Group Health Insurance Glossary
Decoding the complexities of group health insurance can be overwhelming, especially when tackling the multitude of terms and definitions associated with healthcare coverage. Whether you're buying a new policy or adjusting an existing one, understanding the terminology is essential for making informed decisions. This Group Health Insurance Glossary offers clear explanations and definitions, enabling you to navigate through the nuances of group health insurance with confidence.
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A
- Age Limit: The specified age beyond which an individual may not be eligible for certain insurance policies or coverage. Age limits can vary depending on the type of insurance and the policy terms.
- Accident: An unexpected and unintended event that causes bodily injury or property damage, resulting in financial loss. Insurance policies often provide coverage for accidents, depending on the terms and conditions of the policy.
- Annual Renewal Date: The date on which an insurance policy expires each year and must be renewed to maintain coverage. Policyholders typically receive renewal notices before the annual renewal date, allowing them to review their coverage and make any necessary changes.
- Ambulance Cover: Insurance coverage that reimburses the insured individual for expenses related to ambulance transportation in the event of a medical emergency. Ambulance cover may include transportation to a hospital or medical facility for treatment.
- Add-on Covers: Additional coverage options that can be purchased in addition to the standard coverage provided by an insurance policy. Add-on covers, also known as riders or endorsements, allow policyholders to customize their insurance coverage to suit their individual needs.
B
- Benefit: In insurance, a benefit refers to the financial payment or coverage provided to the policyholder in case of a covered loss, injury, illness, or death. Benefits can include reimbursement for medical expenses, compensation for lost income, payment for property damage, or other forms of financial assistance as outlined in the insurance policy.
- Bodily Injury: Bodily injury refers to physical harm or damage sustained by an individual as a result of an accident, negligence, or intentional act. In insurance, bodily injury coverage provides financial protection to the insured individual or a third party for medical expenses, rehabilitation costs, and other damages resulting from bodily injury incidents covered under the insurance policy.
- Broker: A broker is an independent intermediary or agent who facilitates insurance transactions between insurance buyers (individuals or businesses) and insurance companies. Brokers work on behalf of their clients to assess their insurance needs, provide advice on insurance options, and help them obtain suitable insurance coverage at competitive rates. Unlike insurance agents who represent specific insurance companies, brokers typically work with multiple insurance providers to offer a broader range of options to their clients.
- Biometric Screening: A health assessment method that measures physical characteristics such as blood pressure, cholesterol levels, body mass index (BMI), and blood glucose levels to assess overall health and risk factors for chronic diseases.
- Behavior Change: The process of modifying unhealthy behaviors and adopting healthier habits, often facilitated through education, support, and motivation provided in wellness programs.
C
- Cashless Facility/Hospitalization: Cashless facility or hospitalization is a service offered by certain health insurance policies, allowing policyholders to receive medical treatment at specified network hospitals without requiring upfront payments. Instead, the insurance company settles the bills directly with the hospital, subject to the terms and conditions outlined in the policy.
- Claim: A claim is a formal request submitted by the policyholder or their representative to the insurance company seeking compensation or coverage for expenses incurred due to a covered loss or event as specified in the insurance policy.
- Claim Settlement: Claim settlement refers to the process by which an insurance company assesses, evaluates, and resolves claims made by policyholders. This process involves verifying the claim, determining the extent of coverage, and disbursing payments according to the terms and conditions of the policy.
- Claim Settlement Ratio: The claim settlement ratio is a metric used to measure the efficiency and reliability of an insurance company in processing and settling claims. It represents the ratio of the total number of claims settled by the insurer to the total number of claims received within a specific period, typically expressed as a percentage.
- Co-Pay or Co-Payment: Co-pay or co-payment is a cost-sharing arrangement in insurance policies where the insured individual is required to contribute a predetermined percentage or fixed amount towards covered medical expenses. The insurance company then covers the remaining portion of the expenses based on the policy terms.
- Comorbidities/Pre-Existing Diseases: Comorbidities or pre-existing diseases are medical conditions or illnesses that exist prior to the inception of the insurance policy. Coverage for pre-existing conditions may be subject to waiting periods or exclusions as stipulated in the policy terms.
