Let’s face it: the smarter you become, the more you realize that you don’t know.  This is exactly the way smart women should be thinking when it comes to purchasing and maintaining Private Health Insurance plans.  

When weighing the odds and considering the best options for covering yourself in the event of the unforeseen, you should be seeking facts, clarity, and more. With all the challenges of navigating through private medical services and healthcare solutions, we often find ourselves relying heavily on the glorified “expert opinion” from an insurance agent when we don’t fully understand how something works. The ‘expert opinion’ you may be getting will outline the facts, but what about your due diligence? Are these facts decipherable? Are they convoluted? Textbook? Too formally projected?

Do you hang up from a call with an agent or company sales representative still not clearly understanding how your Deductible will be accumulated in a Calender Year, yet you still have Out of Pocket costs to pay under the Co-insurance structure of your plan? Huh?

Exactly.

Health Insurance is NOT always easy to comprehend. We know it’s a necessity because it provides coverage for medical services that are inevitable throughout the course of any given year. We may have had access to it in our different regions and have often done what was considered socially responsible: signed up and paid for the most efficient insurance plan. Over the years, we have maintained these policies. Sometimes we complain as the rates rise due to inflation and other factors. Sometimes, we seek more affordable options. Yet, do we really know what it is we are maintaining, looking for and what to expect from our Health Benefits?

“Private Insurance is a Rip-Off”

Just about every person who has ever worked in Health Insurance has had someone say to them at some point, “Insurance is a Rip-Off” or “Insurance people are crooks.”

Here’s why…

Every once in a while, a news story on the liquidation of an Insurance/Financial firm comes out. This story is usually preceded by stories of the company not paying claims to Providers and Clients. This is because not all businesses operate as they should.  Most of the time, bad management, poor planning, overly ambitious investments, corruption, and big market crashes are all possible, contributing factors. Sometimes, spending exceeds growth and it all goes downhill from there. Whatever the reason, these stories make headlines and they make people very nervous.

There are others stories about Insurance companies that get passed around the industry as well. Some companies develop a reputation for not paying claims on time. Others are accused of not delivering what they say they will in terms of coverage. There are horror stories out there of families who seem to be at war over some legal technicality or the next with their insurer.

Most of the time, for the general public, Health Insurance seems so convoluted and technical that the feeling of being bamboozled brews. Many feel like they’re disadvantaged by what they don’t understand.

So, what is a woman to do?

Well, in the very beginning: research and due diligence.

There are  3 (three) Key Attributes that your Health Insurer of choice should possess:

1. Transparency                                                                                                                                                                                                                                            

You should NEVER have to dig for information on your Health Insurance Company of choice. You should be able to perform a simple internet search and be directed to an informative website. You should be able to view Financial background information online (takes a few more clicks but is usually not hard to find).

When you walk into the establishment and request information on the company and its products and services, there should be no hesitation.

Health Insurance is simply MONEY managed and allocated for your Healthcare needs. There should be nothing vague, indecipherable or confusing about your money.

2. Good Reputation and Credible Affiliation                                                                                                                                                                      

Every good and credible company has a reputation that should speak of its greatness. We know by name the industry leaders and honestly, those should be our top choices always. Their partnerings and affiliations, accreditations and geographical reach say a lot of about the company.  It shows stability and reliability.

Here’s what to look for with Health Insurance companies:

AM Best Rating                                                                                                                                                                                                                                          AM Best is an insurance rating company established as far back as 1899 by Alfred M. Best. This company provides financial ratings and “related analysis” for over 3,400 Health Insurance companies across the world and these ratings are recognized internationally.  You can find out if your company is rated by visiting AM Best’s website and performing a search.

Provider Network and Centers of Excellence                                                                                                                                                                                One company that does a good job at speaking to their credibility is Pinnacle Care.  They list their top providers right on their website’s homepage. This signifies a strong working relationship with the best in the medical field.  You should also check your Health Insurer’s partnerships and affiliations with Centers of Excellence. These are medical service providers and facilities that are the standard in the health industry. Centers of Excellence (COEs) are the very best of the best in terms of expertise in healthcare, including new medical research and innovations. 

