This glossary is designed for international organisations who need clarity on health insurance terms, focusing on terms relevant to globally mobile employees, particularly in Asia and the Middle East. Throughout this glossary, you’ll also find “Did you know?” insights and practical data to help you navigate complex insurance decisions.
Where applicable, we’ve included insights from One World Cover’s work with large employers across Asia and the Middle East, based on our extensive experience helping organisations control costs, improve benefits, and ensure smooth day-to-day operations.
Though the title of this article playfully hints at ‘zero deductibles’, we’d like to highlight that at One World Cover we’re strong advocates of deductibles. In fact, we believe that if an organization is serious about managing their health insurance costs sustainably, a deductible should be high on the list.
- Adverse Selection
- Annual Health Check-up / Annual Physical
- Annual Policy Maximum
- Area of Cover
- ASO (Administrative Services Only)
- Benefit Limit
- Benefit Table / Table of Benefits
- Broker
- Certificate of Insurance
- Chronic Condition
- Claims Dispute
- Claim
- Claim Form
- Claim Reimbursement
- Co-pay / Co-insurance
- Community Rating
- Continuation of Cover
- Country of Residence
- Country of Treatment
- Day Case
- Deductible
- Denied Claim
- Elective Treatment
- Emergency Treatment
- Employee Assistance Program (EAP)
- Employer-Sponsored Plan
- Exclusion
- Experience Rating
- Experimental Treatment
- FMU (Full Medical Underwriting)
- Group Policy
- Guarantee of Payment (GOP)
- Health Risk Assessment (HRA)
- High-Cost Claimant
- In-Network
- Individual Policy
- Inpatient
- Insurer
- Intermediary
- Lifetime Limit
- Loss Ratio
- Medical History Disregarded (MHD)
- Medical Inflation / Medical Trend
- Medical Necessity
- Member
- Member Card
- Member Portal
- MGU (Managing General Underwriter)
- Moratorium Underwriting
- Network
- Offshore Policy
- Onshore Policy
- Out-of-Network Penalty
- Out-of-pocket Maximum
- Outpatient
- Policy Wording
- Portability
- Pre-Authorization
- Pre-existing Condition
- Premium
- Provider
- Provider Co-pay
- Rate Guarantee
- Reasonable & Customary Charges
- Reinsurance
- Second Medical Opinion
- Self-Insured Plan
- Sub-limit
- Telemedicine or Telehealth
- Third Party Administrator (TPA)
- Underwriter
- Underwriting Margin
- Waiting Period
- Wellness Benefit
Adverse Selection
When people who expect to claim more are more likely to enroll in a plan, driving up costs and skewing the risk pool.
Did you know? Adverse selection is one of the key reasons group health insurance plans often impose waiting periods or exclude late joiners. One World Cover helps our clients avoid adverse selection by recommending compulsory enrollment and MHD underwriting terms where possible.
Annual Health Check-up / Annual Physical
Routine preventive exam typically covered once per policy year, often includes lab work and doctor consultation. Usually included as part of a health insurance plan’s wellness benefit.
Did you know? Many chronic illnesses are diagnosed for the first time during these check-ups — making them cost-saving in the long run. One World Cover helps our clients run wellness campaigns to increase check-up participation and ensure this benefit is properly communicated.
READ MORE >> How Much Should You Spend on an Annual Health Check-Up? Essential vs. Overpriced Tests
Annual Policy Maximum
The maximum amount the insurer will pay for all eligible medical expenses combined in a single policy year, per member.
Did you know? Annual policy maximums on international plans often range from US$1 million to US$5 million, but in reality, very few members ever exceed US$100,000 per year. One World Cover helps our clients assess whether their annual maximum is realistic for the care available locally or regionally, and advise on tiered coverage structures or benefit sub-limits that can lower costs while preserving protection against catastrophic claims.
Area of Cover
The geographic region(s) where a health insurance plan provides coverage. The most common areas of cover in international insurance plans are ‘Worldwide’ (or WW) and ‘Worldwide excluding the USA’ (or WWE). Some regional insurers also offer regional areas of cover such as ‘Asia only’, ‘Southeast Asia only’ or ‘GCC countries only’.
Did you know? Plans with full cover in the USA can cost up to 50-100% more than plans without USA cover.
ASO (Administrative Services Only)
An arrangement where the employer funds claims and contracts a TPA (third-party administrator) or insurer to manage plan administration.
ASO plans can lower long-term insurance costs — but they shift the claims risk to the employer, meaning a bad year can hurt the bottom line. One World Cover helps evaluate whether ASO is the right model, assist with setting appropriate stop-loss thresholds, and monitor claims performance year-round to ensure financial sustainability.
