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This Glossary has been constructed to assist in understanding some of the medical terminology which is used by Doctors, nurses and in insurance brochures.
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Abuse: When used as a legal term in healthcare, it normally refers to actions that do not involve intentional misrepresentations in billing but which, nevertheless, result in improper conduct. Consequences can result in civil liability and administrative sanctions. An example of abuse is the excessive use of medical supplies.
Access: The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities: transportation: hours of operation and cost of care. An individual's ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources): geographic (distance to providers): organisational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.
Accident And Health Insurance: Insurance under which benefits are payable in case of disease, accidental injury or accidental death.
Accidental Injury: Injury caused as a direct result of something accidental, outside the body and violent and visible. Accidental injury does not include sickness disease of any natural occurring or deteriorating condition.
Accommodation charges: Charges for your hospital room, meals and nursing directly related to your treatment.
Accreditation: The process by which an organisation recognises a programme of study or an institution as meeting predetermined standards.
Accrual: The amount of money that is set aside to cover expenses. The accrual is the plan's best estimate of what those expenses are, and (for medical expenses) is based on a combination of data from the authorisation system, the claims system and the plan's prior history.
Activities of daily living (ADL's, ADL): An individual's daily habits such as bathing, dressing and eating. ADLs are often used as an assessment tool to determine an individual's ability to function at home, or in a less restricted environment of care.
Actuary In insurance: a person trained in statistics, accounting and mathematics who determines policy rates, reserves, and dividends by deciding what assumptions should be made with respect to each of the risk factors involved (such as the frequency of occurrence of the peril, the average benefit that will be payable, the rate of investment earnings, expenses, and persistency rates), and who endeavours to secure as valid statistics as possible on which to base his assumptions. Professionally trained individual, usually with experience or education in insurance, who conducts statistical studies such as determining insurance policy rates, dividend reserves and dividends, as well as conducts various other statistical studies. A capitated health provider would not accept or contract for capitated rates, or agree to a capitated contract without an actuarial determining the reasonableness of the rates.
Acupuncture: An ancient Chinese treatment using needles which stimulate different energy channels in the body; under Alternative therapy usually
Acute Care: A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialised personnel using complex and sophisticated technical equipment and materials. Unlike chronic care, acute care is often necessary for only a short time.
Acute conditions: A condition of rapid onset with severe symptoms and brief duration (e.g. Tonsillitis, Appendicitis). This may include conditions which are a result of a chronic illness but are deemed as possibly partially or totally curable by the medical profession (e.g. Heart Valve replacements/ heart bypass surgery, prosthesis for knees, hips etc)
Banding: The process of clarifying, the difference between accommodation charges in private hospitals. There are three bands, A, B, C. A being the most expensive. NB. The banding is not a classification of the standard of medical care. It clearly shows the daily/nightly rate for the cost of the bed in the hospital.
Bed Days: Number of inpatient hospital days per 1,000 health plan members for a specified period, usually annual.
Beneficiary (Also eligible; enrolee; member): Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
Benefit: The amount payable in the respect of a claim.
Benefit Limitations: Any provision, other than an exclusion, which restricts coverage in the Evidence of Coverage, regardless of medical necessity.
Benefit Payment Schedule: List of amounts an insurance plan will pay for covered health care services.
Benefits Specific: areas of Plan coverage's, i.e., outpatient visits, hospitalisation and so forth, that make up the range of medical services which a payer markets to its subscribers. Also, a contractual agreement specified in an Evidence of Coverage, determining covered services provided by insurers to members.
Broker: One who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the premium.
Built in Travel Cover: Some Private medical health plans include Travel cover. This section usually covers medical expenses (sometimes both in-patient, day care and out patient are covered), personal liability, personal accident, cancellation and curtailment and delayed departure. Loss of passport, baggage and personal effects and money, additional accommodation for members of the family if the insured is hospitalised. All policies vary and some can be purchased as a Stand Alone plan. Those that are purchased alongside a main policy are known as Bolt on policies.