Included among Centers of Excellence are Mayo Clinic, Cleveland Clinic, Johns Hopkins Precision Medicine, and Columbia University Medical Center.  You’ll find a more extensive list HERE.

You can also ask that your Insurance company provides you with the list from its Provider Network listing.

3. Highly Knowledgeable, Well-Trained and Helpful Staff

The Best Insurance companies have the Best People.

Sound Insurance companies promote ongoing training through their HR Departments. You can tell a well-trained staff by the symmetry within the Department. Everyone you speak to is on the same page. The chain of command is well organized.  Sales Executives and support staff are helpful and informative.

On each Business card or email, check the accreditations/designations. If you want to know what designations to look for, this article “What Do Insurance Designations mean?” can answer some of your questions.

 How Do I Know What I Know?

If someone asked you, “What are the greatest advantages of your Healthcare Policy?”  How would you answer?

Unless you’ve had extensive experience with a long term illness, pre-existing conditions or actually work in the medical or insurance industry, your answer may not be very informative. Trust me, relying heavily on the “expert opinion’ of your insurance agent is probably more beneficial to them than to you. After all, the more they convince you and others, the more consistently they make commission-based sales.

My tenure in the corporate world included working for two well-established Private Health Insurance firms in The Bahamas. Both firms were partnered to provide Overseas care through two of the largest health insurance carriers in the United States and the World. I never worked as a general sales Agent, I was a trained Group Health and Individual Health Insurance Account Executive. I did have responsibility for making policy sales, but it extended beyond that. Another function of my job was  Business retention (keeping clients and renewing policies). A huge part of this was to educate my “insureds” on what benefits they had under their plans and how they worked. My initial on-the-job training extended well into my first year. The Dynamics of Health Insurance require a hands-on approach to truly grasp the concept fully. It’s the only way a Health Insurance Professional is able to efficiently guide and educate their clients. In my last year in the industry, at the second company I worked for, I trained general insurance agents on the company’s health products. 

Learning the fundamental functions of Private Health Care Coverage was an eye-opener for me. In the early months of training, I was shocked to see the numbers and statistics involved with managing and maintaining health care plans for both insurers and the insureds. I was stunned by the amount of illness across different age groups of women. I was introduced to the world of trending medical treatments and advancements, ongoing epidemics, illnesses and diseases by region, evolving medical technology and so much more. There was Case Management, Disease Management, Risk Management and so many facets to the business. All of this knowledge and insight flooded into me and I seriously grasped how important this “stuff” really was.

Through my ongoing training, I committed myself to understanding the ramifications of adequate coverage, not just for the purpose of performing my job well, but for personal use in the future.

You see, the unforeseen is a scary thing. It can be crippling with long-term burdening affects not just for an individual, but for also for their entire family. Essentially, for women, our health needs increase with age and are by far more complex than those of men. Through my experience, I dealt more thoroughly with women when it came to managing health plans for individuals, families, and  Employee Health Benefits.

With all of this in mind, I’ve decided to share my knowledge of what a good Health Care Policy should encompass.

Women’s Health and Protection

For women, especially Women in Business, there are 4 Key Reasons Why It’s Important To Know and Understand The Basics of Health Insurance:

1. Our medical risks require more care and protection.  

   The World Health Organization (WHO)  will frighten you with the numbers concerning health risks and illness among women. However, it is information that you must arm yourself with. Cardiovascular Disease is the number one cause of death for women worldwide. It’s closely followed by Breast and Cervical Cancer. In terms of health complications, Maternity ranks very high along with other illnesses related to the Reproductive System. Our life expectancy is longer than men and medical statistics show that we are more likely than men to seek ongoing health care services in our lifetime. 

   You may have come this far in close to perfect health and that is a blessing. Your lifestyle may attribute to you defending yourself against chronic illness and disease. However, Awareness has always been the marker when it comes to maintaining good health, especially among women. So, if you don’t know what you may be at risk for, it is definitely time to find out.

