Health Insurance Terms & Definitions
Search through 170+ insurance terms and definitions to understand your health, dental, and travel coverage. From Alberta Blue Cross to Canada Life, we explain the terminology that matters. Have questions? Contact Us.
A
Accident
An accident is an unexpected, sudden, and external event that causes bodily injury, occurring independently of any illness or pre-existing condition. In the context of health and dental insurance, an accident typically refers to physical harm resulting from an unforeseen incident such as a fall, collision, or blow to the body. Accidents are distinct from sickness or degenerative conditions because they are caused by an identifiable event rather than a gradual process.
Accidental Death and Dismemberment Insurance (AD&D)
Accidental Death and Dismemberment Insurance (AD&D) provides a tax-free lump-sum payment if you die or suffer a severe injury as the direct result of an accident. It is designed to offer financial protection for you and your family in the event of an unexpected, accidental injury or loss that causes death, dismemberment, or permanent disability.
Accidental Dental
Accidental dental coverage pays for the repair or replacement of natural teeth damaged due to an accidental blow to the mouth or jaw. This benefit is distinct from routine dental coverage because it applies to emergencies caused by external physical impact, not decay or normal wear.
Actuary
An actuary is a professional who specializes in analyzing financial risk and uncertainty, particularly in the fields of insurance, pensions, and investments. Actuaries use mathematics, statistics, and financial theory to calculate premiums, reserves, and probabilities of future events such as illness, disability, or death. Their work ensures that insurance plans remain financially stable and that companies can meet future claim obligations while staying competitively priced.
Advisor/Agent
An advisor or agent is a licensed professional who helps individuals and businesses understand, choose, and manage insurance and financial products. In the context of health, dental, life, and disability insurance, an advisor’s role is to assess a client’s needs, explain plan options, and recommend solutions that provide appropriate protection within their budget.
Age Limit (Travel)
The Age Limit (Travel) refers to the maximum age at which a person is eligible for emergency medical travel insurance coverage or specific benefits under a health or dental plan. Insurers impose age limits to manage risk, as medical expenses tend to rise significantly with age and the likelihood of pre-existing conditions increases.
Ambulance (Ground/Air)
Ambulance coverage provides reimbursement for emergency transportation to a hospital by ground or air when medically necessary. In health insurance plans, this benefit ensures that if you experience a sudden illness or accident, you can access appropriate care without paying the full transportation cost yourself.
Anniversary Year
An anniversary year is a 12-month benefit period that begins on the date your insurance coverage takes effect rather than on a standard calendar year. This means your plan’s annual maximums, deductibles, and claim resets follow your personal enrollment date instead of January 1 to December 31.
Annual Drug Maximum
The annual drug maximum is the highest amount your health plan will pay for eligible prescription drugs during a benefit year. Once you reach this limit, additional drug expenses are your responsibility until the plan renews. This feature helps insurers manage costs while providing predictable protection for routine prescriptions.
Annual Maximum (Overall Plan)
The annual maximum is the most your insurance plan will pay for a specific benefit within a 12-month period (calendar year or benefit year). Once you reach this limit, additional expenses for that category become your responsibility until the next year.
Application for Insurance
An application for insurance is the formal process of requesting coverage from an insurance company. It includes providing personal, medical, and financial information that allows the insurer to evaluate eligibility, assess risk, and determine the appropriate premium and coverage terms. The application serves as both a request for protection and a legal declaration of the information provided by the applicant.
B
Beneficiary
A beneficiary is the person or entity designated to receive the proceeds or benefits from an insurance policy upon the policyholder’s death or when a covered event occurs. In life insurance, the beneficiary receives the death benefit as a tax-free lump sum. In accidental death and dismemberment (AD&D) insurance, the beneficiary receives payment if the insured person dies as the result of an accident. Beneficiaries can also be designated in certain health or travel plans that include accidental death benefits.
Benefit
A benefit is the specific financial protection or coverage provided under an insurance policy. In health and dental insurance, a benefit refers to the payment or reimbursement made by the insurer for eligible medical, dental, or wellness expenses. Each benefit category - such as prescription drugs, dental services, vision care, or physiotherapy - outlines what is covered, how much the insurer will pay, and any applicable limits or conditions.
Benefit Period (Vision)
The benefit period for vision refers to how often your vision care coverage renews and allows you to make new claims for eligible expenses such as glasses, contact lenses, or eye exams. Unlike other benefits that reset each year, vision care often renews every two benefit periods, which can mean every 24 consecutive months rather than every calendar year.
Benefit Survival Period
A benefit survival period is the minimum amount of time a policyholder must remain alive after being diagnosed with a covered condition before an insurance benefit becomes payable. This period ensures that the illness or injury meets the policy’s criteria for a valid claim and prevents immediate payouts for conditions that result in death shortly after diagnosis.
Blood Glucose Monitor / CGM Devices
Blood glucose monitors and continuous glucose monitoring (CGM) devices are tools used to measure and track blood sugar levels for individuals with diabetes. A standard blood glucose monitor requires a small finger-prick blood sample to provide a reading, while a CGM system uses a small sensor worn on the body to record glucose levels continuously throughout the day and night.
Breast Prosthesis / Mastectomy Prosthesis
A breast prosthesis, also called a mastectomy prosthesis, is a covered medical device used to restore body contour after breast surgery. Health plans often reimburse part of the cost of external breast forms, specialized bras, or related supplies when deemed medically necessary by a physician.
Broker
A broker is a licensed professional who acts as an independent intermediary between clients and multiple insurance companies. Unlike agents who represent a single insurer, brokers work on behalf of their clients to compare policies, explain coverage options, and secure the best combination of benefits, price, and flexibility.
C
Calendar Year
The calendar year defines a benefit period that runs from January 1 to December 31. Many annual maximums, deductibles, and claim resets follow this schedule. It provides a consistent framework across most insurers and simplifies tax reporting for medical expenses.
Certificate of Insurance
A certificate of insurance is an official document issued by an insurance company that summarizes the key details of your coverage. It serves as proof that you are insured and outlines the essential terms of your policy, including the type of coverage, effective dates, benefit limits, exclusions, and any dependents or beneficiaries listed under the plan.
Claim
A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.