Benefit Limit
The maximum amount payable for a specific benefit (such as out-patient GP visits, physiotherapy, maternity, mental health) in a policy year.
Did you know? Even plans with high annual maximums such as US$1 million can have strict sub-limits on individual benefits — which can be more relevant in practice. One World Cover helps our clients identify where sub-limits may be too restrictive and renegotiate benefits that are consistently exhausted or underused.
Benefit Table / Table of Benefits
The official listing of coverage, limits, co-pays, and exclusions.
Did you know? Even insurers offering the same headline benefits can differ vastly in sub-limits and service quality. One World Cover helps translate complex benefit tables into staff-friendly summaries for HR teams and help staff understand the real-world value of their plan.
Broker
An independent advisor who helps organizations choose, implement, and manage their health insurance plans.
Did you know? Unlike agents (who represent insurers), brokers act on behalf of the client. One World Cover is a broker. Our work goes far beyond renewal negotiations — supporting HR with claims issues, policy interpretation, onboarding, and staff engagement.
Certificate of Insurance
A formal document proving coverage — often needed for visa applications, admissions, or travel.
One World Cover can help with fast turnaround on certificates, including custom formats for different countries.
Chronic Condition
A long-term health issue like diabetes, asthma, or hypertension.
Did you know? Chronic conditions account for 70–85% of total healthcare spending globally. One World Cover helps our clients leverage wellness, coaching, and disease management tools often embedded in their plans.
Claims Dispute
A disagreement over what was billed vs. what was paid (or reimbursed to the member).
Did you know? Billing errors, misapplied exclusions, and missing paperwork are among the top causes of disputed claims — many of which are avoidable or reversible. One World Cover acts as an escalation point for our clients and their staff, resolving billing and claims issues that would otherwise frustrate HR or staff.
Claim
A request for payment submitted to the insurer or TPA for healthcare services received by a plan member. Claim errors are a major pain point — and often caused by missing documents or unclear policy terms.
Claim Form
A document used to provide details of a medical service, costs incurred, and medical provider information for reimbursement.
Did you know? Many insurers now allow members to submit claims electronically using a mobile app — but paper forms still dominate in some markets. One World Cover prepares simplified claim form guides and pre-filled examples for common staff questions, cutting down on back-and-forth with the insurer (and HR).
Claim Reimbursement
A way of claiming where the member pays the doctor or hospital first, then sends the receipts to the insurer to get paid back.
One World Cover prepares step-by-step claim guides for our clients, helping staff prepare the correct documents, and follow-up with insurers to speed up reimbursement — reducing stress for members and HR.
Co-pay / Co-insurance
A cost-sharing structure, co-pays and co-insurances are terms that are also commonly used interchangebly depending on the country or insurer. A co-pay or co-insuarance is:
- A fixed amount an insured person pays each time (rather than an annual amount) they receive a specific service, such as US$20 for a GP visit or US$50 for a specialist
- A percentage of the cost each time an insured person receives medical treatment — for example, 20% of the bill, with the insurer covering the remaining 80%
Did you know? Even a small co-pay or co-insurance can change healthcare behavior — encouraging responsible use of benefits while still ensuring access. One World Cover helps employers model the cost impact of adding co-pays or co-insurances, to ensure they’re not set so high that they discourage care.
Community Rating
A method of pricing insurance where the risk and pricing (and renewal increases) for everyone in a group or defined population is pooled evenly across the population. If a plan is community rated, a group’s actual claims utilization has no direct impact on the premiums paid.
Did you know? Community rating protects smaller groups from big renewal spikes — but limits rewards for groups with good claims behavior. At One World Cover we help our clients evaluate whether switching to experience rating might unlock long-term savings.
Continuation of Cover
The ability for a member to maintain health insurance coverage after leaving the employer or group plan.
Did you know? Continuation options are often time restricted to 1-3 months.
READ MORE >> Continuation of Cover (COC): An Essential Employee Benefit or a Hidden Financial Risk?
Country of Residence
The country where a member is legally residing or employed, and often where coverage is primarily based.
Did you know? Your country of residence can determine tax treatment, licensing requirements, and even coverage eligibility for cover. At One World Cover we ensure policies are structured in compliance with local laws and aligned with the country where your staff live and work.
Country of Treatment
The country in which a medical service is received — which can impact coverage, claim limits, and reimbursement eligibility.
Did you know? Receiving treatment outside your area of cover — even in an emergency — can result in zero cover without pre-authorization from the insurer.
Day Case
Hospital care that doesn’t require an overnight stay — common for minor surgeries or scopes.