   I strongly recommend exploring this site (WHO.int/en/) and researching women health facts and health insurance reviews in your country/region in more detail. Understanding the dynamics and dimensions of your possible health risk will make the task of understanding your Health Insurance Coverage even more essential.

2. Statistics show we are more hands-on with money management, thus making us the decision makers when it comes to Insurance.

Yes, we are. I read several articles on this before and it when it came to making a point about Health Insurance and decision-making, this definitely applies. Women take fewer risks than when it comes to financial planning and we research better. So, when it comes to Family coverage; we take the lead in coordinating things. Take a look at one of the articles I read, “24 Reasons Why women Are Better At Money Management.

3. Fitness and Health Awareness is at an all-time high currently.

More and more women are becoming involved in organizations and programs that promote healthy lifestyles and Prevention. Health Insurance Coverage plays a major role in securing one’s best interest in the event of any illness.

4. More and more women are becoming Business Owners and need to consider Employee Benefits packages.

The best way to attract and keep the best employees is by offering them the best benefits. Women in Business need to be aware of the fact that the most valuable resource any company has is its staff. In our expanding, innovative business world across industries, credible companies offer good benefits.

HEALTHCARE BENEFITS 101

Up to this point, you may have a point-person at your insurance company on speed dial. You may have an agent who contacts you regularly seeking to sell you a health care policy. You may be shopping the market in your local region. Or, like the busy, middle-class working woman, you’re dedicated to extensive Google searches until you find what you’re looking for.

You may have a Policy Guide or access to an application accompanied by Plan information that you’re considering purchasing in the near future.

I do strongly recommend that those of you who have coverage already read and seek to understand the handbook/policy guide that you should have received. The language might be a bit technical, but those terms are based on EXACTLY what your plan should be providing. My goal here today is to help you to understand in plainer language and a bit more detail the language and concept of Health Insurance. I’ve used my knowledge and done some research in order to provide you with the best possible information.

 

PLAN STRUCTURE AND SCHEDULE OF BENEFITS

All Major Medical Coverage Plans have a structure. The framework of your plan MUST be understood in dollar amounts and percentages for you to properly understand the scope of your plan. You need to be aware of just how much you are covered for and to what limits.

SAMPLE – MAJOR MEDICAL SCHEDULE OF BENEFITS

I found this schedule by doing a simple Google Search until I found one that was both comprehensive and detailed. This schedule represents the Medical Benefits for a real company called STS Systems Integration, LLC. 

View a full copy of the Schedule by clicking on the image of the first page below.

Be sure to cross reference the benefits on this schedule AND the one you have in your policy guide with the terminology below. You should start getting that wonderful feeling of clarity.  If what you’re being sold on is considered a Major Medical Plan, it should include ALL of the benefits listed below and more. The benefits are usually listed in alphabetical order. The policy guide also should have a glossary that includes terms that are common to them.

• Preventive Care
• Hospital – In Patient and Out Patient Services
• GP and Specialist Doctor Visits
• Diagnostics and Lab Testing
• Maternity Benefits
• Surgery
• Prescription Drugs
• Physical Therapy & Rehabilitation
• Cancer Treatment
• Transplant Services
• Mental HealthCare Services
• Emergency Room Service
• Ground & Air Ambulance
• Medical Evacuation
• Repatriation

KEY HEALTH INSURANCE TERMINOLOGY

A great challenge will be to grasp the true meaning of Basic Health Insurance terms, keywords and phrases in order to understand what you should expect and what is expected of you. The truth is, a Policy Guide is very detailed. It has to be. Insurance companies are required to give full disclosure as to how their plans work. The problem is, however, they also use terms and clauses that are not familiar to the general public. That is because they’re big on doing due diligence to cover themselves legally.

So, please grab your brochures, policy guide, and application. Pull up your Health Insurer of choice up online and follow along as I attempt to break down the following 29 Key Health Insurance Terms a little more clearly for you.

