This area contains definitions of common words and phrases you may run across when reading MedBen forms, claims, EOBs and other documents. Most of the definitions are reprinted from materials published by the Health Insurance Association of America (HIAA).

Should you have questions regarding terms not defined here, please contact the MedBen customer service department at 1-800-686-8425 or e-mail medben@medben.com.

CAFETERIA PLAN
Another term used for a flexible benefit plan that allows employees to choose benefits from a number of different options.

CASE MANAGEMENT
Planned approach to manage service or treatment to an individual with a serious medical problem. Its dual goal is to contain costs and promote more effective intervention to meet patient needs. Also called large case management.

CENTER OF EXCELLENCE
A term referring to selected health care facilities that specialize and have demonstrated success in the performance of highly complex medical procedures.

CERTIFICATE HOLDER
The insured person under a group plan who has been issued a certificate of insurance.

CERTIFICATE OF INSURANCE
The document delivered to an individual that summarizes the benefits and principal provisions of a group insurance contract. May be distributed in booklet form.

CLAIM
A demand to the insurer by, or on behalf of, the insured person for the payment of benefits under a policy.

CLAIMANT
The insured or beneficiary exercising the right to receive benefits.

CLAIM COST CONTROL
Efforts made by an insurer both inside and outside its own organization to contain and direct claim payments so that health insurance premium dollars are used as efficiently as possible.

COINSURANCE
The arrangement by which the insurer and the insured share a percentage of covered losses after the deductible is met.

COMPLIANCE
In insurance, the act of conforming to or observing regulatory requirements.

COMPREHENSIVE MEDICAL EXPENSE INSURANCE
A form of health insurance that provides, in one policy, protection for both basic hospital expense and major medical expense coverage.

CONCURRENT REVIEW
Method of utilization review that takes place on-site when a patient is confined to a hospital.

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)
A 1986 law requiring employers that maintain group health plans to give employees and their dependents the opportunity to continue coverage at affordable group rates in cases where they would otherwise lose coverage because of certain events.

CONTESTABLE PERIOD
That time allowed an insurer after a policy is issued to investigate possible misrepresentation in the application and contest the policy’s validity. 

CONTRACT
A binding agreement between two or more parties. A contract of insurance is a written document called the policy.

CONTRIBUTION
That part of the insurance premium paid by either the policyholder or the insured or both.

CONVERSION PRIVILEGE
The right given to an insure person under a group insurance contract to change coverage, without evidence of medical insurability, to an individual policy upon termination of the group coverage.

COORDINATION OF BENEFITS (COB)
A method of integrating benefits payable under more than one group health insurance plan so that the insured’s benefits from all sources do not exceed 100 percent of allowable medical expenses.

COPAYMENT
The arrangement by which the insurer and the insured both pay a percentage of covered losses after the deductible is met.

COST CONTAINMENT
Efforts by medical providers, insurance companies, insureds, or other interested groups to control health care costs.

COST SHARING
Policy provisions that require insureds to pay, through deductibles and coinsurance, a portion of their health insurance expenses.

COVERAGE
A major classification of benefits provided by a policy (e.g., short-term disability, major medical), or the amount of insurance or benefit stated in the policy for which insured is eligible.

COVERED CHARGES
Charges for medical care or supplies, which if incurred by an insured or other covered person, create a liability for the insurer under the terms of a group policy.

COVERED EXPENSES
Those specified health care expenses that an insurer will consider for payment under the terms of a health insurance policy.

COVERED PERSON
Any person entitled to benefits under a policy (insured or covered dependent).

CUSTOMER
Users of health care services, such as patients getting care or providers getting support services from laboratories; payers of service, such as individuals, employers, or the government; or the general public as beneficiaries of services.

DAILY BENEFIT
A specified daily maximum amount payable for room and board charges under a hospital or major medical benefits policy.

DEDUCTIBLE
The amount of covered expenses that must be incurred and paid by the insured before benefits become payable by the insurer.

DEPENDENT
An insured’s spouse (wife or husband), not legally separated from the insured, and unmarried child(ren) who meet certain eligibility requirements and who are not otherwise insured under the same group policy. The precise definition of a dependent varies by insurer.

DIAGNOSIS-RELATED GROUP (DRG)
A system of categorizing inpatient medical services and assigning specific reimbursement fees to each category.

DISABILITY
A physical or mental condition that makes an insured incapable of performing one or more duties of his or her occupation or, for total disability, of any occupation.

DISABILITY BENEFIT
A payment that arises because of the total and/or permanent disability of an insured; a provision added to a policy that provides for a waiver of premium in case of total and permanent disability.

DISCHARGE PLANNING
A managed health care process directed at limiting the duration of inpatient care to that which is medically necessary and systematically facilitating transfer of a patient to a more cost-effective care facility.