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.

EFFECTIVE DATE
The date that insurance coverage goes into effect.

ELIGIBILITY
The provisions of the group policy that state the requirements members of the group and/or their dependents must satisfy to become insured.

ELIGIBILITY DATE
The date on which a member of an insured group may apply for insurance.

ELIGIBILITY REQUIREMENTS
Underwriting requirements that applicant must satisfy in order to become insured.

ELIMINATION PERIOD
A specified number of days at the beginning of each period of disability during which no disability income benefits are paid.

ENROLLEE
Health plan participant, member, or eligible individual in a managed care program.

ENROLLMENT
The process of explaining the proposed group insurance plan to eligible persons and assisting them in the proper completion of their enrollment cards.

EVIDENCE OF INSURABILITY
Any statement or proof of a person’s physical condition and/or other factual information affecting acceptability for insurance.

EXCLUSIONS (EXCEPTIONS)
Specified conditions or circumstances, listed in the policy, for which the policy will not provide benefits.

FLEXIBLE SPENDING PLAN
Employee benefit coverage offered by an employer that allows employees to select type and amount of benefits from among a menu of benefits that employer offers. Also called cafeteria plan or Section 125 plan.

FORMULARY
List of preferred pharmaceutical products to be used by a managed care plan’s network physicians. Formularies are based on evaluations of the efficacy, safety, and cost-effectiveness of drugs.

FRAUD
An intentional act or misrepresentation that results in some type of loss to another.

GATEKEEPER
Role description of a primary care physician who serves to control utilization and referral of enrollees.

GRACE PERIOD
A specified time (usually 31 days) following the premium due date during which the insurance remains in force and a policyholder may pay the premium without penalty.

GROUP CONTRACT
A contract of health insurance made with an employer or other entity that covers a group of persons as a single unit. The entity is the policyholder.

GROUP INSURANCE
An arrangement for insuring a number of people under a single master insurance policy.

GROUP POLICYHOLDER
The legal entity to which the master policy is issued.

HEALTH INSURANCE
Coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
A 1996 law setting forth new responsibilities for the plan sponsors of group health plans, including self-funded medical plans. Among these responsibilities, the act aims to simplify insurance portability by documenting limitation periods for pre-existing conditions. To that end, covered individuals receive credit for time completed during the limitation period – credit that can be carried over to a new plan should the individual change jobs or otherwise lose coverage.

HEALTH MAINTENANCE ORGANIZATION (HMO)
An organization that provides for a wide range of comprehensive health care services for a specified group at a fixed periodic prepayment.

HOME HEALTH CARE
A comprehensive, medically necessary range of health services provided by a recognized provider organization to a patient at home.

HOSPICE
A mode of care provided to terminally ill patients and their families that emphasizes patient comfort rather than cure and addresses emotional needs, such as coping with pain and death.

HOSPITAL EXPENSE INSURANCE
A form of health insurance that provides specific benefits for hospital services, including daily room and board and surgery, during a hospital confinement.

IDENTIFICATION CARD
A form provided to insureds that identifies them as members of a particular insurance plan and may provide basic information about their coverage. Although such cards do not guarantee eligibility for medical care benefits at any given time, they provide procedures for providers to follow to verify that a patient has health coverage.

INDEMNIFY
To compensate for a loss.

INDEMNITY
A benefit paid by an insurance policy for an insured loss.

INDEMNITY INSURANCE
Health care insurance plan providing benefits in a predetermined amount for covered services. Traditionally, payment is made on a fee-for service basis with no involvement by the insurer in the actual delivery of health care services.

INITIAL RATE
A premium rate that is charged on the effective date of a new group policy.

INJURY
Accidental bodily damage sustained while a particular health insurance policy is in force.

INSTALLATION
The process of assisting a group policyholder to set up the administrative practices essential to the proper handling of all initial and ongoing administrative activities of the plan.

INSURANCE
A plan of risk management that, for a price, offers the insured an opportunity to share costs of possible economic loss through an entity called an insurer.

INSURED
The person and dependent(s) who are covered for insurance under a policy and to whom, or on behalf of whom, the insurer agrees to pay benefits.

INSURER
The party to the insurance contract that promises to pay losses or benefits.  Also, any corporation primarily engaged in the business of furnishing insurance protection to the public.