Capitation (Cap, Capped, Capitate): Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment "per covered life" or per member. The method of payment in which the provider is paid a fixed amount for each person served, no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. A payment system whereby managed care plans pay health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilisation.
Cash benefit: A cash payment to the policyholder for a stay in a NHS hospital after receiving treatment which was not available in the Private sector: Some policies offer cash back if the client chooses to be admitted to the NHS instead of the Private sector.
Cash Plan: A policy that usually has a qualifying waiting period e.g. 6 months before claims can be made. Cash is paid depending on the level of cover for consultations, glasses, dentures, alternative therapies, inpatient and outpatient visits etc. This policy does not provide Private Medical Health Care, it is solely cash towards medical services.
Cat (Computerised Axial Tomography) Scan: A computerised axial tomography scan is more commonly known by its abbreviated name CAT scan or CT scan. It is an x-ray procedure which combines many x-ray images with the aid of a computer to generate cross-sectional views and three-dimensional images of the internal organs and structures of the body. A CAT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments. A large doughnut shaped x-ray machine takes images at many different angles around the body. These images are processed by a computer to show as x-ray "slices" of the body, which is recorded on a film. This recorded image is called tomogram. "Computerised Axial Tomography" refers to the recorded tomogram "sections" at different levels of the body.
Certificate of Insurance: A statement of coverage issued to the insured under a group insurance contract outlining the insurance benefits and principal provisions applicable to the insured.
Chemotherapy: Treatment of disease (usually Cancer) by chemical medicine.
Chiropractors/Osteopaths/Cranial Osteopaths: Treatment/consultations with qualified Practitioners.
Chronic Care: Long term care of individuals with long standing persistent diseases or conditions. It includes care specific to the problem as well as other measures to encourage self-care, to promote health, and to prevent loss of function.
Chronic Condition: A condition which medical science at this precise time cannot cure but is usually able to alleviate some of the symptoms if not all for a period of time (e.g. Coeliac disease, Eczema, Asthma).
Claim: The amount of benefit paid for providing the treatment for an accepted condition less the excess if one has been applied to the policy.
Claim Denial: When an insurance claim is submitted to a payor, it is reviewed by the payer, to see if it should be paid. If the payor does not believe that reimbursement is appropriate the claim is rejected. This is known as a claim denial.
Claim Form: A form used to present claim information in an organized manner to a payer.
A Claimant: A person who files an insurance claim with his or her provider company.
Claims experience: An aggregate figure of the total amount claimed over a period of one year.
Claims Review: The method by which an enrolee´s health care service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive.
Compliance: Accurately following the government´s rules on OPCS codes and other regulations. A compliance programme is a self-monitoring system of checks and balances to ensure that an organisation consistently complies with applicable laws relating to its business activities.
Complication: A medical condition that arises during a course of treatment and is expected to increase the length of stay by at least one day for most patients.
Consultant: Specialist in the field of Medicine, Surgery etc.
Continuation Option: Some Providers of Health insurance offer a continuation option to an individual on leaving a Group scheme.
Contract: The legal document issued by an insurance company to the policy holder which outlines the conditions and terms of the insurance. Also referred to as the "policy contract" or the "policy"
Covered Expenses: The term used to describe the benefits provided under a health insurance policy. Found most often in connection with major medical plans, the term defines the type and amount of expenses which will be considered in the calculation of benefits. Also referred to as "insurance coverage" or "covered services"
Critical Illness Benefit: A benefit payable to the policyholder upon diagnosis of a critical illness (e.g. heart attack, stroke, cancer, multiple sclerosis, motor neurone disease etc).
Cytotoxic Drugs Specific medicines used for the annihilation of cancerous cells. The treatment of a critical illness is usually covered by a private medical insurance (providing it was not a pre-existing condition) see pre-existing condition. The benefit is usually covered under a separate policy.
