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.

For example, physiotherapy after a surgery may be medically necessary, while cosmetic Botox for appearance is not. The assessment is based on a physician’s recommendation and the insurer’s criteria for necessity.

Example:

If your doctor prescribes compression stockings to treat poor circulation, the expense may qualify as medically necessary and therefore reimbursable.

What to Watch For:

Even when prescribed, an item must still meet the insurer’s criteria for necessity and frequency. Always check coverage rules before purchase or treatment.

Related Terms

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 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

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