Exclusions and Limitations – Written language or parts of an insurance policy where conditions or medical procedures are limited or excluded from the coverage of benefits. It’s recommended to read all of these exclusions and limitations in your health insurance policy and certificate of coverage to determine which expenses are not covered.
Experimental and/or Investigational Medical Services – A therapy, treatment, procedure, drug, or device that at the time is not within the accepted standards of medical care.

Grace Period – Certain period that follows the premium due date during which a payment can be made to continue a policy without it lapsing or canceling due to non-payment. Life and Health policies are only where this is applicable. To be certain, you should check your policy to see how long the grace period is.

Guaranteed Issue – Is a health insurance policy that will be approved or issued regardless of any preexisting conditions. Underwriting is not determined by the applicants past and current physical condition or past medical procedures. The insurance company will not require a physical examination and cannot decline an applicant coverage due to past medical history on guaranteed issue policies.

Independent Medical Review – A process in which independent expert medical professionals with no ties to your health insurance company or health plan review specific medical decisions made by an insurance company. Independent Medical Review Program is required by California state law, which is administered by the CDI and the DMHC depending upon what type of coverage you have (indemnity or HMO).

Medically Necessary – It can be a device, procedure, therapy, treatment plan, or a drug that your insurance policy will cover. Your physician or hospital will have decided it as necessary for your medical well-being, or health condition.

Policy – A contract that binds an individual or group policyholder to an insurance company or vise-versa. The policy will explain which duties, obligations, and responsibilities the insured and the insurance company have. Included in a policy usually is an application, certificate, endorsement, or any other document that might describe, limit, or exclude coverage benefits under the contract.

Preexisting Condition – A medical condition in which you may have received medical advice or treatment during the six months prior to obtaining health insurance. Group healthcare policies of 3 or more persons cover preexisting conditions after you have been insured for 6 months, and individual policies cover preexisting conditions after you have been insured for 1 year. Creditable coverage, which has been described above, will be counted towards any preexisting condition exclusion in either an individual or group policy.

Usual, Reasonable, and Customary – It is determined by an insurance company, and gives a normal payment range for a specific medical procedure performed within a given geographic area. The price for medical procedures varies throughout the state. Sometimes the charges submitted to an insurance company will be higher than what the insurance company determines as normal for certain medical care services, in which case they may not allow the full amount charged to you.