health check. Diagnostic tests and procedures where no medical condition or symptoms are present.
Short-term Insurance - A type of health insurance that covers certain services for a set time period (6 months or less). Learn more about short-term insurance.
Six week wait benefit. Where you will need to use NHS facilities or self-fund private treatment - unless the waiting list is 6 weeks or more, in which case private treatment can be typically received without delay.
Specialist. A medical practitioner who is practising and has a recognised certificate of higher specialist training or a consultant appointment (or equivalent), in the field of medicine for which the treatment is needed and in the country where treatment is provided.
Start date. The date you join the plan or any future renewal date as shown on a valid certificate of insurance.
Terminal. The end stages of a medical condition where life expectancy is considered to be weeks or months. Treatment is limited to relief of symptoms and no active treatment is being given.
Therapist. A physiotherapist, chiropractor, osteopath, homeopath or acupuncturist who is qualified.
Treatment. Any surgical or medical services, including diagnostic tests and procedures, which are needed to diagnose, relieve or cure a medical condition.
Always talk to an adviser when buying Private Medical Insurance. They will match your requirements to the many different policy options and get you the best deal.
In the private medical insurance arena, these people act more like pension or mortgage advisers than your typical insurance salesperson. And they’re always going to be on your side.