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Glossary

A

Accidental Injury

An accidental bodily injury sustained by an insured person, which is the direct cause of a loss independent of disease, bodily infirmity, or any other cause.

Acupuncture

The insertion of needles into the human body by piercing the skin of the body, to control and regulate the flow and balance of energy in the body.

Age

The insured person’s attained age.

Aggregate Annual Benefit Maximum

The maximum amount of benefits to which you are annually entitled under an insurance plan for all covered services combined.

Alcoholism

A disorder characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning. Also termed alcohol abuse or, if tolerance or withdrawal is present, alcohol dependence.

Ambulance Transportation

Local transportation in a specially equipped certified vehicle from your home, scene of accident, or medical emergency to a hospital, between hospital to hospital, or hospital to your home. If there are no facilities in the local area equipped to provide the care needed, ambulance transportation then means the transportation to the closest facility that can provide the necessary service.

Ambulatory Surgical Facility

A facility (other than a hospital) whose primary function is the provision of surgical procedures on an ambulatory basis and which is duly licensed by the appropriate state and local authority to provide such services.

Anesthesia Services

The administration of anesthesia and the performance of related procedures by a physician or a certified registered nurse anesthetist that may be legally rendered by them respectively.

Application

A form on which the prospective insured states facts that is requested by the insurer on the basis of which, together with information from other sources, the insurer decides whether to accept the risk, modify the coverage offered, or decline the risk.

B

C

Calendar Year

A 12-month period beginning each January 1 at 12:01 a.m. Eastern Time.

Certificate of Credible Coverage

A certificate disclosing information relating to your creditable coverage under a healthcare benefit program.

Chemotherapy

The treatment of malignant conditions by pharmaceutical and/or biological antineoplastic drugs.

Chiropractor

A duly licensed chiropractor who treats disorders of the musculoskeletal system, including the back and the neck.

Claim

Notification in a form acceptable to the insurer that a service has been rendered or furnished to you. This notification must include full details of the service received, including your name, age, sex, identification number, the name and address of the provider, an itemized statement of the service rendered or furnished, the date of service, the diagnosis, the claim charge, and any other information which the insurer may request in connection with services rendered to you.

Claim Payment

The benefit payment calculated by the insurer, after submission of a claim, in accordance with the policy benefits.

Clinical Laboratory

A clinical laboratory that complies with the licensing and certification requirements under the applicable federal, state, and local laws.

Coinsurance

The percentage of covered expenses the insured is responsible for paying after the applicable deductible is satisfied and/or copayment paid.

Coinsurance Maximum

The amount of coinsurance (see above) each insured person incurs for covered expenses in a calendar year.

Complications of Pregnancy

Conditions requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from the pregnancy, but are adversely affected by the pregnancy. This includes, but is not limited to acute nephritis, nephrosis, cardiac decompression, missed abortion, pre-eclampsia, intrauterine fetal growth retardation, and similar medical and surgical conditions of comparable severity. Complications of pregnancy also include termination of ectopic pregnancy and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible. Complications of Pregnancy do not include elective abortion, elective cesarean section, false labor, occasional spotting, morning sickness, physician prescribed rest during the period of pregnancy, hyperemesis gravidarum, and similar conditions associated with the management of a difficult pregnancy not constituting a distinct complication of pregnancy.

Continuing Hospital Confinement

Consecutive days of in-hospital service received as an inpatient or successive confinement for the same diagnosis, when discharge from and readmission to the hospital occurs within 24 hours.

Copayment

The dollar amount of covered expenses the insured person is responsible for paying.

Cosmetic Surgery

Surgery performed to change the appearance of otherwise normal looking characteristics or features of the patient's body. A physical feature or characteristic is normal looking when the average person would consider that feature or characteristic to be within the range of usual variations of normal human appearance.

Country of Residence/Home Country

The insured person’s country of domicile.

Coverage Date

The date on which your coverage begins.

Covered Services

Medically necessary services or supplies that are listed in the benefit sections of an insurance plan and for which the insured person is entitled to receive benefits.

D

Deductible

The amount of covered expenses the insured person must pay for covered services before benefits are available to him/her.

Diagnostic Service

Tests that are rendered for the diagnosis of your symptoms that are directed toward evaluation or progress of a condition, disease, or injury. Such tests include, but are not limited to, x-ray, pathology services, clinical laboratory tests, pulmonary function studies, electrocardiograms, electroencephalograms, radioisotope tests, and electromyograms.

Dialysis Facility

A facility (other than a hospital) whose primary function is the treatment and/or provision of maintenance and/or training dialysis on an ambulatory basis for renal dialysis patients. The facility is duly licensed by the appropriate governmental authority to provide such services.

Doctor or Physician

A general practitioner or specialist who is licensed under the law of the country, in which treatment is given to practice medicine. The specialist practices within the license limits and includes licensed pastoral counselors, marriage and family counselors, certified nurse practitioners, certified nurse midwives, registered nurse first assistants, licensed clinical professional counselors, and dental hygienists.