Claim Submission Deadline
The claim submission deadline is the final date by which an insured person must submit a claim to their insurance company for reimbursement of eligible expenses. After this date, the insurer is not obligated to pay the claim, even if the expense itself would have been covered. This deadline ensures timely processing, accurate recordkeeping, and proper financial reporting for both the insurer and the policyholder.
Claimant
A claimant is the person who submits a request for reimbursement or payment under an insurance policy. In health and dental insurance, the claimant is usually the insured individual who received the service, such as a medical treatment, prescription, or dental procedure. However, a claimant can also be a parent, spouse, or legal guardian submitting a claim on behalf of a covered dependent.
Coinsurance
Coinsurance -sometimes called the *reimbursement rate* - is the percentage of eligible health or dental expenses your plan will pay after any deductible. It’s the insurer’s share of the bill, with the remainder paid by you. Typical plans cover 70–100% of eligible costs; the rest is your out-of-pocket portion.
Combined Dental Maximum
A combined dental maximum is the shared annual limit your insurance plan will pay for multiple categories of dental services grouped together under one total. Instead of assigning separate dollar caps to preventive, basic, and restorative care, the insurer combines them into a single yearly maximum. Once that combined amount is reached, no further reimbursement is available for any of those services until the next benefit period.
Combined Maximum
A combined maximum is a shared limit that applies across multiple services or benefit types. Instead of separate dollar caps for each category, one total amount covers several related expenses. For instance, physiotherapy, chiropractic, and massage therapy might share a $700 combined maximum, meaning any combination of those services counts toward the same pool.
Combined Paramedical Maximum
A combined paramedical maximum is a shared annual limit that applies collectively to several types of paramedical services under your health insurance plan. Instead of assigning a separate reimbursement maximum for each practitioner, the plan pools multiple services together under one total dollar amount. Once that combined limit is reached, no further claims are reimbursed for any of the included disciplines until the plan renews.
Contestability
Contestability refers to the period of time after an insurance policy is issued during which the insurer has the right to review and investigate the accuracy of the information provided in the application. If the insurer discovers that any information was omitted, misstated, or misrepresented during this period, it can deny a claim or void the policy.
Contract
A contract in insurance is the legally binding agreement between the policyholder and the insurance company that outlines the terms, conditions, and obligations of both parties. It specifies what coverage is provided, what benefits are payable, how premiums are calculated, and what exclusions or limitations apply. The insurance contract serves as the foundation for determining how claims are handled and what rights and responsibilities exist under the policy.
Contract Expiry Date
The contract expiry date is the final date on which an insurance policy or agreement remains in effect unless it is renewed or extended. It marks the end of the policy’s coverage period and defines when the insurer’s obligation to pay benefits or accept claims under the existing terms stops. After this date, the policyholder must renew the contract, convert it to a new plan, or allow it to lapse if coverage is no longer needed.
Contract Holder
A contract holder is the individual or organization that owns and controls an insurance policy. The contract holder is responsible for maintaining the policy, paying premiums, and making decisions related to coverage, renewals, and beneficiary designations. In most cases, the contract holder is also the insured person, but in group insurance, the employer or plan sponsor acts as the contract holder on behalf of all covered members.
Convalescent Hospital
A convalescent hospital benefit covers short-term stays in a licensed recovery facility following hospitalization. It helps patients regain strength after surgery or major illness when home care is not yet practical. Coverage usually provides a daily allowance for room, board, and nursing care, subject to an annual or lifetime cap.
Conversion of Benefits
Conversion of benefits is the option that allows an individual to transfer or “convert” their group insurance coverage into a personal plan when they lose eligibility under their employer’s group policy. This typically occurs when someone leaves a job, retires, or loses coverage due to a change in employment status. The conversion option ensures continuity of protection without requiring new medical evidence of insurability, as long as the application is submitted within a specific eligibility window, usually 60 to 90 days.
Conversion Privilege
Conversion privilege is the right to transfer your existing group insurance coverage to an individual policy without providing medical evidence of insurability when your group coverage ends. This option allows you to maintain continuous protection during life transitions such as leaving a job, retiring, or losing eligibility under an employer-sponsored plan. It is a key feature that helps individuals avoid coverage gaps, especially if they have pre-existing medical conditions that could make new insurance difficult to obtain.
Coordination of Benefits
Coordination of benefits (COB) is the process used by insurance companies to determine the order in which multiple plans will pay for the same claim when a person is covered under more than one policy. The goal is to ensure that combined reimbursements do not exceed 100 percent of the eligible expense, while allowing the insured to receive the maximum possible coverage across all plans.
Coverage / Benefit
Coverage, sometimes referred to as a benefit, is the range of health or dental services, supplies, or treatments that your insurance plan agrees to pay for under its terms and conditions. Each benefit represents a category of care, such as prescription drugs, dental services, vision care, or paramedical treatments.
Coverage Period
The coverage period is the span of time during which an insurance policy is active and the insured person is eligible to receive benefits. It begins on the policy’s effective date and ends on the contract expiry date or termination date, depending on whether the policy is renewed or canceled. During this time, the insurer is obligated to pay for eligible claims according to the terms of the plan, as long as premiums are paid and coverage remains in force.
Covered Expenses
See also [Eligible Expenses](https://www.aeva.ca/insuropedia/eligible-expenses)
Critical Illness Insurance
Critical illness insurance is a type of financial protection that pays a one-time, tax-free lump sum if you are diagnosed with a covered serious illness such as cancer, heart attack, or stroke. Unlike disability insurance, which replaces a portion of your income over time, critical illness insurance gives you a single payout that you can use however you choose - for medical expenses, household bills, recovery time, travel, or lifestyle adjustments.
Lifetime Maximum (Multi-Benefit)
A combined lifetime maximum (multi-benefit) is a single limit that applies to multiple benefit categories over your lifetime. Instead of each service having its own separate lifetime maximum, this approach creates one shared total for several types of expenses, such as health, vision, and dental.
D
Deductible
A deductible is the fixed dollar amount you must pay each benefit year before your plan starts reimbursing eligible expenses. Think of it as your yearly participation in costs - once met, your plan covers claims according to its coinsurance. Some individual health plans in Canada have no annual deductible, while others apply one only to certain benefits (often $25–$100 per person).