- Critical Illness: Critical illness refers to severe medical conditions specified in the insurance policy, such as cancer, heart attack, stroke, or organ failure, which require extensive treatment and may result in significant financial expenses. Critical illness insurance provides a lump-sum payment upon diagnosis to assist with covering medical costs and related expenses.
- Cashless Claims/Treatment: Cashless claims or treatment is a process wherein insured individuals can receive medical services or treatment at network hospitals without the need for upfront payments. Instead, the insurance company settles the bills directly with the hospital, subject to the terms and conditions outlined in the policy.
- Coverage Period: The coverage period, also referred to as the policy term, is the duration for which an insurance policy provides coverage. It commences from the policy's effective date and concludes on the policy's expiration date, during which the insured individual is eligible for benefits and protection as specified in the policy.
- Corporate Floater: A corporate floater is a type of health insurance policy offered by employers to cover their employees and sometimes their families. It provides coverage for medical expenses incurred by the employees and their dependents. The coverage is provided on a group basis, with the employer as the policyholder, and the premium is typically paid by the employer.
- Corporate Buffer: A corporate buffer refers to an additional reserve or pool of funds set aside by the employer or sponsoring organization to cover unexpected or high-cost medical claims incurred by employees and their dependents. The corporate buffer acts as a financial cushion to mitigate the impact of large claim expenses on the overall insurance costs for the organization.
- Corporate Wellness: Wellness programs and initiatives offered by employers to promote the health and well-being of their employees, with the goal of improving productivity, reducing healthcare costs, and enhancing employee satisfaction and retention.
D
- Deductible: A deductible is an initial amount that the policyholder must pay out of pocket before the insurance coverage begins. It's a fixed sum determined by the insurance policy, and its purpose is to share the financial burden between the insured individual and the insurance company.
- Dependents: Dependents are individuals who rely on the primary policyholder for financial support, typically including spouses, children, or other family members. In insurance, dependents may be eligible for coverage under the primary policyholder's insurance plan, subject to the terms and conditions of the policy.
- Domiciliary Hospitalization: Domiciliary hospitalization, also known as home hospitalization, refers to the provision of medical treatment or care to an insured individual within their home instead of in a hospital. This option may be available for certain illnesses or injuries that can be effectively managed at home, subject to the terms and conditions of the insurance policy.
E
- Eligibility: Eligibility refers to the conditions that must be met for an individual or entity to qualify for specific benefits or services provided by an insurance policy or program. In insurance, eligibility criteria may include factors such as age, health status, occupation, residency, and relationship to the primary policyholder. Meeting these criteria determines whether an individual can enrol in the insurance plan and receive coverage.
- Exclusions: Exclusions are specific circumstances, conditions, or types of events that are not covered by an insurance policy. Insurance policies often contain exclusion clauses detailing what is not covered under the policy, such as pre-existing conditions, certain types of medical treatments, elective procedures, intentional acts, or high-risk activities. Understanding the exclusions is essential for policyholders to know the limitations of their coverage and avoid misunderstandings during claims processing.
- Emergency Care: Emergency care refers to immediate medical treatment provided to individuals who require urgent medical attention due to severe illness, injury, or life-threatening conditions. Emergency care may include services such as ambulance transportation, emergency room treatment, surgery, diagnostic tests, and stabilization procedures. Health insurance policies typically provide coverage for emergency care, ensuring that individuals receive timely and necessary medical assistance without facing significant financial burdens.
- Employee Assistance Program (EAP): Employer-sponsored programs that offer confidential counseling, support services, and resources to employees and their families to address personal and work-related issues, including mental health concerns, substance abuse, and stress management.
F
- First Diagnosis: The initial identification of a medical condition or illness by a healthcare professional. In insurance, it often refers to the first occurrence of a covered condition, which may trigger benefits or coverage under the policy.
- Financial Wellness: Wellness programs that focus on improving individuals' financial health and literacy, including budgeting, debt management, retirement planning, and financial goal-setting.
G
- Grace Period: A specified period after the due date of an insurance premium during which the policy remains in force, allowing the policyholder to make the payment without penalty. Coverage continues during the grace period, but if the premium remains unpaid after this period, the policy may lapse.
H
- Hospitalization: The process of receiving medical treatment and care in a hospital setting due to illness, injury, surgery, or other medical conditions. Hospitalization may involve staying overnight or for an extended period, depending on the severity of the condition and the treatment required.