29 Key Health Insurance Terms That You Should Understand

 1. Assignment of Benefits

Most Private Health Insurance companies have contracts or agreements in place with Provider Networks.  Your Provider Network consists of ALL the doctor offices, labs, medical clinics and hospital that have agreed to take your insurance. When you present yourself for care or make an appointment, there’s a verification process that takes place. The doctor’s administrative staff calls your insurance or contacts them online to “verify” your benefits.                                      

After they receive approval, they will then charge you co-insurance (a percentage of the bill) or a co-payment (a flat amount that is your responsibility). This is the process of “assigning” your benefits. There are occasions where a benefit may be covered at 100% to a certain maximum and they do not bill you at all. (Keep reading to understand “Co-Insurance and Co-Payments.”)  

There are certain instances where the doctors will not be able to take your insurance. They are:

• If you are on an Employee Benefits Plan and your company has not paid the premiums to the insurer, your coverage will be suspended until they do so.
• If you have not made current payments on your Individual Medical Plan, you will not be able to access your benefits until you submit payment to the insurer.
• You have exceeded your benefit limits
• The medical services you are requesting are not covered
• Your policy has been canceled for one reason or the next a specific case).
• You are at a facility or attempting to see a Doctor who is not in network
• Your insurer has an ongoing dispute with the Doctor or Facility
• The doctor’s office does not take insurance at all.

 2.  Accidental Death & Dismemberment 

 (AD&D) is a Benefit  that pays a benefit to your assigned beneficiary should you die by accident (accidental death).It also pays a benefit to you in the event you suffer any of the following forms of dismemberment:

• Loss of a limb or both limbs (arms or legs)
• Loss of sight in one or both eyes
• Loss of hearing in one of both ears
• Loss of speech

The general rule of this benefit is that it pays the full amount to your beneficiary if you die by accident.

• If you completely suffer the loss of speech, your plan will pay you the full benefit amount.
• If you lose an arm or leg, it will pay you 50% of the benefit amount.
• If you lose the sight of one eye or hearing in one ear, it will pay you 50% of the benefit amount.
• If you lose a combination of any two above, it will pay the full benefit amount

This benefit is ONLY paid in the event the injury or loss of life occurred due to an accident.

3. Calendar Year Deductible

The deductible is the amount that you pay before your plan starts to pay benefits.  For example, if your deductible is $500, you will pay the first $500 toward medical services that are covered under your plan.  After you have met the deductible amount, the plan will then start to pay benefits based on Co-Insurance.

 Here’s a common rule: The higher the deductible, the lower the premiums on the plan are. This is because your participation is more, i.e. you are contributing more toward your healthcare expenses.

 Most Major Medical Plans are based on 20%/80% Co-Insurance. This means that AFTER the deductible is met, you are responsible for 20% of the cost of covered medical services and the plan pays the remaining 80% to the covered benefit limit. Some plans don’t have a Calendar Year Deductible. In this case, you just pay 20% co-insurance directly to the Out of Pocket Maximum.

4. Calendar Year Maximum

The Calendar Year Maximum (or annual max) is in place on some Health Insurance plans, specifically Preferred Provider Organizations (PPOs) and Indemnity plans.

The Calendar Maximum refers to the maximum that your insurance plan will pay for covered medical services within a year. This amount is taken directly from your Lifetime Maximum.  This benefit is usually in place on Group HealthEmployee Benefit Plans that have limitations in place to control the cost of premiums for employees and company. You may not find a Calendar Year Maximum or Maximum Yearly Benefit on most Premium Individual Health Plans. It’s often built into “Value” level plans that have set rates. Adding this limit controls yearly costs to the insurer and therefore allows you to keep paying a low premium.

What you should know:  Even though you have a Lifetime Maximum, in the event of unforeseen major medical expenses due to some devastating illness or disease, you may find yourself coming out of pocket should you exceed the Calendar Year Maximum.

Please be aware:  “Calendar Year” refers to any period of coverage that begins Jan 1.