Dental Accident
A dental accident is a sudden, unexpected event that causes injury to the mouth, teeth, or jaw, resulting from an external force rather than from decay, chewing, or normal use. Examples include being struck in the face, falling and hitting your mouth, or suffering an impact during sports. Dental accident coverage helps pay for the repair or replacement of natural teeth damaged in such incidents.
Dental Fee Guide
A dental fee guide is a provincially issued schedule that lists the standard or recommended prices for dental procedures. Each province and territory in Canada publishes its own guide annually, outlining suggested fees for everything from cleanings and fillings to crowns and dentures.
Dental Insurance
Dental insurance is a type of health coverage that helps pay for the cost of preventive, basic, and major dental services. It is designed to make oral care more affordable and to encourage regular checkups that prevent costly procedures later on. Dental insurance is offered through group employee benefits, individual plans, or conversion plans for people leaving workplace coverage.
Dentist
A dentist is a licensed healthcare professional who diagnoses, treats, and helps prevent conditions affecting the teeth, gums, and mouth. Dentists play a key role in maintaining oral health through preventive care, restorative treatments, and patient education. Common services include cleanings, fillings, crowns, root canals, extractions, and oral examinations.
Dependent
A dependent is a person, usually a family member, who qualifies for coverage under someone else’s insurance plan. Dependents are typically the spouse or children of the primary insured person, also known as the plan member or policyholder. Some plans may also cover other individuals who rely on the plan member for financial support, such as a common-law partner or a child with a permanent disability.
Dependent Eligibility
Dependent eligibility defines who qualifies for coverage under your family health or dental plan. Dependents usually include a legal spouse or common-law partner and children up to a certain age, commonly 21 or 25 if enrolled full-time in school. Some plans extend coverage to disabled dependents beyond these ages.
Dependent Life Insurance
Dependent insurance coverage is often a benefit included on employee [group benefits](https://www.aeva.ca/insuropedia/group-insurance) plans, and is available for an employee's spouse and dependent children.
Diabetic Supplies / CGM
See also [Blood Glucose Monitor / CGM Devices](https://www.aeva.ca/insuropedia/blood-glucose-monitor-cgm-devices)
Diagnostic
Diagnostic refers to tests, procedures, or evaluations performed by healthcare professionals to identify the cause, nature, or extent of a medical or dental condition. Diagnostic services are the foundation of effective treatment, helping doctors and dentists determine the most appropriate care plan. In health and dental insurance, diagnostic expenses are often covered as eligible services when they are medically necessary and performed by a licensed provider.
Disability Income Insurance
Disability income insurance is a type of coverage that replaces a portion of your income if you become unable to work due to illness or injury. It provides ongoing monthly payments designed to help you meet financial obligations such as rent, mortgage, utilities, or living expenses while you recover or adjust to a long-term disability.
Dispensing Fee
A dispensing fee is the professional service charge that a pharmacy adds to the cost of a prescription drug when it is filled. This fee covers the pharmacist’s time, expertise, and services such as verifying the prescription, reviewing potential drug interactions, preparing the medication, and providing counselling on proper use. Each pharmacy sets its own dispensing fee, which can vary based on location, prescription type, and the pharmacy’s policies.
Durable Medical Equipment (DME)
Durable medical equipment refers to reusable devices prescribed to assist with medical conditions or mobility challenges. Examples include wheelchairs, walkers, hospital beds, oxygen systems, and CPAP machines. Health insurance plans typically reimburse a percentage of the cost up to a maximum per item or per period.
E
Effective Date
The effective date is the day your insurance coverage officially begins. From this date forward, you are eligible to receive benefits for covered health, dental, life, or disability expenses under the terms of your policy. The effective date is established once your application has been approved, all requirements are met, and the first premium payment has been received, unless otherwise specified in the policy.
Eligibility Period
The eligibility period is the window of time during which an individual can apply for or enroll in an insurance plan after first becoming eligible. It ensures that applicants join coverage within a reasonable timeframe, helping insurers manage risk and prevent people from waiting until they need care to apply. Eligibility periods are common in both group and individual insurance and are especially important for guaranteed issue or conversion options.
Eligibility Window (Guaranteed Issue)
An eligibility window in a guaranteed issue (GI) plan is the period after losing group benefits during which you can enroll in personal health coverage without completing medical questions. This window is typically 60 to 90 days. Applying within it ensures uninterrupted protection for prescription drugs, dental care, and health services that were previously employer-sponsored.
Eligible Expenses
An eligible expense is any medical or dental service, product, or treatment that qualifies for reimbursement under the terms of your insurance plan. To be eligible, the service must meet several criteria: it must be medically necessary, performed by a licensed or approved provider, and fall within the plan’s specific limits and exclusions.
Elimination Period
The elimination period is the waiting time that must pass after an illness or injury occurs before disability insurance benefits begin to be paid. It functions like a deductible measured in days rather than dollars. During this period, you are responsible for your own income replacement through savings, sick leave, or other sources.
Endodontics
Endodontics is a branch of dentistry focused on treating the interior of the tooth, most commonly through root canal therapy. It addresses infections, inflammation, or damage to the dental pulp and surrounding tissue. Most dental plans classify endodontics as a restorative service, meaning it typically falls under the same category as fillings and crowns.
Evidence of Insurability
Evidence of insurability (EOI) is the information an insurance company requires to assess your health and determine whether you qualify for coverage. It typically includes details about your medical history, lifestyle habits, and current health status. The insurer uses this information to evaluate risk and decide whether to approve your application, exclude specific conditions, or adjust your premium rate.
Exclusions
Exclusions are services, conditions, or expenses that your health or dental plan does not cover under any circumstances. Every policy contains an exclusion list to define what falls outside the scope of coverage. Common exclusions include cosmetic surgery, over-the-counter medications, experimental treatments, fertility procedures, and any service not deemed medically necessary.
Exclusions For Recent Changes
Exclusions for recent changes refer to a rule in travel medical and health insurance policies that limits or denies coverage for medical conditions that have recently changed in treatment, medication, or stability before your coverage began or before you travel. These exclusions are designed to prevent claims related to conditions that may be unstable or unpredictable due to recent medical adjustments.
Extended Health Care Insurance
Extended health care insurance (EHC) is supplemental coverage that helps pay for medical expenses not covered by your provincial or territorial health plan. It protects you from out-of-pocket costs associated with services such as prescription drugs, vision care, medical equipment, hospital upgrades, emergency travel medical care, and paramedical services like physiotherapy or chiropractic treatments.