Day case treatment: The patient is admitted to a hospital and registered as a day case patient and allocated a bed. Usually undergoes some form of surgical procedure or investigation but does not stay in hospital overnight.
Dental condition: Routine dental treatment (check ups, hygienist: scale and polish) is rarely covered by private medical insurance plans. Cover can be available as a "bolt on" policy or as a "stand alone"
Dependants: Either a wife or husband or partner and any children who are financially dependant upon the policy holder.
Diagnostic Procedure: In order to diagnose a medical condition either X-rays, ECGs, EEGs, scans, blood tests etc. are carried out and the results will be evaluated by a specialist.
Disability: From an insurance standpoint, a disability is a physical or mental handicap resulting from sickness or injury. It may be partial or total.
Disclosure: Underwriters of medical insurance companies require full disclosure of previous medical history by an applicant prior to offering a fully medically underwritten plan to a prospective policy holder
Electronic Claim: A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer.
Eligible Dependent: Person entitled to receive health benefits from someone else's plan. See also Dependent.
Eligible Employee: Employee who qualifies to receive benefits.
Eligible Expenses: Charges covered under a health plan. See "Covered and Approved Services".
Eligible Person: Person who meets the qualifications of a health plan contract.
Elimination Period: Most often used to designate the waiting period in a health insurance policy.
Emergency: Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, which, if not treated immediately, would jeopardise or impair the health of the Member, as determined by the payer's Medical Staff. Significant in that Emergency may be the only acceptable reason for admission without pre-certification.
Endorsement: In addition to the usual exclusions which insurance companies impose (i.e. self induce injury etc) the underwriters reserve the right to exclude a pre-existing condition for either a stated period of time or for the life of the policy.
Enrolment Initial process whereby new individuals apply and are accepted as members of a prepayment plan.
Episode of Care A term used to describe and measure the various health care services rendered in connection with identified injury or period of illness.
Episode The period of time for which a medical condition requires treatment.
Evidence of Insurability Proof of a person's physical condition that affects acceptability for insurance or a health care contract.
Evidence or Explanation of Coverage (EOC) or Explanation of Benefits (EOB) A booklet provided by the insurance company/provider to the insured summarising benefits under an insurance plan.
Excess A set amount of money, which the policyholder agrees to pay towards the claim. This can be each and every claim, or the first claim of the year. Variations are available from the majority of companies.
Excess Risk Either specific or aggregate stop loss coverage.
Exclusion A medical condition which the Private medical insurance company will not cover (see pre-existing condition). Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks. Providers will negotiate for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.
Experience A term used to describe the relationship of premium to claims for a plan, coverage, or benefits for a stated time period. Usually expressed as a ratio or percent. See also Medical Loss Ratio.
Experience Rating The process of setting rates partially or in whole on evaluating previous claims experience for a specific group or pool of groups. The rating system by which the Plan determines the capitation rate or premium rate is determined by the experience of the individual group enrolled, based on actual or anticipated health care use by the specific group of insured's. Each group will have a different rate based on utilisation. This system tends to penalise small groups with high utilisation. A method of adjusting health plan premiums based on the historical utilisation data and distinguishing characteristics of a specific subscriber group, such as determining the premium based on a group's claims experience, age and sex or health status.
Experience-Rated Premium: A premium with is based upon the anticipated claims experience of, or utilisation of service by, a contract group according to its age, sex, constitution, and any other attributes expected to affect its health service utilisation, which is subject to periodic adjustment in line with actual claims or utilisation experience.
Extension of Benefits: Insurance policy provision that allows medical coverage to continue past termination of employment.
Fee Schedule: A listing of accepted fees or established allowances for specified medical procedures. As used in medical care plans, it usually represents the maximum amounts the programme will pay for the specified procedures.
Fixed Costs: Costs which do not change with fluctuations in census or in utilisation of services.