Drug Abuse

Any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

E

Effective Date of Coverage

The date on which coverage under an insurance plan begins for the eligible participant and any other insured person.

Emergency Accident Care

The initial outpatient treatment of accidental injuries including related diagnostic services.

Emergency Medical Care

Services provided for the initial outpatient treatment, including related diagnostic services, of a medical condition displaying itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, which possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could result in:

  1. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
  2. serious impairment to bodily functions; or
  3. serious dysfunction of any bodily organ or part.

Experimental/Investigational

Treatment, a device, or prescription medication that’s recommended by a physician, but is not considered by the medical community as a whole to be safe and effective for the condition for which the treatment, device, or prescription medication is being used. This includes any treatment, procedure, facility, equipment, drugs, drug usage, devices, or supplies not recognized as accepted medical practice; and any of those items requiring federal or other governmental agency approval not received at the time services are rendered. The insurer will make the final determination as to what is experimental or investigational.

F

Facility

An institution providing healthcare services or a healthcare setting, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

G

Grace Period

A period of time after the premium due date in which a policyholder can make a premium payment without the insurance policy coverage lapsing. The insurance grace period can vary depending on the insurer and policy type.

Group Health Insurance Coverage

Health insurance coverage offered in connection with a group health plan.

H

Health Insurance

A type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Coverage can be renewed according to the terms and conditions of each plan.

Hearing Aids

Any non-experimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices, including, but not limited to frequency modulation (FM) systems.

Home Care

An organized skilled patient care program in which care is provided in the home. Such home care may be rendered by a hospital’s duly licensed home health department or by other duly licensed home health agencies.

Home Country/Country of Residence

The insured person’s country of domicile.

Hospices

Providers that are licensed according to state and local laws to provide skilled nursing and other services to support and care for person(s) experiencing the final phases of terminal illness.

Hospital

Any establishment that is licensed in the country where it operates and where the medical practitioner permanently supervises the patient.

I

Illness

A sickness, disease, or condition of an insured person.

Individual Coverage

Coverage under an insurance plan for yourself but not your spouse and/or dependents.

Infertility

The condition of an otherwise presumably healthy married individual who is unable to conceive or produce conception during a period of one year.

Infusion Therapy

The administration of drugs (prescription substances), by the intravenous (into a vein), intramuscular (into a muscle), subcutaneous (under the skin), and intrathecal (into the spinal canal) routes.

Inpatient

A registered bed patient that is treated as such in a healthcare facility.

Insurance Coverage Area

The primary geographical region in which coverage is provided to the insured person.

Insured Dependents

Members of the eligible participant’s family who are eligible and have been accepted by the insurer.

Insured Participant

The eligible participant whose application has been accepted by the insurer for coverage.

Insured Person

Both the insured participant and all other insured dependents who are covered under an insurance plan.

Insurer

An individual or company who, through a contractual agreement, undertakes to compensate specified losses, liability, or damages incurred by another individual.

Investigational/Experimental

Treatment, a device, or prescription medication that’s recommended by a physician, but is not considered by the medical community as a whole to be safe and effective for the condition for which the treatment, device, or prescription medication is being used. This includes any treatment, procedure, facility, equipment, drugs, drug usage, devices, or supplies not recognized as accepted medical practice; and any of those items requiring federal or other governmental agency approval not received at the time services are rendered. The insurer will make the final determination as to what is experimental or investigational.

J

K

L

Life Insurance

A type of insurance that pays out a sum of money on the death of the insured person.

M

Maternity Service

The services rendered for normal pregnancy. A normal pregnancy means an intrauterine pregnancy that, through vaginal delivery, results in an infant weighing five pounds or more.

Medical Care

The diagnosis, care, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body.

Medically Necessary

Healthcare services or products provided to the covered person for the purpose of preventing, diagnosing, or treating a sickness, injury, disease, or the symptoms of a sickness, injury, or disease in a manner that is:

  1. Consistent with generally accepted standards of medical practice;
  2. Clinically appropriate in terms of type, frequency, extent, site, and duration
  3. Demonstrated through scientific evidence to be effective in improving health outcomes
  4. Representative of "best practices" in the medical profession
  5. Not primarily for the convenience of the covered person, physician, or other healthcare practitioner

Medicine/Occupational/Physical Therapy

The therapeutic use of physical agents other than drugs. It comprises the use of physical, chemical, and other properties of heat, light, water, electricity, massage, exercise, spinal manipulation, and radiation.

Mental Illness

Illnesses including psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit and disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (including bulimia and anorexia), and substance abuse or alcoholism-related disorders.

Missionary Insurance

A type of insurance that is specifically for individuals or groups who are involved in missionary or non–governmental organizations (NGO) activity outside of their home country.

N

Network

The group of participating providers offering services to a managed care plan.

Nursing at Home

Physician-prescribed skilled nursing service at your residence immediately after or instead of inpatient or outpatient care treatment.