Eye Exam Maximum
The eye exam maximum is the highest dollar amount your vision or health plan will pay toward the cost of a routine eye examination within a defined period, usually every two years. This benefit encourages preventive eye care by offsetting the cost of visits to an optometrist or ophthalmologist.
F
Financial Needs Analysis
A financial needs analysis (FNA) is a detailed assessment used by financial advisors and insurance professionals to evaluate an individual’s or family’s current financial situation and determine the level of protection or investment required to meet their goals. It examines income, expenses, debts, assets, savings, and existing insurance coverage to identify gaps and recommend suitable financial strategies.
Fracture Benefit
A fracture benefit is a lump-sum payment provided under certain accident or supplemental health insurance plans when you sustain a broken bone as a result of an accidental injury. This benefit is designed to help cover unexpected costs associated with recovery, such as lost income, medical equipment, transportation, or rehabilitation expenses.
Free-Look Period
A free-look period is the short window of time after purchasing a health or dental insurance policy during which you can review the plan and cancel it for a full refund if you are not satisfied. This consumer protection feature allows you to read the policy in detail and ensure it meets your needs before committing long-term.
G
Generic Substitution
Generic substitution means your plan reimburses prescription drugs based on the cost of the lowest-priced equivalent generic medication rather than the brand-name drug, unless a doctor indicates “no substitution” for medical reasons.
Government Health Insurance Plan (GHIP)
A Government Health Insurance Plan (GHIP) is the publicly funded healthcare program administered by each Canadian province and territory. It provides residents with access to medically necessary hospital and physician services at no direct cost, funded through provincial taxes and federal health transfers. GHIP ensures that all eligible residents receive essential medical care regardless of income or health status, forming the foundation of Canada’s healthcare system.
Grace Period
A grace period is the additional time granted after a premium payment is due during which an insurance policy remains active, even though payment has not yet been received. It provides policyholders with a short window to make late payments without losing coverage. The grace period ensures continuity of protection and helps prevent accidental policy lapses caused by missed or delayed payments.
Group Insurance
Group insurance is a type of coverage that provides benefits to a defined group of people, typically employees of a company or members of an organization, under a single master policy. Instead of each person purchasing an individual policy, the group is insured collectively, which allows members to access broader coverage at lower rates. The employer or organization acts as the contract holder, while individual participants receive a certificate of insurance outlining their specific benefits.
Group Policyholder
A group policyholder is the organization or employer that owns and administers a group insurance plan on behalf of its members or employees. The group policyholder holds the master policy issued by the insurer, manages enrollment, collects premiums, and ensures that the plan complies with contractual and regulatory requirements. In most cases, the policyholder is the employer, while the insured members are the employees and their eligible dependents.
Guaranteed Acceptance
Guaranteed acceptance refers to an insurance plan that does not require medical questions, health history, or evidence of insurability for approval. Coverage is automatically granted to anyone who applies and meets basic eligibility criteria such as age or residency. This type of plan is designed for individuals who may not qualify for medically underwritten insurance due to pre-existing conditions, chronic illnesses, or other health concerns.
Guaranteed Issue (GI) / Conversion
Guaranteed Issue (GI) or Conversion refers to an insurance option that allows individuals leaving a group benefits plan to obtain personal coverage without completing medical questionnaires or providing evidence of insurability. This feature guarantees approval as long as the individual applies within a specific time frame, usually 60 to 90 days after group coverage ends. It ensures continuity of protection and prevents gaps in coverage during employment changes, retirement, or loss of eligibility under a group plan.
H
Health Insurance
Health insurance is a type of coverage that helps pay for medical and healthcare expenses not fully covered by Canada’s public health system. It protects individuals and families from the high cost of prescription drugs, medical services, and treatments that fall outside provincial or territorial government health plans. Health insurance can be obtained through an employer’s group benefits plan or purchased individually from a private insurer.
Healthcare Spending Account (HCSA)
A Healthcare Spending Account (HCSA) is a flexible, employer-funded benefit that reimburses employees for a wide range of eligible healthcare expenses not fully covered by their group insurance plan or a government health plan. It allows employees to use allocated funds toward medical, dental, and vision expenses based on their personal needs. The Canada Revenue Agency (CRA) regulates which expenses qualify under the Income Tax Act, and reimbursements from an HCSA are received tax-free.
Hearing Aids
Hearing aids are devices that amplify sound for individuals with hearing loss. Most health insurance plans reimburse a portion of the cost for hearing aids every few years, often every four or five years. Coverage may include the device, fitting, and adjustments, up to a per-ear or combined dollar limit.
Home Health Aide / Home Support Services
Home health aide or home support services coverage pays for non-medical assistance provided in your home to help with daily activities during recovery from illness or injury. This may include bathing, dressing, meal preparation, and light housekeeping.
Hospital Cash
Hospital cash is a supplemental benefit that provides a fixed daily payment when you are hospitalized, regardless of the actual cost of your care. It offers financial support to cover incidental expenses such as transportation, meals for family members, or other non-medical costs during recovery.
I
In-Home Nursing / Home Care
In-home nursing, also known as home care nursing, covers professional medical services delivered in your residence by a registered nurse (RN), licensed practical nurse (LPN), or registered practical nurse (RPN). This benefit supports individuals recovering from illness, surgery, or long-term conditions who require medical supervision outside of a hospital.
Individual Insurance
Individual insurance is a personal policy purchased directly from an insurance company to provide financial protection for a single person or family, rather than through an employer or group plan. It allows you to customize coverage according to your health needs, lifestyle, and budget. Common types of individual insurance include health, dental, life, critical illness, and disability coverage.
Insured Person
An insured person is the individual covered under an insurance policy who is entitled to receive benefits for eligible claims. In a personal policy, the insured person is typically the policyholder who owns the coverage. In a group insurance plan, the insured person is the employee or member enrolled in the plan, and their eligible dependents may also be covered under the same contract.
Insurer
An insurer is the insurance company or organization that provides financial protection to individuals or groups in exchange for premium payments. The insurer assumes the risk of potential loss and agrees to pay benefits for covered claims according to the terms of the policy. Insurers evaluate applications, determine premiums, issue policies, and manage claims through underwriting and administration processes.
