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Health Insurance Coverage

Health insurance policies are contracts between you and a health insurance company. A list of benefits that are covered by the policy will be provided with your health insurance policy. Benefits could include medication, treatment, testing, or other medical care. The benefits that are covered by the health insurance are known as covered services.

Waiver of Premium Provision

This is a provision insuring that if you become severely ill, you won't have to pay the premium. A waiver of premium provision means you wouldn't need to pay the health insurance premium payments during an extended period of poor health. This is a valuable benefit if you become ill and are unable to work for a period of time.

Medical Needs May Not be Covered

Your physician may recommend a prescription drug or treatment that isn't covered by your health insurance plan. It is important to understand your policy because the health insurance company, not the health care provider, will decide what is covered. For this reason, it is a good idea to have your health insurance provider or agent explain your health insurance policy to you in depth.

Ask About the Appeal Process

You can appeal the ruling if your health insurance claim is denied. Ask your doctor for advice; he or she may be able to help with this. It's a good idea to understand how your health insurance company deals with appeals before you have to make one. Remember that even if your insurance denies a claim, you can still get the treatment, you will just have to pay for it on your own.

Basic Health Insurance Coverage

Hospital, surgical, and physician's expenses should be included in basic health insurance coverage. Major medical coverage can protect you in case of a severe illness or accident.

You are permitted to purchase basic health insurance and Major Medical Insurance separately, but usually they are combined into one health insurance policy.

The components of your health coverage and exactly what the health insurance company will contribute will be clarified in the policy. The policy also has the information about what the patient has to contribute - deductibles, co-payments, and coinsurance, and also your maximum out-of-pocket costs.

Typical Elements of Basic Health Coverage


Hospital Expense Coverage

This covers many hospital expenses if you become hospitalized. Some health insurance plans pay the actual cost, regardless of the dollar amount, while other health insurance plans cover a certain amount per day for a particular number of days. You may need a range of services while in the hospital such as x-rays, anesthesia, lab tests, and monitoring equipment, so look to see what services your hospital expense coverage includes.


Surgical Expense Coverage

Many surgery fees and related costs are included with this kind of health insurance coverage. There is often a table that lists what the health insurance company will pay for particular procedures. Some health insurance companies pay what is considered usual, customary, and reasonable (UCR) in a certain area.


Physicians Expense Coverage

This pays for most costs associated with doctors visits and is also known as regular medical expense insurance. There is normally a maximum number of doctor visits for each condition and a maximum dollar amount they will cover; the health insurance policy will list what these are.


Major Medical Insurance Coverage

This type of health insurance coverage protects you from many costs associated with severe illness or injuries. The policy is normally extremely broad with a high dollar amount for maximum benefits. At least $250,000 in coverage is nearly always part of this type of health insurance policy, but some experts recommend $1,000,000 or more in coverage.

The following items are often covered by major medical insurance policies:

-Lab services
-X-Rays
-Diagnostic tests including MRIs and CAT-scans
-Ambulance services
-Radiology
-Blood (and plasma)
-Oxygen
-Intensive care and other hospitalization (including all supplies and services including surgery)
-Medication (prescription and other)
-Nursing services and other medical services (including in-home care)
-Physicians services (surgical, medical, and diagnostic)
-Anesthesia
-Dental treatment for injuries
-Prosthetics

* This is not a complete list, read your health insurance policy for information about what is included in your particular policy.


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