Glossary
Health Insurance
D to E

You will find an expanded list and definition of terms in this glossary health insurance D to E section.

Use it often, especially when you begin to review your health insurance options and benefits.

D

denial: An insurance company decision to withhold a claim payment or preauthorization, if the medical service is not covered, not medically necessary, or experimental or investigational.

dental benefits: Some health plans offer dental care as an optional benefit or rider that you or may decide to add at an additional cost.

dependent: For most plans, this refers to your spouse and/or children. Some plans allow non- traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional paperwork.

discount dental plans: These are not insurance plans, and are considered cheaper alternative to dental insurance. Typically, these are ‘membership programs’ that offer discounts on dentist visits and dental procedures.

domestic partner: Domestic partners is commonly defined as "two adults who share an emotional, physical and financial relationship similar to that of a married couple but who either choose not to marry or cannot legally marry. They share a mutual obligation of support for the basic necessities of life." Some insurance companies may require that domestic partners own property together to qualify.

disability income insurance: This plan will provide you with an income in case you become unable to work due to an injury or illness. Benefits are usually 60% of your income at the time of disability.

duplication of coverage: Coverage under two or more policies for the same potential loss (see also, Coordination of Benefits).

dual choice: Dual choice enables employers to offer employees not one, but two health plans. Usually, this is a choice of between an HMO and PPO, or HMO and POS. Dual Choice allows you to choose the type of plan that best meets your needs or budgets. Typically, your employer pays a portion of the premium in these plans, and you pay the balance.

E

eligible expense(s): The portion of a medical care provider's services that are covered for payment under the terms of the health plan.

elimination period: The period when no benefits are received during a stay in a long-term care facility.

elimination rider: A rider or an amendment to insurance contracts that excludes coverage for certain medical conditions (e.g., hypertension, payment for high blood pressure drugs), either permanently or for a period of time.

emergency care: Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.

emergency-room visit: A visit to a hospital for treatment of an accidental injury or for emergency medical care. To qualify as an emergency, the symptoms must be sudden, severe and require immediate medical attention.

Keep in mind that some plans won't cover a trip to the emergency room if the symptoms appeared more than 24 hours earlier.

employee contribution: Your share of the premium for your employer-provided health insurance plan.

Employee Retirement Income Security Act of 1974 (ERISA): ERISA is a federal law that regulates employer-sponsored pension and health benefits plan. It is administered by the U.S. Department of Labor Employee Benefits Security Administration.

enrollment or eligibility period: The time during which a new group member may first enroll for group insurance coverage.

evidence of insurability: Information used by the plan or insurance company to evaluate whether or not and at what rate the coverage can be offered (see "underwriting"). It uses a procedure that reviews factors concerning your and your dependant’s physical condition and medical history.

experience rating: Determining the premium rate for a group based wholly or partially on that group's claims experience.

experimental and/or investigational medical services: A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care.

explanation of benefits (EOB): A document you receive when the insurance company handles a claim. This document explains how reimbursement was made or why the claim was not paid.

It also outlines your rights in case your claims have been denied and procedures on how to appeal.

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