L
Lapsed Policy
A lapsed policy is an insurance contract that has ended because the required premium was not paid within the grace period. Once a policy lapses, coverage stops, and the insurer is no longer obligated to pay any benefits for claims incurred after the lapse date. A lapse can occur in any type of insurance - including health, dental, life, or disability - when the policyholder fails to make a payment by the due date and does not bring the account up to date before the grace period expires.
Laser Eye Surgery Allowance
A laser eye surgery allowance is a vision care benefit included in some health insurance plans that provides reimbursement toward the cost of corrective laser procedures such as LASIK or PRK. These procedures permanently reshape the cornea to improve vision and reduce or eliminate the need for glasses or contact lenses. Because laser eye surgery is considered elective and not medically necessary, it is not covered by provincial health insurance plans, making this allowance a valuable feature in private coverage.
Licence
A licence in the context of insurance refers to the official authorization granted by a provincial or territorial regulatory body that allows an individual or company to sell, advise on, or administer insurance products. Licensing ensures that insurance professionals meet educational, ethical, and legal standards required to operate in their jurisdiction. It protects consumers by ensuring that only qualified and accountable individuals provide insurance advice and services.
Life Insurance
Life insurance is a financial protection product that provides a tax-free lump-sum payment, known as a death benefit, to designated beneficiaries when the insured person dies. It is designed to replace income, pay debts, cover final expenses, or provide financial stability for dependents and loved ones. Life insurance helps ensure that family members can maintain their quality of life and meet ongoing financial obligations even after the loss of the primary earner.
Life Insured
The life insured is the individual whose life is covered under a life insurance policy. If the life insured passes away, the insurer pays the death benefit to the designated beneficiary or to the policyholder, depending on the policy structure. The life insured may or may not be the same person as the policyholder. For example, a spouse, parent, or business partner may own a policy that insures another person’s life.
Lifestyle Drugs
Lifestyle drugs are prescription medications used to improve quality of life rather than to treat or manage life-threatening or medically necessary conditions. These drugs address personal or lifestyle-related concerns, such as sexual performance, hair growth, weight management, or cosmetic enhancement.
Lifetime Maximum
A lifetime maximum is the total amount your insurance plan will pay for a specific benefit over the course of your life. Once the limit is reached, no further reimbursement is available for that benefit. Lifetime maximums commonly apply to orthodontics, medical equipment, or travel emergency medical coverage.
Long-term Disability insurance
Long-term disability (LTD) insurance provides income replacement if you are unable to work for an extended period due to illness or injury. It ensures financial stability by paying a percentage of your regular income, typically between 60 and 85 percent, after you have been disabled for a specific waiting period known as the elimination period. LTD benefits continue until you recover, reach a set benefit end date, or reach retirement age, depending on the terms of the policy.
M
Major Restorative
Major restorative coverage includes complex dental procedures designed to restore the function and appearance of teeth. Examples include crowns, bridges, onlays, dentures, and sometimes implants. These treatments are more extensive and expensive than basic restorative services such as fillings.
Material Facts
Material facts are the pieces of information that are essential for an insurer to accurately assess risk and decide whether to approve an application, determine premiums, or apply exclusions. These facts include any details that could influence the insurer’s decision to issue coverage or the terms of that coverage. Examples include medical conditions, medications, family health history, lifestyle habits, and participation in hazardous activities.
Medical Condition
A medical condition refers to any illness, injury, disease, disorder, or ongoing health issue that affects a person’s physical or mental well-being. In the context of insurance, the term includes both acute and chronic conditions, whether diagnosed, treated, or undiagnosed at the time of application or claim. Examples include high blood pressure, diabetes, asthma, depression, or past surgeries.
Medical Emergency
A medical emergency is a sudden and unforeseen illness, injury, or medical condition that requires immediate medical attention to prevent serious harm, disability, or death. In the context of health and travel insurance, it refers to an unexpected situation where urgent care is needed while away from home or outside your province or territory of residence.
Medically Necessary
Medically necessary describes any service, treatment, or supply required to diagnose, treat, or manage a health condition, rather than for convenience, appearance, or personal preference. Insurers use this term to determine whether a claim qualifies for payment under your policy.
Medically Underwritten (MU)
Medically underwritten (MU) refers to the process used by insurers to evaluate an applicant’s health history before approving coverage and determining eligibility, premiums, and benefit limits. In a medically underwritten plan, you must answer health questions, disclose pre-existing conditions, and often complete a medical questionnaire or provide additional documentation
Member
A member is an individual who is enrolled and covered under a group insurance plan, typically through their employer, association, or organization. The member is often referred to as the insured employee or plan participant and receives coverage for benefits such as health, dental, life, and disability insurance. The member may also extend coverage to eligible dependents, such as a spouse or children, under the same plan.
Misrepresentation
Misrepresentation occurs when false, incomplete, or misleading information is provided to an insurance company, either intentionally or unintentionally, during the application process or while a policy is active. It can involve misstating or omitting facts related to medical history, lifestyle, occupation, or any other information that could influence the insurer’s decision to issue coverage or determine premiums.
Misstatement of Age
Misstatement of age occurs when the age of the insured person is recorded incorrectly on an insurance application or policy. Because age is a key factor in determining eligibility, premiums, and benefit amounts, any error - whether accidental or intentional - can affect the terms of coverage. The misstatement may be discovered during underwriting, at the time of a claim, or during a policy review.
Morbidity Rate
Morbidity rate is a statistical measure used by insurers and health professionals to indicate the frequency or likelihood of illness, injury, or disability within a defined population over a specific period of time. It reflects how many people in a given group are expected to experience a health-related event that may result in medical costs or lost productivity. In the insurance industry, morbidity rates are used to predict claim patterns, set premium levels, and design sustainable health and disability products.
Mortality Rate
Mortality rate is a statistical measure that represents the frequency or probability of death within a specific population during a defined period of time. In insurance, it is a key actuarial factor used to determine life insurance premiums, reserves, and the expected financial risk to the insurer. Mortality rates are derived from large-scale data that reflect age, gender, health, lifestyle, and other risk factors, allowing insurers to predict how many people in a given group are likely to die each year.
Multi-Trip Coverage (Days per Trip)
Multi-trip coverage provides emergency medical protection for an unlimited number of trips within a 12-month period, each lasting up to a specified number of days. For example, a plan might cover unlimited trips of up to 30 days each.
