Health Insurance

Question 1

Premium

Answer 1

What you pay insurance co. for having active insurance plan.

-Usually monthly & cost may be shared by employer

Question 2

Deductible

Answer 2

What you pay annually for health services before insurer
pays its share

Question 3

Copayment

Answer 3

Amount you owe each time you receive certain types of
medical care.

Question 4

Coinsurance

Answer 4

The percentage you pay of medical costs after deductible if you don’t have a copay.

Question 5

Out-of-pocket maximum

Answer 5

The most you’ll pay each year toward costs including deductible, copays, and coinsurance.

-Doesn’t include non-covered services such as hearing aids or
acupuncture

Question 6

WHO definition of health

Answer 6

“A state of complete physical, mental and social
well-being and not merely the absence of
disease or infirmity”

Question 7

Katskee v. Blue Cross (Nebraska)

Answer 7

Facts:

-P has breast-ovarian carcinoma syndrome and family history of related cancers.
-P undergoes prophylactic surgery
-Blue Cross (D) only pays for medically necessary treatments and refuses to pay for surgery
-D argues breast-ovarian carcinoma syndrome isn’t an “illness”
-Illness defined by insurer as “bodily disorder or disease”

Issue: Will an ambiguous term contained in an insurance policy be construed in favor of the insured?

-Court: Yes, and Katskee had an illness & insurer should pay for
surgery