Lesson 1, Topic 2
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Health Insurance Explained

Master August 6, 2020
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1. What is Health Insurance?
It is an insurance investment that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over numerous persons. It is also known as Medical Insurance

It is a contract between the Insurance Company (Insurer / HMO) and an interested individual (Insured / Beneficiary) for the HMO to assume the responsibility of subsequently paying the medical, surgical and hospitalization (Healthcare) expenses incurred by the Beneficiary

The Beneficiary pays a Premium and, in return, the HMO promises to pay a predetermined sum of money (Cover Limit) to meet healthcare costs of the Beneficiary (Claims) for a specified period (Cover Period) – which is usually one year, but renewable annually

2. Key Benefits?

It protects the Beneficiary and his/her dependents against the financial, emotional and human losses caused by unpredictable healthcare issues and expenses. You are financially covered by the HMO for your healthcare costs

3. HealthInsurancePlans

These are designed to cover Beneficiaries’ healthcare costs. Health Insurance Plans have different healthcare services (facilities) and premium costs.

4. How does it work?
a. Get informed
. Obtain information and be

sufficiently educated about Health Insurance and its Benefits, the different Health Insurance Plans offered by the HMO, Plan Covers, Service Exclusions and Limitations, as well as other related Terms and Conditions

b. Decide on the Health Insurance Plan to choose, and the preferred Hospitals to use

c. Enrol: Execute a contract with your chosen HMO for your chosen Health Insurance Plan. The HMO gives you an assurance that they will pay up to a stipulated amount (Cover Limit) for your healthcare costs. For this coverage, you need to pay the stipulated Premium for your chosen Health Insurance Plan

d. Pay the stipulated Premium to your HMO. The coverage is usually for one (1) year. Renewal Premium payment need to be done every year to remain covered

e. Go to hospital when necessary, without paying, subject to applicable Waiting Period

f. Hospital gives you medical care, subject to your Plan Cover

g. Hospital sends the bill to your HMO

h. HMO pays the bill, subject to your Cover Limit