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Occupational Class
Occupational class is the category assigned to an individual based on the type of work they perform and the level of risk associated with their job. Insurers use occupational classes to help determine eligibility, premium rates, and benefit levels for life, disability, and accident insurance. The classification reflects how likely a person is to experience injury, illness, or death related to their occupation.
Optional Benefit / Rider / Add-On
An optional benefit, also called a rider or add-on, is an additional feature that can be purchased to enhance your existing health, dental, life, or disability insurance plan. Optional benefits allow you to customize coverage by adding protection that suits your personal needs, rather than relying only on the base plan design.
Oral Surgery
Oral surgery refers to surgical procedures performed in or around the mouth and jaw by a licensed dentist, oral surgeon, or maxillofacial specialist. It includes both minor procedures, such as tooth extractions, and more complex surgeries involving the jawbone, soft tissue, or dental implants.
Orthodontics
Orthodontics covers the cost of correcting tooth alignment and jaw positioning using braces or aligners. In individual and group dental plans, orthodontic benefits are usually separate from preventive and restorative coverage. Most plans apply a lifetime maximum and a waiting period before orthodontic treatment is eligible.
Orthopedic Shoes / Custom Orthotics
Orthopedic shoes and custom orthotics are specialized footwear and inserts designed to support proper alignment, relieve pain, and improve mobility for individuals with foot, leg, or posture-related conditions. These items are often prescribed to correct biomechanical issues, provide additional cushioning, or accommodate deformities caused by medical conditions such as arthritis, diabetes, or plantar fasciitis.
Overall Plan Maximum
An overall plan maximum is the total amount your health and dental plan will pay for all combined benefits within a single policy year. Once the limit is reached, you must pay any additional expenses out of pocket until the next renewal period.
Oxygen and Equipment
Oxygen and equipment benefits cover the cost of oxygen tanks, concentrators, and related respiratory equipment for individuals with chronic or temporary breathing difficulties. These devices are considered medically necessary when prescribed by a physician.
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Paramedical Disciplines
Paramedical disciplines refer to regulated health professionals who provide therapy or rehabilitation services outside of hospital settings. Common examples include physiotherapists, chiropractors, massage therapists, acupuncturists, naturopaths, osteopaths, psychologists, and speech-language pathologists.
Pay-Direct card / Drug card
A pay-direct card, also known as a drug card, is a plastic or digital card issued by your health insurance provider that allows pharmacies to bill your insurer directly for eligible prescription drugs. Instead of paying the full cost upfront and submitting a claim later, you pay only your portion - such as a deductible or coinsurance - at the point of sale.
Per Incident
Per incident refers to the way certain insurance benefits are calculated or limited based on each separate event, illness, or accident rather than by year or lifetime. When a benefit is paid “per incident,” it means you are eligible for reimbursement each time a new, distinct occurrence happens, up to the maximum amount specified for that type of claim.
Per Person / Per Family
Per person and per family describe how benefit limits, deductibles, or maximums are applied within a health or dental insurance plan. A per person limit means the specified amount applies individually to each insured member, while a per family limit represents the total combined coverage for all members under one policy.
Per-Practitioner Annual Maximum (Paramedical)
The per-practitioner annual maximum is the total amount your plan will reimburse for services from one specific type of provider in a single benefit year. For example, if your plan pays up to $500 for massage therapy annually, once that amount is reached, additional treatments from that provider type are no longer covered until the next year.
Per-Visit Cap (Paramedical)
The per-visit cap is the maximum amount your insurance plan will reimburse for a single visit to a paramedical provider, such as a physiotherapist, chiropractor, or massage therapist. If the provider charges more than the cap, you are responsible for the difference. This cap ensures fairness and cost control by aligning payments with typical local pricing.
Per-Visit Maximum
A per-visit maximum is the highest dollar amount your insurance plan will reimburse for a single appointment or treatment with a healthcare provider. If the provider charges more than this set amount, you are responsible for paying the difference. This type of limit is most common in extended health plans for paramedical services, such as physiotherapy, chiropractic care, massage therapy, or acupuncture.
Per-X-Years Limit
A per-X-years limit means a benefit can only be claimed once during a specified number of years. This rule applies to items or treatments that are not needed annually, such as hearing aids, orthotics, or major dental appliances.
Periodontics
Periodontics is the area of dentistry concerned with the prevention, diagnosis, and treatment of gum disease and supporting bone structures around the teeth. Treatments may include deep cleaning (scaling and root planning), gum grafts, and maintenance therapy.
Pharmacist
A pharmacist is a licensed healthcare professional who prepares, dispenses, and provides guidance on the safe and effective use of prescription and non-prescription medications. Pharmacists play a key role in ensuring that medications are used correctly, preventing harmful drug interactions, and advising patients on dosage, side effects, and storage. In many provinces, pharmacists also provide additional healthcare services such as administering vaccines, renewing prescriptions, and offering health consultations.
Physician
A physician is a licensed medical doctor who diagnoses, treats, and helps prevent illness, injury, and disease. Physicians play a central role in healthcare by providing medical assessments, prescribing medications, ordering diagnostic tests, and coordinating patient care with specialists or allied health professionals. In Canada, physicians are regulated by provincial colleges of physicians and surgeons to ensure professional standards and ethical medical practice.
Plan Member
A plan member is an individual who is enrolled in and eligible to receive benefits under a group insurance plan. Typically, the plan member is an employee of a company or a member of an organization that sponsors the group policy. The plan member is covered for the benefits outlined in the plan - such as health, dental, life, and disability insurance - and may also extend coverage to eligible dependents, including a spouse or children.
Plan Sponsor
A plan sponsor is the employer, association, or organization that establishes and maintains a group insurance plan for its employees or members. The plan sponsor acts as the policyholder, holding the master contract with the insurance company and determining the benefits, eligibility rules, and cost-sharing arrangements for the group. Plan sponsors play a central administrative role by enrolling members, collecting premiums, and communicating plan details to participants.
Plan Tiers
Plan tiers refer to the different levels of coverage available within a group or individual insurance plan. Each tier offers a varying combination of benefits, coverage limits, and premium costs, allowing members to choose the option that best fits their needs and budget. Tiers are commonly labeled as Basic, Enhanced, or Premium, though terminology can differ by insurer. Higher tiers typically provide more comprehensive coverage and higher annual or lifetime maximums, while lower tiers focus on essential protection at a lower cost.
