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A
Authorisation: Official permission or approval.
Acute: Having or experiencing a rapid onset and short but severe course of illness.
Allergy: Hypersensitivity reaction to a particular allergen; symptoms can vary greatly in intensity.
Alternative treatments: Any of a range of medical therapies not regarded as conventional by medical profession, e.g. homeopathy and reflexolgy.
Amendment: A statement that is added to or revises or improves a proposal or document.
Application: A verbal or written request for assistance in any matter-here in our case maybe for issuance of policy.
Arbitration: The hearing and determination of a dispute by an impartial referee agreed to by both parties.
Authenticate: Establish the truth or genuineness or validate.
B
Balance Billing: The practice of a provider billing a patient for all charges not paid for by the insurance plan.
Basic insurance: The health insurance policy pursuant to which basic healthcare services are offered to the categories set out under the Implementing Regulations.
Best Practices: Actual practices, in use by health care providers following the latest treatment modalities that produce the best measurable results on a given dimension.
Body Mass Index: An index that expresses adult weight in relation to height. Body Mass Index (BMI) is used to estimate healthy weight of average people.
Benefit Period: It refers to the time period for which payments for benefits of an insurance policy are available.
Beneficiary: Person covered by health insurance.
Breach: Act in disregard of laws, rules, contracts, or promises/ failure to perform something promised.
Broker: The broker offers advice and arranges the insurance normally as agent for the insured and is usually remunerated by a commission from the insurer.
C
Cancellation: A termination of a policy before its normal expiration date.
Cessation: A pause or stopping of coverage/benefit.
Charity health program: Organisations or institutions helping those in need of health care.
Chronic: Being long-lasting and recurrent or characterized by long suffering.
Claim Administration: The process of receiving, reviewing, adjudicating, and processing claims.
Claim Form: An application for payment of covered benefits under a health plan.
Claim Review: A process which monitors the claim, its appropriateness and ensures that it is not excessive.
Claim Examiner: A professional who considers all the information pertinent to a claim and make decisions about the payment of the claim.
Claim Investigation: The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.
Clerical error: A mistake committed while copying or writing out some document or a part of it.
Covered Services: Benefits that are covered under the terms & conditions of the policy.
Conditions: A part of an insurance policy that states your obligation and those of your insurance company.
Co-insurance: In Health Insurance, it is a percentage of each claim paid by the policyholder after the deductible has been paid.
Complaint: A health plan member's expression that his expectations regarding the product or the services have not been met.
Compliance: Acting according to certain accepted standards.
Complications: Any disease or disorder that occurs during the course of (or because of) another disease.
Confinement: An uninterrupted overnight stay following formal admission to a hospital.
Congenital diseases: A disease or disorder that is inherited genetically.
Contribution: If an insured is covered under two plans for same risk, a ratable proporion of losses are shared among insurers on the basis of their liabilities.
Controlling document: A document which has the power to check and direct some activity and thus regulate the Act.
Coordination of Benefits (COB): An agreement to prevent double payment for services when a subscriber has coverage from two or more sources. Agreement determines which organization has primary responsibility for payment and which organization has secondary responsibility.
Cosmetic procedures: Procedure intended to improve physical appearance or for restoring or enhancing the normal appearance- a procedure generally not required medically.
Coverage: The total amount and type of insurance carried/ the extent to which benefits are covered.
Custodial care: Treatment under care of some person or institution or organisation.
D
Daman card: The identification card the Company issues for every member covered under this health insurance scheme.
Day treatment: Medical treatment which must be provided in the Hospital, but which does not require confinement.
Declination: Rejection by a Health insurance company of a Health insurance application.
Deductible: In health Insurance, a fixed monetary amount paid by the Insured for a defined benefit.
Dependant: A person who relies on another person for support (especially financial support).
Diagnosis: Identifying the nature or cause of an illness/ailment.
Dispute resolution: Means of resolving a dispute or a disagreement.
Domiciliary care: Treatment undertaken at home or residence under professional medical supervision and assistance.
E
Effective Date: The date that Coverage becomes effective, which may be either the Enrollment Date of a Covered Person, or the date on which Coverage renews.
Earned Premium: The proportion of premium related to the period of insurance that has already elapsed.
Effective date of coverage: The date on which coverage becomes effective, which may be either the Enrollment date of a person or the date on which the coverage renews/is renewed.
Elective diagnostic services: Those diagnostic services which are sought without them being medically necessary at that particular time.
Eligibility conditions: Some basic requirements based on which the rights conferred are decided.
Employer: Any Person or entity employing resident expatriate in UAE including resident expatriate on work or resident permits.
Emergency: A sudden unforeseen crisis (usually involving danger) that requires immediate action.
Entitled: Qualified for, by right, according to law.
Epidemic: A widespread outbreak of an infectious disease in which many people are infected at the same time.
Excluded healthcare services: The health care services which are not covered by the health insurance policy.
