Medical Insurance

Health insurance is a form of insurance, where individuals pay premiums in order to help protect themselves from high or unexpected healthcare expenses. Health insurance works by estimating the overall "risk" of healthcare expenses and developing a routine finance structure (such as a monthly or annual premium) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement.

How it works

A Health insurance policy is a contract between an insurance company and an individual. The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms.

Terms applied to a Medical Policy:

Certificate period:
The dates on your insurance certificate that show the start date and end date of the period for which your benefit cover is in force.

Premium:
The amount the policy-holder pays to the health plan each month to purchase health coverage.

Deductible OR Excess:
To reduce premiums, some clients select a policy, which carries an excess (sometimes called a deductible). An excess is the amount you pay towards the cost of a claim for any insured person on your plan. You can choose the type and level of excess at the time of taking out or renewing the plan. Some benefits carry an additional automatic excess. Any excess you choose is shown on your insurance certificate and charged in the same currency as your premiums.

There are two types of policy excess you can choose from:

1. an excess payable per person, per medical condition, per certificate period (the amount of this excess is fixed – either £50/$85/€75/AED50depending on the currency you have chosen for your plan). With this type of excess an amount will be subtracted from your claims settlement each time you claim for a different medical condition. So if you claim for stomach ulcers and headaches, you will pay the excess twice.
2. alternatively you could opt for an excess per person, per certificate period. With this type of excess you do have the choice of different excesses, either £500/$850/€750/AED100 and these are payable per person, per certificate period. With this type of excess, the excess would only apply once for each certificate period no matter how many medical conditions you were claiming for, until it gets used.

Making a Claim:

Co-insurance:
The specified percentage of money you have to pay towards the cost of certain services each time you use them. The services with co-payments are shown on your insurance certificate.

Exclusions:
Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.

Renewal date:
The renewal date is shown on your insurance certificate and will normally be the date on which your cover is due for renewal.

Definitions:

Annual Limit:
A benefit may be limited to a certain Amount or utilization limit (example: chiropractic care may be limited to 20 visits per calendar year).

In-Network:
Medical providers who have an established relationship with an insurance company

Out-of-Network:
Medical providers without an established relationship with an insurance company.

Chronic conditions or chronic illness:
Chronic means a disease, illness or injury which has no known cure and / or which is likely to continue or to keep recurring and or which needs prolonged supervision, monitoring or treatment and / or which requires you to be specially trained or rehabilitated and for which the treatment has become palliative.

Dental treatment (routine):
Treatment that mainly involves teeth, their roots and surrounding tissue. This benefit is only available if it is shown on your insurance certificate.

Dependant:
Your husband or wife or partner you live with, and any unmarried children, stepchildren, foster children and legally adopted children aged 18 and under or up to and including the age of 24 if they are in full-time education. Your dependants must be named on the insurance certificate, to qualify for benefit.

If you would like your child to be added to your plan from the date of birth, you must provide the details to your insurance company within 30 days of the date of birth. Insurance companies do not add newborn babies unless you ask us to.

Emergency medical evacuation:
Medically necessary transport and care (during the transport) to move an insured person who has a critical medical condition to the most suitable medical facility, if the necessary facilities are not available locally. In this case, you must contact your assistance providers for pre-authorization. The insurance will also pay the transport costs for an insured person to accompany you if it is medically necessary. Return tickets to the area you were evacuated from are included. The insurance company has the right to decide where the insured person is transported. The insurance company will only cover emergency medical evacuation from a landmass. Only applicable to a condition for which benefit is available.

Geographic area (sometimes called area of cover):
The specified area of the world in which your benefits apply, and for which the appropriate premium has been paid.

Home country:
Home country means your country of origin for which you hold a passport.

In-patient treatment:
Treatment for which it is medically necessary for you to stay in hospital overnight or for more than eight hours.

Physiotherapy:
Physiotherapy must be provided by trained and licensed physical therapists under the direction of the patient’s doctor. Your benefit for physiotherapy is shown on your insurance certificate.

Pre-authorisation, pre-authorised:
The process by which an insured person contacts the policy administrator (Found on back of the card) before receiving specified types of medical care.

Pre-existing conditions:
Pre-existing conditions are medical conditions or any related conditions, for which symptom(s) have been shown at some point during the 5 years prior to commencement of cover, irrespective of whether any medical treatment or advice was sought. Any such condition or related condition about which you or your dependants know, knew or could
reasonably have been assumed to have known, will be deemed to be pre-existing.

Birth defects and congenital conditions:
Birth defects and congenital conditions are any abnormality, deformity, disease, illness or injury present at birth (whether diagnosed or not), hereditary conditions, problems caused by things that happened before the baby was born (for example, the effects of a drug) or problems due to an early or abnormal birth.