Full Medical Underwriting: Applicant is required to declare in detail their past medical history to enable the underwriter to evaluate the risk. On assessment of the history a policy will be offered: depending on past history the policy terms may involve a loading of the premium or imposition of exclusions of cover for a specific time or for the lifetime of the policyholder.
Full Refund/Full cover: The insurance company will pay out on a claim in full ie. no shortfall for the policyholder.
General Practitioner Family doctor registered in the UK. Policy holders have to be referred by the GP to the Consultant etc.
Grievance Procedures: The process by which an insured can air complaints and seek remediesor recourse.
Group Insurance: Any insurance policy or health services contract by which groups of employees (and often their dependants) are covered under a single policy or contract issued by their employer or other group entity.
Health Insurance: Protection which provides payment of benefits for sickness or injury which is covered by the policy. Included under this heading are various types of insurance such as accident insurance: disability income insurance: regular medical expense insurance: accidental death and dismemberment insurance.
Health Screening: Discount some private health insurance companies offer a discount on screening procedures.
HIV Human Immunodeficiency Virus (HIV), The virus which causes AIDS (Acquired Immune Deficiency Syndrome). AIDS can damage the brain and destroy the body's ability to fight off illness. AIDS is 100% fatal and is currently incurable. It poses major problems for insurance companies and policy holders.
Home Nursing: The insured is nursed at home by a qualified nurse for medical reasons. Usually this is after an inpatient stay. Has to be recommended by the Consultant. This benefit is available on the more comprehensive plans.
Home Nursing Care: Care provided by a registered nurse, or a licensed practical or vocational nurse under the supervision of a registered nurse, which includes observation, assessment, care planning and implementation, evaluation of client response to care. Nursing includes care of persons experiencing changes in normal health processes, maintenance of health and prevention of illness, and caring for the ill.
HRT/ Hormone Replacement Therapy: The use of hormones in the treatment of a hormone deficiency. Usually used to treat menopausal symptoms.
Hospital Private medical insurance companies now use the following: Private Hospitals; Private beds within the NHS hospitals; Pay-beds in NHS; Trust wards within Trust hospitals (NHS).
Hospital Expense Insurance: Health insurance protection against the cost of hospital care resulting from the illness or injury of the insured person.
Health: The state of complete physical, mental and social well- being and not merely the absence of disease or infirmity. It is recognised, however, that health has many dimensions (anatomical, physiological and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms of morbidity and mortality.
Hospice: Facility or programme providing care for the terminally ill.
Hospital: Any institution duly licensed, certified and operated as a Hospital. In no event shall the term "Hospital" include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescence facility, rest facility, nursing facility, or facility for the aged.
Inpatient Care: Care given a registered bed -patient in a hospital, nursing home or other medical or post- acute institution.
Inpatient Drugs and Dressings: Drugs and dressings used in the treatment of the insured during their stay in hospital.
Inpatient: The insured is admitted into the hospital and occupies a bed overnight for treatment.
Insurance Premium Tax: The tax levied by the Government at 5% on general insurance policies from July 1999.
Invasive Surgery: Any form of procedure that involves invading any human tissue with an instrument of any kind.
Incurred Claims: All claims with dates of service within a specified period.
Indemnify: To make good a loss.
Individual Plans: A type of insurance plan for individuals and their dependants who are not eligible for coverage through an employer group coverage.
Insurance: Protection by written contract against the financial losses, in whole or in part, through the occurrence of specified fortuitous events.
Insurance Company: Any corporation primarily engaged in the business of furnishing insurance protection to the public.
Insured: The person who represents the family unit in relation to an insurance program. This is usually the person whose employment makes this coverage possible. Also referred to as the "policy holder" "enrolee" or "subscriber"
Long-term care: A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g. the chronically ill, aged, disabled/ retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.
Low Claims Discount: Only applicable to Group Corporate schemes :equivalent to a No Claims Discount and is available on some individual plans. Depending on the number of claims that are made by the group, there will be an effect on the future premiums.