Exclusions: Items or conditions that are not covered by the general insurance contract.
Exempted: Grant relief or an exemption from a general rule or requirement.
Ex-Gratia Payment: Done voluntarily, out of kindness or grace. In law, an ex gratia payment is a payment made without recognizing any liability or legal obligation.
Expatriate: A person living away from one's own native country.
Experimental: A medical, surgical, diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that the Company determines as experimental, subject is of an ongoing clinical trial, not demonstrated through prevailing pre-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.
Expiration: End of a contract period.
H
Hazardous activity: A circumstance or activity that increases the likelihood or probable severity of a loss.
Healthcare providers: Organisations and institutions providing health care and authorised to do the same.
High Cost Case: A patient whose condition requires large financial expenditures or significant human and technological resources.
High Risk Case: A patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.
I
Impairment: The condition of being unable to perform as a consequence of physical or mental unfitness.
Inception: An event that is a beginning; a first part or stage of subsequent events.
Incurred but not reported (IBNR): Claims or benefits that occurred during a particular time period, but that have not yet been reported or submitted to an insurer.
Indemnity: Payment made to compensate the Insured for their Illness or Injury.
Infringement: Act contrary to or in violation of law that disregards an agreement or a right.
Insurance: Promise of reimbursement in the case of loss; paid to people or companies that have made prepayment to insurance companies against these risks.
Insurer: The party in an insurance agreement who undertakes to pay the losses.
Insured: A person who is covered under the insurance plan.
Intermediary: A negotiator who acts as a link between parties.
Irreversible: Incapable of being brought back to original form or incapable of undoing that which has been done.
L
Large Group: A large group may be defined as more than 11 employees and in some policies 25 employees and above.
Lesion: An injury to living tissue (especially an injury involving a cut or break in the skin) or Any localized abnormal structural change in a bodily part.
Liable: Legally bound under an obligation, the term is more used in a pecuniary sense.
Limit: The maximum amount of benefits the insurance company agrees to pay on a loss.
Loss Ratio: The ratio of losses(claims) paid and outstanding to premiums.
Loading: Administration costs paid upon purchasing insurance.
M
Material Facts: A fact that would influence the judgment of a prudent underwriter in deciding whether to accept a risk for insurance and on what terms.
Malicious: A desire to do wrong or to do evil.
Mandatory: Required by rule, or made compulsory by law.
Mediation: The act of intervening for the purpose of bringing about a settlement.
Medically necessary: A service given at a provider that should be in consistent with the diagnosis, be in standards of good medical practice and not be for the convenience of the patient or the family members.
Medical Underwriting: The evaluation of health questionnaires submitted by all proposed plan members to determine the insurability of the group.
Misleading information: Any wrong or misleading information given to the insurer, which may affect underwriting decision.
Misrepresentation: A wilful perversion of facts.
N
Negotiate: Confer with another in order to come to terms or reach an agreement.
Network: A group of health care providers under contract with a insurance company within a specific geographic area.
O
Obesity: Abnormal or excessive fat accumulations that presents a risk to health.
Obligations: A legal agreement specifying a payment or action and the penalty for failure to comply.
Occupational diseases: A disease or a chronic ailment that occurs as a result of work or occupational activity.
Open Access: A provision that plan members may self-refer to a specialist, either at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider.
Optional: Possible but not necessary; left to personal choice.
Orthodontics: The branch of dentistry dealing with the prevention or correction of irregularities of the teeth.
Out-of-pocket Limit: A predetermined amount of money that an individual must pay before insurance will pay 100% for an individual's health-care expenses.
Outpatient care: Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor's office, clinic, the patient's home or hospital outpatient department.
P
Performance-enhancement drugs: Drugs used to enhance or improve the performance - those that are not medically necessary.
Physician: Any practitioner of medicine who is duly licensed and qualified under the laws of the country in which treatment is received.
Policy holder: Policy holder is a person or an entity that sponsors the policy or in other words pays the premium for the policy.
Policy period: The period of time (typically one year) from the Effective Date of Coverage, to the termination of coverage prior to renewal.
Pre-authorization: Prior approval or official permission taken before certain procedures which according to the terms of the policy require to be taken for claiming the cover.
Pre-existing condition: Existing previously or before something, Exist beforehand or prior to a certain point in time.
Premium: The price payable by an insured person under any type of insurance policy.
Prescription: Written instructions from a physician or dentist to a pharmacist concerning the form and dosage of a drug to be issued to a given patient.
Preventive: Remedy that prevents or slows the course of an illness or disease.
Premium Refund: This insurance is non-transferable. Premium will be refunded on the basis of short term basis on cancellation.
Primary healthcare: Essential health care based on practical, scientifically sound and socially acceptable methods made accessible to the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development.
Provider: Any person or entity providing health care services, including hospitals, medical centres and clinics. Usually licensed by the state.
Provider Manual: A document that contains information concerning a provider's rights and responsibilities as part of a network.
