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.