5. Certificate of Insurance

Your Certificate of Insurance is the official document you receive when your application is approved, your premiums are paid and your plan benefits become effective. It usually includes a Schedule of Benefits and if you’re on a Group Health Employee Benefits Plan, it will include the specific “principal provisions” of the plan.

In recent years, most insurers have issued a complete Policy Guide that outlines benefits in more detail to accompany the Certificate. The Policy Guide can be made available to you in booklet or electronic form prior to you submitting your application or signing a contract.

I strongly recommend getting your hands on one and going through it thoroughly.

6. Claims Adjudication / Claims Processing

This is your insurance company’s process of reviewing your medical services paid, applying the payments to the benefits according to plan’s coverage and approving them for payment to you or the Doctor/Facility.  In terms of how long the process takes depends on a few factors: 1. The form is completed correctly with the right service codes and required information. 2. The availability of any supporting documents required like a cash receipt (if payable to you).

Most companies specify a general processing time of between 7 business days and 2 weeks.There are times when claims are not paid for months due to misinformation, missing information, or price discrepancies with Providers.

It is beneficial to you to do some research on insurance carriers you are considering in terms of claims payments. Unfortunately, not every company operates transparently nor ethically. Some are subject to poor management. Inevitably over time, they establish a reputation for being slow at the claims process and not paying out on time. Some companies have bad relationships with Providers also when it comes to claims processing. This then affects YOU as a patient or client in that some Physicians simply won’t take the Assignment of Benefits, leaving you to pay the full amount out of pocket. So, a little research is always helpful.

7. Co-Insurance vs. Co-Payments

This one will ALWAYS be tricky to explain, but here goes.

Co-Insurance is the percentage that you are required to pay toward a covered medical benefit. It is usually 20% with the Insurer responsible for 80%.  Your Co-Insurance applies against your Out of Pocket Maximum.

A Co-Payment is a flat dollar amount that is paid by you for certain medical services. These are often applied to Doctor sick visits, prescription drugs, and other out-patient services. A co-payment or copay is meant to give you easy access to your benefits and is usually set against standard medical services.  A Co-Payment does NOT apply to your Deductible nor your Out of Pocket Maximum.

Please be aware that you will NOT be responsible for deductible or coinsurance where there is a co-payment in place.

To simplify the difference, just remember: Co-Insurance = %   Co-Payment = $ flat/set dollar amount

8. Coordination of Benefits

If you’re covered under more than one insurance policy and would like to maximize on your coverage, there is a process called “Coordination of Benefits”.

The first thing that must be determined is which one of the plans you’re on is the Primary and which one is the Secondary. This is determined by the Insurance Act in your country or region. In some nations, your Primary is the plan you’ve been on the longest. That may not be the case worldwide, so checking and confirming this is important. 

Whichever plan is the Primary is required to adjudicate your claims (evaluate and prepare for payment) without considering your secondary insurance. They must pay based on the covered benefits schedule you have with them. Then, your secondary insurer will take into consideration what has already been paid, what is left and payable under  Usual, Customary, and Reasonable costs and process your claim. 

If you have now or are considering dual coverage, this article by Bobbie Sage “Coordination of Benefits – Should You Have More Than One Insurance Plan?” found at thebalance.com will give you more detail on this.

9. Covered Benefits & Limits

As you’re going through your plan guide, you’ll see a Schedule of Benefits or Table of Benefits. This is very SPECIFIC to your plan.

The Schedule of Benefits should tell you exactly how each benefit is covered (there’s a whole section below on this). There will be dollar amounts ($) included where are there are Co-Payments and percentage (%) amounts where there is Co-Insurance.  Some benefits will be limited to a number of visits or sessions (most therapy). These are your Covered Benefits. 

10. Critical Care Benefits

There are certain medical illnesses, conditions, diseases and treatments that fall in the bracket of “Critical Care”.  Subsequently, some Insurance Companies offer limited plans (known as Critical Care Plans) that ONLY cover these to specific limits. Each benefit on these plans is subject to a Maximum Benefit Amount. These plans are suitable for older persons on a fixed income and are offered to them even considering their advanced age.

