Back to all terms

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.

Your plan’s coverage outlines what is included, the percentage the insurer pays, and any applicable limits such as annual maximums, coinsurance, or deductibles. Coverage can vary widely between plan types. For example, medically underwritten plans often provide higher benefit maximums, while guaranteed-issue or conversion plans may have lower combined limits to manage risk.

The purpose of coverage is to protect you financially against routine healthcare costs and unexpected medical expenses. By defining covered benefits, your plan helps you plan for out-of-pocket costs and ensures clarity on what services qualify for reimbursement.

Example:

If your plan includes 80 percent coverage for physiotherapy up to $500 per year, and your treatment costs $100 per session, the insurer pays $80 per visit until the $500 limit is reached.

What to Watch For:

Review your plan booklet carefully to understand what is covered and what is excluded. Even if a service is medically necessary, it must fall within your defined benefits to qualify for reimbursement. Some benefits, such as orthodontics or medical equipment, may require pre-authorization before claims are approved.

Related Terms

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.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.

Contact Us