- Home Nursing: Medical care and assistance provided to patients within their own homes by qualified healthcare professionals, such as nurses or caregivers. Home nursing services may include wound care, medication administration, monitoring vital signs, and assistance with activities of daily living, allowing patients to receive necessary care in the comfort of their homes.
- Hospital Cash Allowance: Group Health Insurance policies may include hospital cash allowance as a supplementary benefit. This allowance provides insured individuals with a fixed daily sum for each day spent hospitalized due to illness or injury. It offers financial support to cover incidental expenses such as transportation, meals, and other necessities during hospitalization.
- Health Assessment: An evaluation of an individual's current health status, typically conducted through surveys, questionnaires, or biometric screenings, to identify health risks and tailor wellness interventions accordingly.
- Health Coaching: Personalized guidance and support provided by trained professionals to help individuals set and achieve health-related goals, make behavior changes, and adopt healthier lifestyles.
- Health Promotion: Activities and initiatives aimed at raising awareness, educating, and empowering individuals to take proactive steps towards improving their health and well-being.
- Health Risk Assessment (HRA): A comprehensive evaluation of an individual's health risks, including lifestyle factors, medical history, and family health history, to identify areas for intervention and preventive measures.
- Health Promotion Campaign: A coordinated series of activities and communications aimed at raising awareness and motivating individuals to adopt healthy behaviors, such as smoking cessation, physical activity challenges, or healthy eating campaigns.
- Holistic Wellness: A comprehensive approach to well-being that considers the interconnectedness of physical, mental, emotional, and social aspects of health, emphasizing balance and integration across all dimensions of wellness.
I
- Illness: A state of poor health or disease affecting the body or mind, often requiring medical treatment or intervention to alleviate symptoms and restore health.
- Insurer: An insurance company or entity that provides insurance coverage and assumes financial responsibility for risks covered under an insurance policy in exchange for premium payments.
- Insured/Insured Person: The individual or entity covered by an insurance policy entitled to receive benefits or compensation from the insurer for covered losses, damages, or expenses.
- In-Patient Treatment: Medical care and treatment provided to a patient who requires hospitalization and stays overnight or for an extended period under the supervision of healthcare professionals.
- ICU Charge or Room Rent: The cost associated with occupying an intensive care unit (ICU) or a specialized hospital room for medical treatment and monitoring of critically ill patients. This charge may vary depending on factors such as the level of care provided and the facilities available in the ICU or hospital room.
J
- Lapse: The termination or discontinuation of an insurance policy due to non-payment of premiums within the grace period. When a policy lapses, coverage ceases, and the policyholder may lose the benefits and protection provided by the insurance policy.
- Long-Term Care Policy: An insurance policy designed to provide coverage for the cost of long-term care services, such as nursing home care, assisted living facilities, or in-home care, for individuals who are unable to perform activities of daily living due to age, illness, or disability.
K
- Maternity Cover: Insurance coverage that includes benefits and services related to pregnancy, childbirth, and postnatal care for expecting mothers. Maternity cover typically includes expenses such as prenatal check-ups, hospital delivery, and newborn care, helping to mitigate the financial burden associated with maternity and childbirth.
L
- Network Provider/Hospital: Healthcare providers or hospitals that have agreements with an insurance company to provide medical services to policyholders at pre-negotiated rates. Policyholders usually receive full or partial coverage for services obtained from network providers.
- Non-Network Provider/Hospital: Healthcare providers or hospitals that do not have agreements with an insurance company. Policyholders may still seek treatment from non-network providers, but coverage and reimbursement rates may differ, and they may be required to pay higher out-of-pocket costs.
- New-Born Baby Cover: In Group Health Insurance, coverage for newborn babies is available from the first day if the policy includes coverage for dependents and this option is selected. Alternatively, if this coverage is not initially chosen, newborns can be added to the policy after 90 days. However, any claims related to the newborn before the completion of this waiting period will not be eligible for coverage under the policy.
- Nutrition Counseling: Professional advice and guidance on nutrition and dietary habits to promote healthy eating behaviors, manage weight, and prevent or manage chronic diseases.
M
- Out-Patient Department (OPD)/Treatment: The department within a hospital or healthcare facility where medical consultations, diagnostic tests, and minor treatments are provided to patients who do not require admission to the hospital. Out-patient services are often covered under health insurance policies, although coverage may vary depending on the policy terms and conditions.