O

Occupational Therapist

A duly licensed occupational therapist.

Occupational Therapy

Constructive therapeutic activity designed and adapted to promote the restoration of useful physical function. Occupational therapy does not include educational training or services designed and adapted to develop a physical function.

Occupational/Physical Therapy/Medicine

The therapeutic use of physical agents other than drugs. It comprises the use of physical, chemical, and other properties of heat, light, water, electricity, massage, exercise, spinal manipulation, and radiation.

Office Visit

A visit by the insured person, who is the patient, to the office of a physician during which one or more of the following three specific services are provided:

  1. History (gathering of information on an illness or injury)
  2. Examination 
  3. Medical decision making (the physician’s diagnosis and plan of treatment)

Optometrist

A duly licensed optometrist.

Outpatient

An individual who receives treatment while not an inpatient. Services considered outpatient include, but are not limited to, services in an emergency room regardless of whether you are subsequently registered as an inpatient in a healthcare facility.

P

Period of Coverage/Policy Year

A period for which the insured member is covered by an insurance plan.

Physical Therapist

A duly licensed physical therapist.

Physical Therapy

The treatment of a disease, injury, or condition by physical means by a physician or a registered professional physical therapist under the supervision of a physician and which is designed and adapted to promote the restoration of a useful physical function. Physical therapy does not include educational training or services designed and adapted to develop a physical function.

Physical/Occupational Therapy/Medicine

The therapeutic use of physical agents other than drugs. It comprises the use of physical, chemical, and other properties of heat, light, water, electricity, massage, exercise, spinal manipulation, and radiation.

Physician or Doctor

A general practitioner or specialist who is licensed under the law of the country, in which treatment is given to practice medicine. The specialist practices within the license limits and includes licensed pastoral counselors, marriage and family counselors, certified nurse practitioners, certified nurse midwives, registered nurse first assistants, licensed clinical professional counselors, and dental hygienists.

Preexisting Condition

Any disease, illness, sickness, malady, or condition which was diagnosed or treated by a legally qualified physician prior to the effective date of coverage.

Primary Plan

A group health plan, an individual health benefit plan, or a governmental health plan designed to be the first payor of claims for an insured person.

Psychologist

A registered clinical psychologist who specializes in psychology.

Q

R

Reconstructive Surgery

Surgery to correct the appearance of abnormal looking features or characteristics of the body caused by birth defects, injury, tumors, or infection. A feature or characteristic of the body is abnormal looking when an average person would consider it to be outside the range of general variations of normal human appearance.

Renal Dialysis Treatment

One unit of service including the equipment, supplies, and administrative service that are customarily considered as necessary to perform the dialysis process.

S

Skilled Nursing Facility

An institution or a distinct part of an institution which is primarily engaged in providing comprehensive skilled services and rehabilitative inpatient care. The institution or distinct part of an institution is duly licensed by the appropriate governmental authority to provide such services.

Speech Therapist

A duly licensed speech therapist who helps patients speak more clearly and overcome any speech or language complications.

Speech Therapy

The treatment for the correction of a speech impairment resulting from disease, trauma, congenital anomalies, previous therapeutic processes, psycho-social speech delay, behavioral problems, attention disorder, conceptual handicap, or mental retardation. Treatment is designed and adapted to promote the restoration of a useful physical function.

Student Insurance

A type of insurance that is specifically for students, faculty, and staff who reside outside their home country for educational purposes.

Substance Abuse

The uncontrollable or excessive abuse of addictive substances consisting of alcohol, morphine, cocaine, heroin, opium, cannabis and other barbiturates, amphetamines, tranquilizers and/or hallucinogens, and the resultant physiological and/or psychological de-pendency that develops with continued use of such addictive substances requiring medical care as determined by a physician or psychologist.

Substance Abuse Treatment Facility

A facility (other than a hospital) whose primary function is the treatment of substance abuse and is licensed by the appropriate state and local authority to provide such service. It does not include half-way houses, boarding houses, or other facilities that provide a primarily supportive environment.

Surgery

The performance of any medically recognized, non-investigational surgical procedure including specialized instrumentation and the correction of fractures or complete dislocations.

T

Travel Insurance

A type of insurance that is intended to cover losses incurred while traveling. Example of covered losses may include medical expenses, trip cancellation, lost luggage, flight accident, etc.

U

U.S.

The abbreviation for The United States of America.

Usual, Reasonable & Customary (UCR) Fee

A fee reasonably determined by the insurer based on the amount which the physician, dentist, podiatrist, psychologist, clinical social worker, chiropractor, or optometrist, who renders the particular service would charges patients. The fee is within the range of usual fees other physicians, dentists, podiatrists, psychologists, clinical social workers, chiropractors, or optometrists of similar training and experience in a similar geographic area charge their patients for the same service, under similar or comparable circumstances.

V

W

Waiting Period

The period of time specified in a health insurance policy which must pass before some or all of the healthcare coverage can begin. Waiting periods can vary depending on the insurer and policy type.

X

Y

Z