Policy (Contract)
A policy, also referred to as a contract, is the legally binding agreement between an insurance company (the insurer) and the policyholder that defines the terms, conditions, and obligations of coverage. It outlines what is insured, the benefits provided, the premium amount, exclusions, and the responsibilities of both parties. Once the insurer accepts the application and the first premium is paid, the policy becomes active and enforceable.
Policy Maximum (Travel)
The policy maximum is the highest amount your travel medical insurance plan will pay for all eligible emergency medical expenses during a covered trip. This limit represents the maximum liability the insurer assumes and typically ranges from $1 million to $5 million per person, depending on the plan.
Policyholder
A policyholder is the individual or organization that owns an insurance policy and holds the legal rights and responsibilities associated with it. The policyholder is responsible for paying premiums, maintaining coverage, and making key decisions such as naming beneficiaries, adding or removing dependents, or canceling the policy. In return, the insurer is obligated to provide the benefits outlined in the policy contract.
Pre-Determination of Benefits
Pre-determination of benefits is the process of submitting a treatment plan or cost estimate to your insurance provider before receiving care to confirm how much of the expense will be covered. This step helps you understand your expected reimbursement and out-of-pocket cost before proceeding with services that may be costly or complex.
Pre-Existing Condition
A pre-existing condition is any medical issue, illness, or symptom that existed before your insurance coverage began, regardless of whether it was formally diagnosed. Insurers use this definition to assess risk and determine eligibility for certain benefits, particularly in medically underwritten or travel plans.
Pre-Existing Medical Condition
See [Pre-Existing Condition](https://www.aeva.ca/insuropedia/pre-existing-condition)
Preferred Hospital Accommodation
See [Hospital Room (Semi-Private / Private)](https://www.aeva.ca/insuropedia/hospital-room-semi-private-private)
Premium
A premium is the amount of money an individual or organization pays to an insurance company in exchange for coverage under an insurance policy. It is the cost of maintaining protection against financial loss and ensures that the insurer can pay claims, manage risk, and cover administrative expenses. Premiums can be paid monthly, quarterly, semi-annually, or annually, depending on the policy and payment arrangement.
Prescription Drugs
Prescription drugs are medications that can only be dispensed by a licensed pharmacist with a valid prescription from a qualified healthcare professional, such as a physician or nurse practitioner. These drugs are used to treat, manage, or prevent medical conditions and form one of the core components of most extended health care insurance plans. Prescription drug coverage helps offset the cost of medications that are not funded by provincial or territorial health programs.
Preventive (Dental Subcategory)
Preventive dental care focuses on maintaining oral health through regular cleanings, examinations, and minor treatments. It helps detect issues early, reducing the need for major dental work later. Services in this category include exams, X-rays, scaling, polishing, fluoride treatments, and sealants for children.
Preventive / Basic Services
Preventive and basic services cover routine and common dental procedures that maintain and restore oral health. Preventive services include cleanings, X-rays, and exams, while basic services include fillings, extractions, and simple restorative work.
Prior Authorization
Prior authorization is the process through which an insurer reviews and approves certain medical treatments, procedures, or prescription drugs before they are performed or dispensed. It ensures that the recommended care is medically necessary, appropriate, and covered under the policy before expenses are incurred. Prior authorization helps manage costs and ensures the use of safe, evidence-based treatments that align with clinical guidelines.
Private Duty Nurse
A private duty nurse is a licensed nurse hired to provide one-on-one medical care to a patient in their home or hospital outside of standard public healthcare services. This specialized care is typically required for individuals recovering from surgery, managing chronic illness, or living with a serious medical condition that requires close monitoring or skilled nursing services. The nurse may perform duties such as administering medication, wound care, post-operative support, or palliative care under a physician’s supervision.
Provider
A provider is a licensed healthcare professional, facility, or service organization that delivers medical, dental, vision, or paramedical care to patients. In the context of insurance, a provider is any individual or entity authorized to perform covered services and submit claims for reimbursement to an insurer. Providers include physicians, dentists, pharmacists, physiotherapists, chiropractors, optometrists, hospitals, and clinics.
Provider Networks / Digital Tools
Provider networks and digital tools refer to the network of healthcare professionals, pharmacies, and service providers that partner with your insurer, along with the digital platforms that make it easier to find and use those services. A provider network helps ensure you have access to trusted practitioners who meet specific standards for pricing, credentials, and quality of care. Digital tools complement these networks by simplifying access to care and claims management through online portals, apps, or virtual services.
Provincial Coordination
Provincial coordination refers to the process of aligning private insurance benefits with the coverage provided by your provincial or territorial government health plan. It ensures that the public plan pays for all eligible expenses first, and your private insurance covers only the remaining costs that are not paid by the government. This coordination helps prevent duplicate payments while maximizing your overall coverage.
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Reasonable & Customary
Reasonable and customary refers to the typical fee charged for a particular service in your geographic area. Insurers use this standard to determine how much they will reimburse for eligible expenses. If a provider charges more than the reasonable and customary rate, you must pay the difference.
Recall Interval (Dental)
A recall interval specifies how often you can claim preventive dental services such as cleanings and exams. Common intervals are every six or nine months. Insurers use recall intervals to encourage regular maintenance while controlling unnecessary repeat treatments.
Reimbursement / Coinsurance
Reimbursement is the amount an insurance company pays back to the insured person or directly to a healthcare provider for eligible expenses covered under a policy. Coinsurance is the portion of the cost that the insurer agrees to pay, expressed as a percentage, with the remaining balance paid by the insured. Together, these terms describe how healthcare costs are shared between you and your insurer once a claim is approved.
Reinstating a Policy
Reinstating a policy refers to the process of restoring insurance coverage after it has lapsed due to non-payment of premiums or other policy violations. When a policy is reinstated, it becomes active again with the same or similar terms as before the lapse, subject to approval by the insurer. Most insurers allow reinstatement within a specific timeframe, typically up to one year after the lapse date, although the exact period depends on the policy type and the insurer’s rules.