Loyalty discount: A discount offered by the insurance company to a policyholder who remains loyal to the insurance company.
Malpractice Insurance: Insurance against the risk of suffering financial damage due to professional misconduct or lack of ordinary skill. Malpractice requires that the patient proves some injury and that the injury was the result of negligence on the part of the professional. A practitioner is liable for damages or injuries caused by malpractice.
Market Share: A certain percentage of the market area or targeted market population. Usually used to describe a forecast goal or a past penetration of the market.
Maternity Cash Benefit: The benefit payable on the birth of a child. Insurers will usually stipulate that a mother should have been covered for at least 10 continuous months under the policy, prior to claiming.
Medical Declaration: The process of filling out details of medical history for underwriting purposes.
Medical Health Disregarded: A level of underwriting usually only available to Companies who have more than 50 employees on the policy.
Medical History: The medical history of the applicant for insurance is required by the underwriters prior to the commencement of a policy. This takes the form of any medical treatment or advice previously received from either GP or Specialist. Only required for Fully Medically Underwritten policies not Moratorium Policies.
Medical Inflation: The rate of increase in the cost of healthcare treatment per year. It is expressed as a percentage for the year. It is usually higher than the Retail Price Index (RPI).
Moratorium: This is an alternative method of dealing with pre-existing conditions. It removes the need to disclose evidence of medical history. In effect, it is a blanket "pre-existing condition" clause. The mechanics are essentially as explained below:
"The clause excludes cover during an initial period (usually 2 years) of membership for any conditions or related condition for which medical treatment was received, advised on or was known about during a time period (usually 5 years) prior to cover commencing. However, after completing the initial period, all pre-existing conditions then become eligible for benefit (provided that at the time of receiving treatment the member has been free from treatment and advice for that condition during the period)."
MRI Scan (Magnetic Resonance Imaging): An MRI scan is a radiology technique which uses magnetism, radio waves and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed which is inserted into the magnet. The magnet creates a strong magnetic field, which aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body and they produce a faint signal, which is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced. The image and resolution is quite detailed and can detect tiny changes of structures.
NHS Cash Benefit: The benefit paid should a member have to receive treatment in an NHS hospital as an inpatient in a non-fee paying part of an NHS hospital.
NHS Hospital: Hospitals in the UK run under the National Health Service with specialist facilities for treatment.
No-Claims Discount Facility: The "no claims discount" offered by a provider on a policy under which the policyholder has made no claims during a covered year.
Non-Participating Physician (or Provider): A provider, doctor or hospital which does not sign a contract to participate in a health plan which usually requires reduced rates from the provider. In company plans, non-participating providers are also called "out -of -network" providers or "out - of - plan" providers. If a beneficiary receives service from an "out - of - network" provider, the health plan will only offered limited benefits or may not offer some benefits at all.
Nurse Practitioner: A registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. Nurse practitioners generally function under the supervision of a physician, but not necessarily in his or her presence.
Nursing At Home: When a qualified nurse cares for the patient at home (usually only on the recommendation of the specialist and as a consequence of inpatient or day-case treatment).
Nursing Home: A general term applied to skilled nursing facilities and facilities providing custodial care.
Occupancy Rate: A measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
Occupational Health: Occupational health programme's include the employer activities undertaken to protect and promote the health and safety of employees in the workplace, including minimising exposure to hazardous substances, evaluating work practices and environments to reduce injury, as well as reducing or eliminating other health threats. Many health providers offer occupational health consultations as well as occupational health screenings, treatments and case management.
Overall Annual Limits Payable: The overall annual limit of benefits payable by an insurer in a contract year.
Occupational Therapy: The therapeutic use of self-care, work and play activities, to increase independent function, enhance development and prevent disability; may include adaptation of task or environment to achieve maximum independence and to enhance quality of life.
