Insurance & Claims
Names and abbreviations on this page
FDA — Food and Drug Administration. A United States agency regulating products including medicines, medical devices and many foods.
CMS — Centers for Medicare & Medicaid Services. A United States agency administering major health-coverage programmes and publishing coverage guidance.
NAIC — National Association of Insurance Commissioners. An organisation supporting state insurance regulators through standards, data and coordination.
1 — Read the coverage, not only the policy name
Health
Check the premium, deductible, copay or coinsurance, network rules, out-of-pocket maximum, exclusions and required approvals.
Auto
Check which coverage applies, the deductible, coverage limit, exclusions and endorsements, and which policy may respond.
Home
Check covered causes of loss, exclusions, deductibles, limits and endorsements. Similar-looking policies can contain different protections.
2 — Follow what happened when coverage was used
Start with the bill, damage or repair cost. Then compare the insurer's covered or allowed amount, your deductible or cost sharing, the insurer payment, any limit, and the reason given for anything denied or left unpaid.
For health coverage, an Explanation of Benefits (EOB) explains how a claim was processed; it is not itself a medical bill.
3 — Something does not match? Verify it
Find the actual policy provision, exclusion, endorsement, Explanation of Benefits (EOB) or claim determination involved. Keep estimates, bills, photographs, correspondence and other supporting records. Check the policy or plan's review and appeal process rather than assuming the first claim decision is final.
Auto medical coverage can include Medical Payments Coverage (MedPay) or Personal Injury Protection (PIP). What they cover varies by policy and state.
Medical decisions — understand, verify, decide
A treatment recommendation can involve benefits, risks, uncertainty and alternatives. Evidence and safety information can also change after a medicine is approved and used more widely.
Understand: What is the treatment intended to accomplish, and what are the important benefits and risks?
Verify: What evidence supports it, what alternatives exist, and is there newer safety information?
Decide: Ask questions and, when useful, seek another qualified medical opinion. Avmuri does not diagnose, prescribe or tell someone to stop medication.
FDA: postmarket drug safety information ›Insurance words — plain language
Premium — what you pay to keep insurance active.
Deductible — the amount you may have to pay before insurance pays its covered share.
Copay — a set amount you pay for certain covered health services.
Coinsurance — the percentage of a covered health cost you pay.
Network — providers that have arrangements with your health plan.
Coverage limit — the most a policy will pay under a particular coverage.
Exclusion — a loss, service, circumstance or risk the policy says it does not cover.
Endorsement — a change to the original policy that can add, modify or exclude coverage.
CMS: read an Explanation of Benefits ›CMS: appealing health-plan decisions ›NAIC: understanding home coverage ›NAIC: endorsements and riders ›