Procedure: A particular course of action intended to achieve a result.
Pro-rata premium: Proportionate amount collected for coverage for a partial period which is less than the cover generally extended.
Prosthetic devices: An artificial device, either external or implanted, that substitutes for or supplements any part of the body.
Provisions: A stipulated condition.
Psychiatry: A mental condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological, social, or work performance of the individual.
Pursuant: In conformance to or agreement with.
R
Recipient: A covered person who received or is receiving an organ transplant covered under this policy.
Reconstructive Surgery: Surgery incidental to an injury, sickness or congenital anomaly with the primary purpose of is to improve the physiological functioning of the involved body part.
Recreational: Engaged in as a pastime, source of enjoyment.
Referral: A person whose case has been referred to a specialist or professional group/ A recommendation to consult the person or group to whom one has been referred.
Reimbursement: Compensation paid (to someone) for covered benefits availed at a non-network provider.
Reinsurance: An insurance company that protect against the risk of losses of other insurance companies.
Repatriation: In case the insured member has passed away the Mortal Remains will be sent back to his/her country of origin.
Rescind: Cancel or terminate officially.
Restrictions: Restriction means to limit the extent of something. Insurance restriction refers to limiting the benefits or services in insurance.
Revocation: The state of being cancelled or annulled /The act (by someone having the authority) of annulling something previously done.
Riders: Any attached rider to a policy maybe subject to payment of additional premiums and are subject to all conditions, limitations and exclusions of the Policy unless specifically amended.
Risk: Risk means uncertainty of financial loss.
Risk Factors: Things about you that affect your risk (e.g., older age, smoking, heart disease, occupation.
Routine examinations: Medical examinations which are done on a regular basis just as a preventive measure without them being medically necessary at that point of time.
S
Schedule of benefits: A summary of the details of cover extended, the territorial limits and also the terms and conditions of coverage.
Scheme: In insurance “scheme” refers to different kind of plans with certain specific benefits, in view to target certain segment or achieve some pre specified objectives.
Screening Programme: Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem.
Second Opinion: Where Surgery is recommended, taking second opinion from other doctor for given medical condition.
Settlement: A conclusive resolution of a matter and disposition of it /Something settled or resolved; the outcome of decision making
Short Term Cancellation: A cancellation by the insured of an insurance policy for which the returned, unearned premium is diminished by administration costs incurred when the insurance company places the policy on its books.
Sponsor: Any person or entity that sponsor the resident expatriate for the of working,residing, whether temporarily or otherwise in Emirate of Abu Dhabi.
Small Group: In Daman policy it is generally composed of 10 or less employees irrespective of size of members for which health coverage is provided by the group sponsor.
Standard of benefits: It explains the coverage, benefits and limit of policy. See the schedule of Benefits.
Standard of care: A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
Subrogation: When an insurer indemnifies an insured,it's permitted to take over the right of the insured to recover any amount payable from other parties who might be liable for the loss.The insured is said to have subrogated their right to the insurer.
Supplementary insurance: Coverage provided by non-profit charity health care program.
T
Termination: A coming to an end of a contract period, or the act of ending something.
Termination of provision: A provider contract clause that describes how and under what circumstances the parties may end the contract.
Terms and conditions: The basis on which the contract is formed, benefits are granted and the rules governing the coverage of the policy.
Territorial coverage: The area or territory over which the cover is extended under a policy.
Therapeutic: Relating to or involved in therapy, A medicine or therapy that cures disease or relieve pain.
Third Policy Administration (TPA): It refers to system where the processing of claims is outsourced to another company but the risk of loss remains with the insurer or the employer.
Tranquilizer: A drug used to reduce stress or tension without reducing mental clarity.
Transplant: An operation where an organ is transferred from the donor to the recepient.
Traumatic: Of or relating to a physical injury or wound to the body, Psychologically painful.
U
Underwriter: The individual trained in evaluating risks and determining premiums and coverages for them.
Underwriting: The process of selecting risks for insurance and classifying them according to their degrees of insurability so that the appropriate rates may be assigned.
Underwriting Impairment: Factors that tend to increase an individual's risk above that which is normal for his or her age.
Underwriting Manual: A document that provides background information about various underwriting guidelines and suggests the appropriate action to take if such an impairment exists.
Unearned Premium: That part of the premium or reinsurance premium applicable to the unexpired portion of the policy.
Usual customary and reasonable (UCR) fee: The amount commonly charged for a particular medical service within a particular geographic region.
V
Validity: The quality of having legal force or effectiveness.
Violation: An act that disregards an agreement or a right - resulting in right to revoke the contract or take legal action against the offending party.
W
Workers' compensation: A state-mandated insurance program that provides benefits for healthcare costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.
Workers' compensation indemnity benefits: Benefits that replace an employee's wages while the employee is unable to work because of a work-related injury or illness.
Waiting period: The time which must pass before policyholder can collect insurance benefits.