Health insurance terms

A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.

• claim

• deductible

• pre-existing conditions

• in-network

Spouse and/or unmarried children (whether natural, adopted or step) of an insured.

• depedent

• claim

• deductible

• benefit

A period of time when you are not covered by insurance for a particular problem.

• Waiting period

• pre-exiting conditions

• claim

• provider

This phrase usually refers to physicians, hospitals or other healthcare providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO).

• out-of-network

• pre-existing conditions

• dependent

• deductible

Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.

• benefit

• provider

• claim

• waiting period

a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.

• provider

• dependent

• claim

• client

a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.

• co-payment

• claim

• deductible

• pre-existing conditions

Providers or health care facilities which are part of a health plan's network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider because those networks provide services at lower cost to the insurance companies with which they have contracts.

• in-network

• out-of-network

• pre-existing conditions

• claim