Ombudsperson or Ombudsman: A person within a managed care organisation or a person outside of the health care system (such as an appointee of the state) who is designated to receive and investigate complaints from beneficiaries about quality of care, inability to access care, discrimination and other problems that beneficiaries may experience with their managed care organisation. This individual often functions as the beneficiary's advocate in pursuing grievances or complaints about denials of care or inappropriate care.
Oncology Research into tumours.
Optical Cover: Routine eye treatment is not normally covered by all Private Medical Insurance policies (i.e. check-ups and spectacles etc.). However, medical treatment required in a hospital is normally covered.
Oral Surgery: A dental procedure classified under a schedule of oro-surgical operation published by an insurer (i.e. those covered by the policy). These procedures refer to specific procedure relating to teeth, jaws and other parts of the mouth or face. Should not be confused with routine dentistry, which is not normally covered by Private Medical Insurance.
Orthotic and prosthetic devices: Orthoses (braces) provide artificial support for weakened or malformed body parts. Prostheses (artificial limbs) provide article replacement of missing limbs or organs. These are often custom-made, and always custom-fitted, to each individual patient. Orthotic and prosthetic devices are unique to each patient´s needs, physical condition and ability.
Osteopathy: The practice of treating medical conditions through the manipulation of the bones. The treatment can be related to the spine and or limbs. It can take different forms of manipulation of all areas of the body.
Ostomy Supplies Persons of all ages may undergo ostomy surgery for reasons including birth defects, trauma, inflammatory bowel disease and cancer. After this re-routing of the urinary or intestinal tract to the surface of the abdomen, prosthetic supplies collect body waste and associated odour until a convenient time for disposal. This affords the individual dignity and ability to have as normal a life as possible, allowing him or her to pursue education, employment and social activities.
Out-Of-Band Benefit: The benefit payable per night/day in respect of the cost of hospital accommodation. The benefit ceiling paid is dependant on the scale of cover chosen (i.e. if a member is covered for a "C" scale hospital but needs to attend a "B" scale hospital for treatment then the maximum benefit an insurer would pay is that of the "C" scale limit)
Out of Pocket Expenses Out of Pocket Costs Portion of health services or health costs that must be paid for by the plan member including deductibles, co-payments and co-insurance. In the age of managed care, out of pocket expenses can also refer to the payment of services not covered by or approved for reimbursement by the health plan.
Outpatient Care: Many investigations/minor surgery and treatment are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalisation. Some say this is considered to be the fastest growing segment of healthcare.
Outpatient Services: The services received or eligible as an outpatient (e.g. for physiotherapy, radiology or pathology). These can take the form of both treatment and consultations
Parental Accommodation: A parent staying with their child during a time in hospital. The benefit is usually paid if there is a medical reason, and is restricted to the child´s age.
Participating Physician or Participating Provider: A physician or hospital agreeing to provide services for a set payment provided by a payer, or who agrees to other arrangements, or who agrees to provide services to a set of covered lives or defined patients.
Pathology: The tests for the cause of bodily diseases.
Pay-Bed: An NHS hospital bed for use by private patients.
Period of Cover: The period of insurance commencing with the Inception Date and finishing at the Renewal Date.
Physical Therapy: The planning, administration and modification of therapeutic interventions that focus on posture, locomotion, strength, endurance, cardiopulmonary function, balance, coordination, joint mobility, flexibility, pain, healing and repair as well as functional abilities in daily living skills, including work.
Physiotherapy: Treatment of disease or injury by massage, heat and exercises using ultra-sound machines and lasers amongst other media.
Policy: A legal document which outlines the conditions and terms of insurance issued by an insurance company to a policy holder, Also referred to as the "policy contract" or the "contract."
Policy Holder: A person who represents the family unit in relation to an insurance program. Usually, this is the employee whose employment makes coverage possible. Also referred to as the "insured," "enrolee" or "subscriber".
Policy Term: The period for which a policy provides coverage.