Although these are Critical Care Benefits, they are included under the coverage of Major Medical Plans without this stipulation. On Critical Care plans, these would be the ONLY benefits offered. All of the other Major Medical benefits would not be included.

Critical Care Benefits are as follows:

• Organ Transplant (heart, kidney, liver, lung, pancreas)
• Multiple Sclerosis 
• Paralysis (Two or more limbs) 
• Dismemberment (Two or more limbs) 
• Severe Burns 
• Blindness 
• Heart Attack 
• Heart Surgery 
• Cancer (except Skin Cancer other than malignant melanoma) 
• Stroke 
• Brain Tumour (must require surgery)
• Kidney Failure 

11. Dependent Health Coverage

This is coverage that is extended to your spouse and or children under a policy where you are the Primary Insured Person.

Covered dependents usually have the same level of medical benefits as you, except in some instances on some plans where Preventive Care Benefits levels may be at different according to age. If there are any other differences in coverage levels, they will be outlined specifically.

All your dependents are subject to underwriting during the application process. Dependent coverage monthly premium costs are based on the family’s full risk combined.

12. Dependent Life Insurance

Some Employee Group Health Insurance plan contracts provide insurance coverage on the lives of employees’ dependents. These are fairly small benefits that are staggered according to age.

Dependent Life Insurance is often viewed as a “Survivor’s Benefit” in that it is usually paid right away to defray funeral and burial expenses in the event of your dependent’s untimely death. You, as the primary insured would automatically be named the beneficiary.

13. Different Types of Plans 

a.Indemnity Plan

An indemnity plan is the most flexible kind of Major Medical Health Insurance Plan that you can purchase. This kind of plan allows you to choose your doctor, any doctor, healthcare professional, medical facility, or hospital for medical healthcare. Unlike an HMO, you’re not required to choose a Primary Physician. Unlike a PPO and an HMO, you are not restricted to a network.

An indemnity plan is set up with Co-Insurance features, yet it gives you so much more freedom and control over your own healthcare. It doesn’t require Referrals to Specialists like PPOs and HMOs do. You can seek Specialist care as you see fit. Of course, these plans are very costly compared to PPOs and HMOs due to this flexibility. If you’re seriously interested, this would be an option for you to consider for Individual Health Coverage. There are not a lot of companies that would run the risk of allowing this structure for a Group Health Employee Benefits plan.

b. PPO (Participating Provider Organization)

With a PPO, you are at liberty to use any of the physicians within your Healthcare Provider Network.  This is the most popular kind of Major Medical Health plan structure found on the market for both Individual Health Coverage and Group Employee Benefit Plans.  

Using providers inside of your network guarantees full plan coverage. If you choose to visit a doctor outside your network and it is not a medical emergency, you will be subject to a reduction in your benefits (plan will pay less) or you will simply not be covered. Depending on the discretion of your Insurer, some will pay reduced benefits while others will tell you up front that they will not pay at all. Most of the plans you see marketed or advertised today are PPOs. These plans offer good management with a good level of flexibility.  Most Provider Networks are huge and growing so there is often not a problem actually getting to use the Doctor/Facility of your choice.

c. EPO (Exclusive Provider Organization)

An EPO is both flexible and cost efficient. You do not have to select a Primary Care Physician and you don’t need to get referrals. You WILL have a very limited Network. You have to be mindful of this because there is absolutely NO coverage outside of it. 

d. HMO (Health Maintenance Organization)

An HMO plan includes major medical coverage but is limited in a few ways. You are required to select one Primary Care Physician. This one Doctor then coordinates all of your Health Care Services.  This means that this Doctor must provide you with a referral before you visit any other facility or health care professional, except in an emergency. You have no coverage under your plan outside of the Provider Network.

There is one exception for women: you won’t be required to provide a referral to see an Obstetrician/Gynaecologist or for any Pap smear or Reproductive system-associated lab testing. You can simply use a Provider in your network and be covered.

