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 the medical profession, e.g., homeopathy and reflexology.
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 the issuance of a 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.
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 an agent for the insured and is usually remunerated by a commission from the insurer.
Cancellation
A termination of a policy before its normal expiration date.
Cessation
A pause or stopping of coverage/benefit.
Charity health program
Organizations 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 makes 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 the same risk, a ratable proportion of losses is 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 the care of some person or institution or organization.
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.
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.
Hazardous activity
A circumstance or activity that increases the likelihood or probable severity of a loss.
Healthcare providers
Organizations and institutions providing health care and authorized 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.
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.
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.
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 willful perversion of facts.
Negotiate
Confer with another in order to come to terms or reach an agreement.
Network
A group of health care providers under contract with an insurance company within a specific geographic area.
Obesity
Abnormal or excessive fat accumulations that present 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.
Performance-enhancement drugs
Drugs used to enhance or improve 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
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 being 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 centers, 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.
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 improving the physiological functioning of the involved body part.
Recreational
Engaged in as a pastime, a 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 protects 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 canceled or annulled /The act (by someone having the authority) of annulling something previously done.
Riders
Any attached rider to a policy may be subject to payment of additional premiums and is 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 in time.
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 kinds of plans with certain specific benefits, aiming to target a 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 a second opinion from another doctor for a 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 sponsors the resident expatriate for the purpose of working, residing, whether temporarily or otherwise in the Emirate of Abu Dhabi.
Small Group
In Daman policy, it is generally composed of 10 or fewer employees irrespective of the size of members for which health coverage is provided by the group sponsor.
Standard of benefits
It explains the coverage, benefits, and limit of the 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 a non-profit charity health care program.
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 relieves pain.
Third Policy Administration (TPA)
It refers to a 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 recipient.
Traumatic
Of or relating to a physical injury or wound to the body, Psychologically painful.
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.
Validity
The quality of having legal force or effectiveness.
Violation
An act that disregards an agreement or a right – resulting in the right to revoke the contract or take legal action against the offending party.
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.