Pre-Existing Condition: Any disease, illness or injury which began before the policy inception date.
Pre authorization: The process of obtaining permission to perform a service from an insurance company before the service is performed. Also referred to as "pre certification".
Preferred Provider: Some insurance plans now use preferred providers to help control costs. These plans are based on the same principle as traditional indemnity (fee for service) plans, except that each beneficiary is encouraged through financial incentives, such a minimal co-payment to use providers who have contracted with the insurance company at a pre-arranged fee schedule. These providers are known as preferred providers.
Premium: The periodic payment required to keep a policy in force.
Private Ambulance Benefit: The benefit provided by the insurance policy to pay for the use of a private ambulance for appropriate use.
Primary Care: Treatment Provided by the General Practitioner (not normally covered under a standard Private Medical Insurance policy).
Private Medical Insurance: Is designed to cover the costs of private medical treatment for curable short-term illness or injury (commonly known as acute conditions) The policies can be purchased by individuals or by Companies for their employees. The policies vary in the way that they are underwritten . See Moratorium. Fully Medically Underwritten. Medical Health Disregarded.
Prosthesis: An artificially made body part which is designed to form a permanent part of the body. Some policies do not pay for this and some only pay for certain prosthesis.
Provider: The person or organization which provides covered services and supplies to the beneficiary of an insurance programme.
Psychiatric Cover: Insurance provision against the cost of treating a mental disease. Psychiatric cover can be applied to in-patient and outpatient treatment. Some insurers specifically exclude psychiatric cover on PMI policies.
Quality: Can be defined as a measure of the degree to which delivered health services meet established professional standards and judgements of value to the consumer.
Radiotherapy: Treatment of cells by radioactive means.
Rate Band: The allowable variation in insurance premiums . Acceptable variation may be expressed as a ratio from highest to lowest or as a percent from the community rate (e.g. +/-20%). Usually based on risk factors such as age, gender, occupation or residence.
Rate Review: Review by a government or private agency of a hospital's budget and financial data, performed for the purpose of determining the reasonableness of the hospital rates and evaluating proposed rate increases.
Registered Nurses (R.N.'s): Responsible for carrying out the physician's and surgeon`s instructions. They supervise practical nurses and other auxiliary personnel who perform routine care and treatment of patients. Registered nurses provide nursing care to patients or perform specialised duties in a variety of settings from hospitals and clinics to schools and public health departments. For licensure as a registered nurse (R.N.), an applicant must have graduated from a school of nursing approved by the Royal College of Nursing (RCN ) and have passed a RCN board examination.
Reimbursement: Under traditional indemnity insurance plans, the provider or patient initially pays for the cost of therapy. The insurance company is billed and provides payment to the patient or provider for allowable charges. This is generally referred to as the payment or reimbursement.
Re-instatement: The resumption of coverage under a policy which has lapsed.
Reinsurance: The acceptance by one or more insurers, called re-insurers, of a portion of the risk underwritten by another insurer who has contracted for the entire coverage.
Renewal: Continuance of coverage for a new policy term.
Repatriation: The process of returning the policyholder or member to their homeland in an emergency.
Respiratory Care: Respiratory Care is an allied health care profession, provided under physician direction for patients suffering from diseases of the cardio-pulmonary system. Respiratory care practitioners treat a range of patients from the premature infant with under-developed lungs, to the child with asthma, to the young adult dependent on a ventilator, the elderly suffering from chronic lung diseases such as emphysema. Respiratory care includes diagnostics, therapeutics, monitoring, rehabilitation and public/patient/family education.
Risk: Any chance of loss.
Secondary Care: All patients must first seek care/advice from primary care providers (i.e. General Practitioners). Then referred to secondary and/or tertiary providers (i.e. consultants/alternative medicines providers etc.) as needed.