HMOs are considerably less expensive than Indemnity Plans and PPOs due to the minimal administration and coordination required due to its limits and restrictions.

14. EOB – Explanation of Benefits 

 An explanation of benefits comes in statement-form from your Health Insurance Company after you have accessed your healthcare benefits.  It outlines and explains what covered medical services it paid on your behalf. If you paid in full for services, you will see a reimbursement check attached to the statement.

15. Exclusions

There are medical expenses that are NOT covered under your plan.

Toward the back of your policy guide, you should see a section that outlines the Plan’s Exclusions or things not covered. If you don’t see a list of exclusions, you should immediately request one from your Insurer. If they have a problem providing that, please find another insurer right away!

Please be sure to go through this section of your booklet thoroughly before you submit an application with any premiums! You don’t want to get stuck with a plan that doesn’t cover certain things without shopping around for one that does.

 16. In-Patient and Out-Patient Care

Inpatient care refers to medical care where you are admitted to the hospital and medical facility. 

Out-patient care refers to doctor’s office visits, procedures that are done within the hospital or office but don’t require you to be admitted.

Visits to the Emergency Room sometimes lead to Inpatient services or you being admitted. Through verification, your coverage will be adjusted to reflect this.

 17. Life Insurance

Some Major Medical Health Policies come with a Life Insurance policy attached for the Primary Insured person only.

In the case of an Individual Health Insurance plan, some companies will give you an option to increase this at an additional cost. This policy is usually assigned to the insured’s estate or to their spouse (if they have one), or a child nor relative over the age of 18 years. A good agent will not recommend assigning this policy to your minor dependent child. If this is done, and you meet a timely death, your child will not be able to access those funds until they turn 18.

In the case of Group Health Employee Benefits Plans, the Life Insurance amounts may differ across categories. Some companies provide their Executives and Management a Life Insurance attachment amount that is higher than what is provided for the rest of the company’s employees.

Side Note: You will find that Group Health plans can be set up where ALL benefit levels are different depending on what your employment status is (Executive, Management, Administrative, Line Staff, etc)

Beneficiaries of this policy often use this to cover funeral and burial costs.

18. Lifetime Maximum

Your plan will have a Lifetime Maximum. This is the total amount of money you have available to cover your medical expenses for the full time you are insured under the plan.

This amount ranges usually between $1 Million and $2.5 Million. Should you be met with a devastating illness, your coverage will end or terminate once should your expenses covered arrive at the Lifetime Maximum amount. In terms of the odds of this happening; it rarely does. However, it is entirely possible nonetheless.

19. Major Medical Insurance Plans

 “Major Medical” refers to the core medical services for the illnesses, conditions, and treatments that are most commonly accessed by people on insurance plans.

Major Medical plans include things like the following:

• Preventive care, like check-ups at the doctor
• Medication
• Emergency services care
• Services related to Pregnancy and Maternity
• Inpatient or outpatient mental healthcare
• Labwork

If you keep reading, when you get to the section on Schedule of Benefits, I’ve listed the core Major Medical services/treatments in more that should be made available to you.

20.  Out of Pocket Maximum

An Out-of-Pocket Maximum is the most you’ll have to pay during a Policy Period (usually a year) for Health Care Services.

Once you’ve reached your Out-of-Pocket Maximum, your plan begins to pay 100% (percent) of the allowed amount for Covered Services.

Your Deductible applies against the Out of Pocket Maximum. Once you have met the Deductible, all your 20% Co-Insurance payments will then apply to the Out of Pocket maximum until it is met. So, you may get a plan option from an Insurance Agent that reads along the lines of:

“Major Medical coverage at 200/2000”

This means your Deductible is $200 and your Out of Pocket is $2,000.

So, once you have met the $200, you start to then pay at 20% ($2,000 – $200 = $1800 OOP).

