Glossary of Health Insurance Terms (Part One)

Ancillary services: Services that are part of general hospital patient care, including pathology tests, anesthesia, and X-rays.

Certificate of coverage: Document that describes the benefits, limitations, and exclusions of coverage provided by an insurance company under a specific policy.


Claim: A demand for benefits provided under an insurance policy. To make a claim, the doctor or hospital submits information about the medical services provided. In some cases, the insured has to submit details about medical services to the insurance company to support the request for payment.

Co-insurance: An agreement between the insured and the insurer under a health insurance policy to share the covered costs after the deductible has been paid. Unlike co-payments, which are shared on an amount basis, co-insurance is shared on a percentage basis.

Coordination of benefits: If you are covered by more than one medical insurance policy, you cannot be paid twice for the same services. To avoid duplication of benefits, payment coordination is necessary.

Co-payment: The specific amount of out-of-pocket expenses for healthcare services paid by the insured for doctor visits, prescription drugs, etc., when the services are utilized.

Covered Expenses: These are the medical services for which the insurer agrees to pay under the health insurance plan. Covered expenses are listed in the health insurance policy.

Covered Persons: These are the people who are entitled to receive the benefits listed under the health insurance policy; they must meet eligibility requirements and pay a premium.

Deductible: This is the portion of the claim that is not covered by the insurer. If a claim is made under the health insurance policy, the claim amount is paid to the insured after subtracting the deductible. The deductible is paid for each calendar year, and this out-of-pocket expense has to be paid before the insurance company pays the remaining costs.

Dependent: A person who is covered because of another person's health insurance, typically a child or spouse.

Effective Date: The date health insurance coverage begins per the terms of the policy.

Eligible Dependent: A dependent of an insured who can be included under the health insurance policy to be covered for the benefits available, who meets all eligibility requirements, and for whom a premium is paid.

Eligible Expenses: The expenses for supplies and services covered under a health insurance plan, as well as the reasonable and customary or agreed-upon fees.