Six Week: NHS Policies Commonly referred to as Budget Schemes. These policies utilise the private sector for the required operation or treatment if a bed is not available within the NHS within 6 weeks of being seen by a consultant. If the operation or treatment is available within the NHS in the local area within a 6-week period from the date of seeing the specialist the patient is obliged to have that operation/treatment within the NHS. Most 6-week plans apply the rule to in-patient and outpatient treatment. However, some only apply the rule to in-patient treatment.
Social Services: The activities of social workers and other professionals in promoting the health and well-being of people. In helping people to become more self-sufficient preventing dependency, strengthening family relationships and restoring individuals, families, groups, or communities to successful social functioning. Specific kinds of social services include helping people obtain adequate financial resources for their needs, evaluating the capabilities of people to care for children or other dependents, counselling and psychotherapy. In addition referral and channelling, mediation, advocating for social causes and forming organization of their obligations to individuals, facilitating health care provisions and linking clients to resources.
Specialist: A medical or dental practitioner registered under the Medical Acts who is or has been a Consultant in an NHS hospital or who holds a Certificate of Higher Specialist Training.
Subrogation: Procedure where insurance company recovers from a third party when the action resulting in medical expense (e.g. auto accident) was the fault of another person. The recovery of the cost of services and benefits provided to the insured of one health plan when other parties are liable.
Subscriber: Person responsible for payment of premiums, or person whose employment is the basis for membership in a health plan.
Subscriber Contract: A written agreement that describes the individual's health care policy. Also called subscribe certificate or member certificate.
Support Groups and Networks: Groups of individuals who are available to provide emotional and other support for home care patients and their care-givers.
Surgeon´s / Anaesthetists Fees: Fees charged in respect of the surgeon and anaesthetist for an operation. Insurers who do not provide full refunds in respect of these fees usually provide cover up to the limits suggested by the BMA guidelines.
Table of Benefits: A document which sets out the benefits payable under a Private Medical Health Insurance policy.
Termination Date: Date that a group contract expires or an individual is no longer eligible for benefits.
Tertiary: Care Services provided by highly specialised providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technology and facilities.
Therapeutic: Alternatives Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Drug Formulary.
Time Limit: The period of time during which a notice of claim or proof of loss must be filed.
Treatment: Surgical or medical procedures solely to cure "acute" medical conditions or to relieve acute episodes of "chronic" or incurable condition.
Treatment Episode: The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalisation and outpatient or the period of time between the first procedure and last procedure on an outpatient basis for a given diagnosis. Many healthcare statistics and profiles use this unit as a base for comparisons.
Triage: The act of categorising patients according to acuity and by determining which need services first. Most commonly occurs in accident/emergency departments but can occur in any healthcare setting. Classification of ill or injured persons by severity of condition. Designed to maximise and create the most efficient use of scarce resources of medical personnel and facilities. Managed care organisations, health plans and provider systems are setting up programs or clinics called "triage centres". These centres serve as an extension of the utilisation review process as diversions from accident/emergency department care or as case management resources. These triage centres also serve to steer patients away from more costly care (for example, a child with a cold is steered away from accident/ emergency department). Triage can be handled on the telephone. Also known as a pre-authorisation centre, crisis centre, call centre or information line.
Trust Hospital: An NHS hospital operating an independent, private unit.
Underinsured: People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that can exceed their ability to pay.
Underwriter: An insurance company which writes and administers a health insurance policy. Also referred to as an "administrative agent," "carrier" or "insurer."
Underwriting: Process of selecting, classifying, analysing and assuming risk according to insurability. The insurance function bears the risk of adverse price fluctuations during a particular period. Analysis of a group determines rates or determines whether the group should be offered coverage at all.
Waiting periods: The length of time an individual must wait to become eligible for benefits of a policy for a specific condition after overall coverage has begun.
Waiver: An agreement attached to a policy which exempts from coverage a disability or injury which is normally covered by the policy.
Waiver Of Premium: A provision which may be included in a policy which exempts the policy holder from paying the premiums while the insured is totally disabled, during the life of the contract.