Benefits and Claims

The benefits and claims to any health insurance claim begins with the initial insurance policy you decided to choose. Even though this is one of the areas that most individuals need to research, very few take the time until after they have a need to submit an insurance claim. This initially is where the difficulties begin and sadly, it is much too late for the insured to change the terms.

There are a few items of interest that you will want to retain for future health insurance policies to help keep the confusion and all of the legal talk down to a minimum.  Learning the meaning of a few of the terms is a beneficial place to begin.

1.    Co-insurance

2.    Percentage of Company Insurance

3.    Insured’s co-insurance portion

4.    Participating Provider

5.    Non-Participating Provider

Co-insurance is by definition a shared expense between your insurance provider and you. Before the co-insurance even kicks in by your health care provider, you first must meet your portion of the deductible you agreed to. Depending upon whether you agreed to a high deductible or a low deductible and what your current expenses for health insurance are will determine when your health insurance provider kicks in. No matter how you choose to look at it though, you still pay the lion’s share, unless hospitalization is involved.

The basis behind the percentage of the company insurance is that portion the insurance provider takes responsibility for meeting the necessary obligatory payment to the medical physician or to the hospital in the case of hospitalization. In essence, this is the health insurance company’s portion of the covered expense remaining, such as:

1.    Applicable co-payments

2.    Applicable deductibles

3.    The co-payment percentage that applies

On the other hand, the insured’s co-payment percentage is usually equal to or lower than the co-payment percentage of payment due by the health care provider. This is where you will see the split percentages such as 80/20, 50/50, 75/25, and 70/30, which is written into your low cost health insurance policy with each annual renewal.

This usually works well with medical physician office visits, but can become a royal nightmare when hospitalization is involved. You could conceivably be expected to reimburse the hospital for your percentage co-payment that could still equal thousands upon thousands of dollars. This is exactly what does happen many times and causes the insured to call the health insurance provider to clear up the misunderstanding. Unfortunately, this is not the time you want to find out you still owe more money than you possess.