Did you know? Some insurers classify procedures like endoscopies or colonoscopies as outpatient — others as day case — which can impact pre-authorization and reimbursement.
Deductible
The amount an insured person must pay out of pocket each policy year before the health insurance plan starts covering certain benefits. For example, if a plan has an US$800 deductible, the insured person will need to pay the first US$800 of eligible medical costs before the insurer begins covering the costs of treatment.
Deductibles are not the same as co-pays — they apply once annually, not per visit, and can significantly reduce premiums.
READ MORE >> Why Adding a Deductible Could Be the Easiest (and Smartest) Way to Cut Your Health Insurance Costs
Denied Claim
A claim that the insurer refuses to pay, often due to lack of documentation, pre-authorization, or exclusions.
Did you know? Claim denials are often reversed when staff appeal with the right information — but many don’t try. One World Cover manages claims appeals and documentation reviews for our client’s staff, giving rejected claims a second chance — with far less stress for HR or the employee.
Elective Treatment
Planned, non-urgent treatment that can be scheduled in advance.
Emergency Treatment
Immediate care required to preserve life or prevent serious harm.
Employee Assistance Program (EAP)
A confidential service offering support for stress, anxiety, family or financial issues. Sometimes also known as IEAP – International Employee Assistance Program.
Did you know? EAPs are typically provided free-of-charge as part of most international insurer’s servcie offering but still have low utilization globally. Utilization is often under 3% due to lack of awareness. When promoted effectively EAPs can reduce sick leave and presenteeism. One World Cover helps our clients to launch, ‘relaunch’ and promote underused EAPs through HR comms and onboarding.
Employer-Sponsored Plan
A health insurance policy provided by the employer for employees and often their dependents.
Exclusion
A medical service, condition, or situation not covered under the insurance policy — commonly cosmetic procedures or experimental treatments.
Did you know? Exclusions vary widely by insurer — and what’s excluded in one country might be standard care in another. One World Cover audits policies for hidden or country-specific exclusions that could affect your team — especially when relocating or expanding operations.
Experience Rating
Premiums (and renewal increases) are calculated based on the group’s actual claims utiliization — unlike community rating.
Did you know? Experience-rated groups can benefit from lower premiums during good years — but may also face higher volatility in bad years.
READ MORE >> Navigating the Premium Curve: Predictable Increases vs. Responsive Pricing in Health Insurance
Experimental Treatment
Unproven therapies that lack scientific evidence or regulatory approval — typically excluded.
Did you know? Some treatments labeled “experimental” in one country may be standard elsewhere — particularly for cancer or fertility. One World Cover helps our client’s members understand their treatment options and navigate global second opinion services when facing rare or complex conditions.
FMU (Full Medical Underwriting)
Detailed health history questionnaire used to assess individual risk before issuing cover. FMU allows insurers to exclude or load premiums for certain conditions — unlike group plans with MHD underwriting, where no health information or disclosure of pre-existing conditions is needed.
Did you know? Most insurers only require FMU for small groups (usually under 10 lives). Larger groups can often get access to MHD (Medical History Disregarded) underwriting terms — where pre-existing conditions are covered without individual health checks. For smaller companies, FMU may be unavoidable, but it can delay onboarding and result in uneven coverage. One World Cover help small companies navigate FMU efficiently, support staff through the application process, and negotiate MHD terms as soon as group size allows.
Group Policy
A health insurance plan that covers a defined group of people — typically employees and their dependents.
Did you know? Group policies typically provide better benefits at lower premiums than individual plans.
Guarantee of Payment (GOP)
An official document (usually sent by email) by the insurer or TPA confirming that they will pay a medical provider directly for covered treatment. GOPs are typically required for inpatient admissions, day case procedures, or high-cost outpatient care before services are rendered.
Did you know? Having a GOP (or not having one) is often the difference between being admitted to a hospital or being turned away — especially in countries where up-front deposits are the norm. One World Cover assists our clients by working with insurers and hospitals to fast-track GOPs when members are hospitalized, especially across time zones or during holidays.
Health Risk Assessment (HRA)
A questionnaire or screening tool used to evaluate a member’s health risks, often as part of a wellness program. Some insurers use HRA data to offer targeted wellness programs — or even tailor chronic disease support services.
High-Cost Claimant
An insured person who generates significantly higher-than-average claims, often due to cancer, chronic illness or complex care.
Did you know? In group plans it’s common for just 1–2% of members to account for 30–40% of the total claims in a policy year. One World Cover monitors emerging high-cost claimants and works with insurers to manage their care compassionately but cost-effectively — avoiding future premium spikes.
