CSU Health Network Care for Body and Mind

Insurance Glossary

This glossary is to assist you in understanding the most used terms related to the insurance industry. It can also help in understanding the optional student insurance program; however, all of the terms are not specific to the program offered at Colorado State, but should be used educationally.

Accident/Injury:

Bodily injury to the insured person resulting directly from an accident and independent of all other causes which occurs while the policy is in force and which is an injury covered by the policy.

Assigned Benefits:

A statement allowing your insurance company to make (assign) payments for your medical treatment directly to the hospital or physician. Otherwise, the money will be paid to the insured when bills and claim forms are returned to the insurance office.

Carrier, Underwriter, Insurer:

The company that insures you.

Claim Form:

A document that an insured person must complete as a part of the filing process. The form will usually ask specific questions relating to the medical treatment, previous history, etc.

Coinsurance/Co-payment:

A provision of the insurance by which the covered person and the insurance carrier share in a specified ratio the eligible hospital or medical expenses resulting from a sickness or accident, (e.g. 80%:20% the carrier paying 80%, the insured person paying 20%).

Coordination of Benefits/Anti-Duplication Provision:

Provision of the insurance designed to eliminate duplicate payments and provide the sequence in which coverage will apply when a person is insured under two or more health plans. This provision assures that no more than 100% of all incurred expenses will be paid by all insurance companies combined.

Cosmetic Surgery:

Surgery/treatment given to correct/reconstruct a defect caused from an injury or disease (See elective surgery/treatment).

Deductible:

The amount of out-of-pocket expenses that must be paid in for health services by the insured person before benefits become payable by the insurance carrier.

Dependent:

The insured student’s spouse residing with the insured student; or the insured student’s unmarried child or children over the age of fourteen(14) days (including step children if dependent on the insured student), and under the age of nineteen (19) years, who are not self-supporting and who reside with the Insured student.

Doctor:

A licensed practitioner of the healing arts acting within the scope of his or her license and practice.

Effective Date:

Date the insurance coverage commences.

Elective Surgery and Elective Treatment:

Surgery or medial treatment which is not necessitated by a pathological or traumatic change in the function or structure in any part of the body.

Eligible Expenses:

Usual and customary expenses that may be used as the basis for a claim under the terms of the insurance.

Emergency Admission:

A hospital admission for inpatient hospital confinement for a condition which, unless promptly treated on an inpatient bases, would (1) put the patient’s life in danger; or (2) cause serious damage to a bodily function of the patient.

Exclusions:

Specified conditions or circumstances for which a policy does not provide benefits.

Hospital:

An institution operating under the supervision of a licensed physician primarily for the care and treatment of injured and sick persons confined as inpatients, having organized facilities on the premises for diagnosis, major surgery and 24 hour-a-day nursing services but not primarily a place for alcoholics or drug addicts, not a nursing, rest or convalescent home.

Hospital Stay:

A medically necessary overnight confinement in a hospital when room and board and general nursing care are provided and a per diem charge is made by the hospital.

Illness:

Sickness or disease for which no treatment or expense has been incurred for the six (6) month period immediately preceding the effective date of coverage of the insured person whose illness is the basis of the claim.

Loss:

Medical expense or indemnity covered by the policy as the result of “injury” or “sickness”.

Open Enrollment:

Time period when students are eligible to enroll for coverage without having to prove insurability.

Out-of-Pocket:

Includes the 20% coinsurance payable by the claimant and any co-payments paid by the claimant. Out of Pocket does not include any excluded amounts ( including but not limited to amounts over Reasonable and Customary or Usual and Customary and charges not covered by the policy) or amounts that exceed the maximum benefit allocation as listed in the Schedule of Benefits.

Pre-existing Condition:

A pre-existing condition is a condition for which the person received medical treatment or advice, or which was diagnosed in the six months preceding the effective date of the person’s coverage. An accidental injury sustained during the six months preceding the effective date of the persons coverage will also be considered a pre-existing condition.

Surgical Procedure:

Cutting, suturing, treating burns, correcting fracture, reducing a dislocation, manipulating a joint under general anesthesia, electrocauterizing, tapping (paracentesis), applying plaster casts, administering pneumothorax, endoscopy or injecting, sclerosing solution.

Therapy Services (Medical):

Services used to treat or promote recovery from illness/injury.
A) radiation therapy is treatment using x-ray, radium, cobalt, or high energy particle sources. Radiation therapy includes rental or cost of radioactive materials. Diagnostic services requiring use of radioactive materials are not radiation therapy.
B) Chemotherapy is treatment of malignant disease by using chemical or biological antineoplastic agents.

Treatment:

Medical care provided by means of consulting any medical provider about symptoms resulting from injury or sickness. Also includes, (but is not limited to) care by means of diagnostic procedures (i.e., x-rays, lab, surgery); the taking of medications; therapy (physical, mental health, etc.); or the use of any appliance (mental or dental).

Usual and Customary Charge/Reasonable and Customary:

The charge for the offered service or supply usually made by the provider when there is no insurance, not to exceed the prevailing charge in the area for a service of the same nature and duration and performed by a person of similar training and experience, or for a substantially equivalent supply.