N
- Policy Period: The policy period indicates the duration during which an insurance policy remains in effect. It starts from the policy's effective date and continues until its expiration date, as outlined in the policy terms.
- Premium: The premium in group health insurance refers to the total amount paid by the employer or sponsor to the insurance company to provide health coverage to a group of individuals, such as employees or members of an organization.
- Pre and Post-Hospitalization Expenses: Pre-hospitalization expenses refer to medical costs incurred by the insured individual before hospitalization, including diagnostic tests and consultations. Post-hospitalization expenses, on the other hand, encompass medical expenses after discharge, such as follow-up visits and medication.
- Private Room: A private room in a hospital is designated for the exclusive use of a single patient or their family members. These rooms offer enhanced privacy and comfort compared to shared rooms. Depending on the insurance policy, private room accommodations may be available at an additional cost or covered by certain insurance plans.
- Physical Activity: Any bodily movement that engages muscles and requires energy expenditure, including exercise, sports, and recreational activities, aimed at improving fitness levels and overall health.
O
- Renewal: Renewal in insurance refers to the process of extending or continuing an insurance policy beyond its expiration date. Policyholders typically have the option to renew their policies by paying the required premium.
- Reimbursement: Reimbursement is the repayment or compensation provided by the insurance company to the insured individual for covered expenses incurred as a result of a claim. The insured pays for the expenses upfront to the non-network hospital and then submits a claim to the insurer for reimbursement.
- Room Rent: Room rent refers to the charges incurred for occupying a hospital room during a period of hospitalization. Depending on the type of room chosen (e.g., general 2 ward, semi-private room, private room), the room rent may vary, and insurance policies may have limits or coverage restrictions for room rent expenses.
- Resilience Training: Programs and interventions designed to enhance individuals' ability to cope with adversity, stress, and challenges, building resilience and promoting mental and emotional well-being.
P
- Sum Insured: The sum insured is the maximum amount of coverage provided by an insurance policy, which represents the limit of the insurer's liability. It is the total amount that the insured individual or entity is entitled to claim under the policy for covered losses or expenses.
- Sub-Limit: A sub-limit or capping is a specific monetary cap or limit set by the insurance policy on certain types of coverage or expenses within the overall sum insured. It restricts the maximum amount that the insurer will pay for particular categories of expenses, such as room rent, ambulance charges, or specific medical procedures.
- Stress Management: Techniques and strategies to cope with and reduce stress levels, such as relaxation exercises, mindfulness meditation, breathing techniques, and time management skills.
Q
- Third-Party Administrator (TPA): A third-party administrator (TPA) is an independent organization appointed by the insurance company to process insurance claims, provide customer service, and manage administrative tasks on behalf of the insurer. TPAs are crucial in facilitating communication between policyholders, healthcare providers, and the insurance company.
- Terminal Illness: Terminal illness refers to a severe and incurable medical condition diagnosed by a healthcare professional, with a prognosis indicating that the patient is expected to die within a relatively short period, usually within six months to one year. Insurance policies may provide coverage for terminal illnesses, offering financial support to the insured individual and their family during this challenging time.
- Telemedicine: Remote healthcare services that allow individuals to consult with healthcare providers via phone, video, or online platforms, providing convenient access to medical advice, consultations, and treatment options.
R
- Wellness Program: A structured program designed to promote the health and well-being of individuals through various activities and initiatives, often provided by employers or insurance companies as part of employee benefits packages.
- Wellness Incentives: Rewards or incentives offered to individuals for participating in wellness activities, achieving health goals, or demonstrating healthy behaviors, often in the form of discounts on insurance premiums, gift cards, or other incentives.
- Workplace Ergonomics: The design and arrangement of workspaces, equipment, and furniture to optimize comfort, safety, and productivity, reducing the risk of musculoskeletal injuries and promoting overall well-being in the workplace.
- Wellness Portal: An online platform or website where participants can access resources, tools, and information related to wellness programs, including health assessments, educational materials, tracking tools, and social support networks.
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Disclaimer: Above mentioned insurers are arranged in alphabetical order. Policybazaar.com does not endorse, rate, or recommend any particular insurer or insurance product offered by an insurer.
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