Within the Policy year, as you continue to use your coverage, whenever you make a 20% payment it goes toward your Out of Pocket Maximum. When that remaining $1,800 is met, the plan will then start to cover at 100% of Usual, Customary and Reasonable medical fees. (keep reading for the definition of this). Meeting $2,000 in a year under your insurance plan doesn’t seem likely at first glance. However, it only takes one bout of serious illness to exhaust that amount in just days, even minutes. Accidents happen, illnesses are unforeseen at times. Medical trending (advances in technology and new services) causes the price of Healthcare Services to rise year to year.

Don’t be scared off by the Out of Pocket Maximum nor your Calendar Year Deductible. Cost sharing in Insurance works out well for everyone in the end.

Here’s a common rule: The higher the Out of Pocket Maximum, the lower the premiums on the plan are. This is because your participation is more, i.e. you are contributing more toward your Healthcare Expenses.    

21. Precertification 

There are certain Medical Services that must go through a Precertification or Pre-verification process with your Insurance Provider. There are usually in-office procedures, certain lab tests, surgeries and other high-cost medical services. 

They must be deemed Medically Necessary with supporting medical documents from your Physician. This process is coordinated between the Doctor’s Office, your Insurer’s Clinical Administrator, and the Insurance Customer Service Representative.

 22. Provider Network

An Insurance Company’s Provider Network is the complete listing of General Doctors, Specialists, Healthcare Facilities and Hospitals that accept your insurance. In some instances, your Provider Network also outlines Providers who are in different World Regions that are accessible to you.

For US Providers, this list is usually quite extensive and is usually accessible via a web link where you are able to search as it covers all States and Jurisdictions. Most Insurance Companies will provide you access to state/region, country, doctor, medical service, specialty, or hospital.

Large Insurers like United Healthcare and Coventry HealthCare make the Provider Network research process easily accessible through their “Find A Doctor” tools.

23. Reduction of Benefits 

There are instances where you may experience a reduction in paid benefits.  

This normally occurs when you choose to visit a Doctor outside of your Provider Network. Instead of your plan paying 80% and you 20%, you may see it pay 70 or 60% leaving you to cover more at 30-40%.

Another instance where you will see a reduction of benefits is for one reason or another, something in your Medical History that was not disclosed previously manifests and you must be treated. A reduction of benefits, in this case, is at the discretion of the Insurer.  They have every right to outright deny coverage based on the Policy’s Full Disclosure Clause/Agreement.

Please note that the Insurer has the right to deny coverage for any benefit not disclosed. They are also within their rights to cancel your policy due to nondisclosure.

Here is why it is crucial to read the Disclaimer page of any Application you are completing whether in paper form or electronically. If you don’t see a Disclaimer about Non-Disclosure, you really should request one.

The Disclaimer on a Health Insurance Application also states that by signing, you give the Insurer the right to request further Medical Information on you. So, here you can see the importance of FULL disclosure. It protects you just as much as them. To be denied coverage based on fraud is a serious offense and can possibly lead to you having no coverage at all.

There’s also a section in most Health Insurance Applications that asked if you’ve ever been denied coverage or had your coverage canceled (and the reason why). You’re expected to be truthful here too. If you’ve not disclosed your full Medical Profile in the past, you may find it difficult to get approved in the future.

24. Referral

.Your Primary Physician may conclude that you must be treated specifically for a condition or illness. A doctor’s referral is required when you seek the services of a Specialist

This changes your scope of coverage.  Your treatment costs will increase. Therefore, to verify that it is all “Medically Necessary”, your Insurer requires a letter of Referral or a Referral form completed and signed by your Doctor. The referral usually precedes the Pre-Certification that will, in turn, come from the Specialist that you have been referred to.

25. Repatriation

Repatriation means to return someone to their Country of Origin.  In insurance, The Repatriation of Mortal Remains is a benefit that covers you and your dependents (if any) should you die while overseas. The benefit pays for the preservation, preparation, and transportation of your body to the country you are from for burial or cremation.

26. Risk Assessment & Underwriting

It’s important to have your risk properly assessed when buying insurance. Certain factors like age, weight, pre-existing medical conditions, family medical history all play a role in your insurability.