Renewal Date
The renewal date is the day on which an insurance policy is scheduled to be reviewed and extended for another term. It marks the end of the current coverage period and the start of a new one, during which updated premiums, benefits, or policy terms may take effect. Renewal dates ensure that insurance coverage continues seamlessly as long as the policyholder meets all conditions, such as paying premiums and maintaining eligibility.
Restorative (Minor/Major)
Restorative dental care repairs and replaces damaged or missing teeth. It is divided into two categories: minor restorative, which includes fillings and simple repairs, and major restorative, which covers crowns, bridges, dentures, and complex work.
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Hospital Room (Semi-Private / Private)
Hospital room coverage pays for the cost of upgrading from a standard ward room to a semi-private or private hospital room. This benefit allows greater privacy and comfort during inpatient stays.
Shared Dispensing Fee / Fee Limit
The shared dispensing fee, or fee limit, refers to the portion of a pharmacy’s dispensing charge that your insurance plan will cover. Pharmacies add this professional fee each time a prescription is filled to cover handling, verification, and counselling.
Short-term Disability Insurance
Short-term disability (STD) insurance provides temporary income replacement when you are unable to work for a limited period due to illness, injury, or surgery. It helps protect your income during the early stages of a disability, usually before long-term disability (LTD) benefits begin. This coverage ensures financial stability while you recover and are expected to return to work within a few weeks or months.
Smoking-Cessation Drugs
Smoking-cessation drugs are prescription medications designed to help individuals quit smoking by reducing nicotine cravings and withdrawal symptoms. Examples include bupropion and varenicline. These medications are considered lifestyle-related but medically supported treatments.
Split Modules
Split modules refer to the structure of a health insurance plan that allows members to mix and match different coverage categories, such as drug, dental, and extended health care. Each module operates independently with its own premiums and limits.
Spouse / Partner
A spouse or partner is the person legally married to or living in a committed relationship with the insured plan member or policyholder. In insurance terms, a spouse includes both legally married and common-law partners who meet the eligibility requirements defined by the insurer. Common-law partners are generally recognized after living together continuously for a specific period, often 12 months or longer, in a relationship similar to marriage.
Stability Clause
See [Stability Period](https://www.aeva.ca/insuropedia/stability-period)
Stability Period
Also known as a 'Stability Period Exclusion', or 'Stability Clause'.
Stable
See [Stability Period](http://aeva.webflow.io/insuropedia/stability-period)
Supplementary Health Insurance
See Extended Health Care Insurance: A type of insurance that pays for hospital and medical expenses not covered by your provincial health plan.
Surgical Stockings / Brassieres
Surgical stockings and brassieres are specialized medical garments prescribed to assist in recovery or to manage health conditions such as poor circulation, lymphedema, or post-surgical healing. Health plans often reimburse a portion of the cost up to a defined annual or per-item limit.
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Term Life Insurance
Term life insurance provides financial protection for a specific period of time, known as the term, such as 10, 20, or 30 years. If the insured person dies during that period, the insurer pays a tax-free lump-sum death benefit to the designated beneficiary. This type of insurance is designed to provide affordable coverage for temporary needs, such as replacing income, paying off a mortgage, or supporting dependents until financial independence is achieved.
Travel Insurance
Travel insurance provides financial protection for unexpected events that occur while you are traveling outside your home province, territory, or country. It helps cover emergency medical expenses, trip cancellations, interruptions, delays, lost luggage, and other unforeseen travel-related incidents. The most important component of travel insurance is emergency medical coverage, which pays for hospital and physician costs, medical evacuations, and repatriation in case of serious illness or injury abroad
Treatment
Treatment refers to any medical, dental, or therapeutic care provided by a licensed healthcare professional to diagnose, manage, or improve a health condition, injury, or disease. In the context of insurance, treatment includes all services, procedures, medications, and interventions that are deemed medically necessary to restore or maintain health. It can range from routine doctor visits and prescription drug use to surgery, rehabilitation, and specialized therapies.
Trip Cancellation and Interruption Insurance
Trip cancellation and interruption insurance provides financial protection when a trip must be canceled, delayed, or cut short due to unforeseen events beyond the traveler’s control. This coverage helps reimburse non-refundable travel expenses such as flights, hotels, and tour bookings that would otherwise be lost if a covered reason prevents or disrupts your travel plans.
Trip Length Limit
The trip length limit defines the maximum number of consecutive days a travel medical insurance policy will cover per trip. If your trip exceeds this limit, coverage stops at the end of the specified period unless you purchase a top-up extension.
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Underwriting
Underwriting is the process by which an insurance company evaluates an applicant’s risk to determine whether coverage can be offered, what terms will apply, and how much the premium will cost. It involves reviewing personal, medical, occupational, and lifestyle information to assess the likelihood of future claims. The goal of underwriting is to ensure fairness by matching the cost of coverage to the level of risk presented by each applicant.
Usual & Customary Fee List (dental)
The usual and customary fee list is a provincial or insurer-based schedule that outlines standard dental fees used to determine reimbursement. Insurers use this list to calculate the amount payable for each procedure, regardless of what your dentist charges.
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Virtual Counselling
Virtual counselling refers to mental health or psychological therapy sessions conducted remotely through secure online platforms, such as video calls, phone consultations, or messaging-based services. It allows individuals to access professional support from psychologists, social workers, psychotherapists, or counsellors without needing to attend appointments in person.
Vision Care
Vision care coverage helps pay for prescription glasses, contact lenses, and sometimes laser eye surgery. It promotes preventive eye health and ensures access to corrective eyewear when needed.
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Waiting Period
A waiting period is the amount of time you must be covered under a plan before certain benefits become available. Insurers use waiting periods to prevent individuals from joining a plan solely to claim an expensive procedure immediately. Waiting periods vary by benefit type and plan.
Waiver of Premium
A waiver of premium is a policy feature that allows insurance coverage to remain active without requiring premium payments if the insured person becomes totally disabled and unable to work. It protects policyholders from losing coverage during a period of financial hardship caused by disability, ensuring that benefits such as life, disability, or health insurance continue without interruption. The insurer waives future premium payments while maintaining all original policy benefits.
Wigs & Hairpieces
Wigs and hairpieces, sometimes referred to as cranial prostheses, are covered under some health plans when hair loss results from a medical condition or treatment, such as chemotherapy or alopecia. These benefits help restore appearance and confidence during recovery.