In-Network
A medical provider (hospital, clinic, or doctor) that has a direct contract with the insurer — usually offering discounted rates and direct billing. Also known as ‘Direct Billing Network’.
Did you know? Seeing a direct billing medical provider brings convenience and often means no paperwork, no pre-payments, and lower out-of-pocket costs. One World Cover helps clients select insurers with strong networks near their staff locations — and educate staff on where and how to access them.
Individual Policy
A health insurance plan purchased by a person for their own use or for their family, rather than through an employer or group. These plans are typically underwritten based on the individual’s health history and may include exclusions, waiting periods, or premium loadings.
Did you know? Individual plans often have less generous benefits, tighter limits, and stricter exclusions compared to group plans — and can be significantly more expensive, especially for older individuals or those with pre-existing conditions. One World Cover support staff transitioning off a group plan — such as retirees, departing staff, or dependents — by helping them find suitable individual coverage, clarify continuation options, and understand how underwriting may impact access to care.
Please complete this form if you are interested in an individual or family health insurance quote: https://oneworldcover.com/quotes/
Inpatient
Medical treatment that requires an overnight stay in a hospital or surgical facility.
Did you know? Different insurers might classify procedures as ‘inpatient’ or ‘day case’ based on local norms — even if it’s the same treatment. One World Cover reviews how insurers classify care across countries to ensure members get fair reimbursement, especially when travelling or relocating.
Insurer
The company that provides your health insurance.
Did you know? Some insurers don’t process claims themselves — they outsource to a Third Party Administrator (TPA), which can affect how fast or smoothly claims are handled. One World Cover helps our clients look beyond just the insurer’s brand — assessing their claims performance, network strength, and the quality of their TPA or admin partners to ensure your staff get the service they expect.
READ MORE >> Cheap Premiums, Unknown Insurer — The Hidden Dangers of Price-First Decisions
Intermediary
A general term for an entity (like a broker, agent, or consultant) that connects the employer to the insurer.
Did you know? Some intermediaries operate only as “introducers” — with limited ability or incentive to manage the plan once it’s live. One World Cover is a broker. We function as a full-service intermediary, actively managing policy performance, staff issues, and insurer accountability year-round.
Lifetime Limit
The maximum amount the insurer will ever pay for an individual over the course of their lifetime.
Did you know? Most international health insurance plans have removed lifetime limits entirely — replacing them with rolling annual limits. However there are still some benefits for which lifetime limits are common such as transplants, hospice care or orthodontic dental treatment.
Loss Ratio
The ratio of claims paid to premiums collected — a key metric used by insurers to assess your plan’s performance.
Did you know? A loss ratio of over 100% means the insurer paid out more than they took in — that’s not always bad for the client, but it will always result in big premium hikes at renewal. One World Cover helps track your group’s loss ratio year to year and negotiate with insurers based on broader portfolio context — not just one bad year.
READ MORE >> Read This Before Renewing Your Group Health Insurance — It Could Save You 15–30% on Your Premium
Medical History Disregarded (MHD)
A group underwriting method where all pre-existing conditions are covered from day one — no health questionnaires needed.
Did you know? Insurers typically only offer MHD if a group is large enough — usually 10+ lives. MHD is one of the most valuable features of group cover — especially for older staff or those with chronic conditions. One World Cover helps our clients secure and retain MHD terms by building strong insurer relationships.
Medical Inflation / Medical Trend
Medical inflation refers to the percentage rate at which healthcare costs increase over aperiod of time. Medical trend includes more than just medical inflation and cost increases, such as changes in healthcare utilization, advancements in medical technology, shifts in thetypes of services being used, and changes in clinical practices or patient behavior – and therefore provides a more comprehensive view of the evolving landscape of healthcare. Medical trend is an important metric that impacts health insurance premiums. Understanding medical trend is essential if organizations are to effectively budget for any future increases to their health insurance premiums.
Did you know? Global medical trend is projected to be 10.4% in 2025, only frationally down from 10.5% in 2024. One World Cover clients clients always stay ahead of the medical inflation trend.
READ MORE >> Download One World Cover’s 2025 Medical Trend Report
Medical Necessity
A standard used by insurers to determine whether a treatment is reasonable, appropriate, and eligible for coverage.
Did you know? Just because a doctor recommends it doesn’t mean it’s considered “medically necessary” by the insurer.
Member
Any person enrolled on the policy — includes employees and any dependents covered under the plan. Also known as an ‘Insured Person’.
Member Card
A physical or digital ID card provided by the insurer that confirms active insurance cover and facilitates access to care.
Did you know? Most insurers now offer digital cards via apps — but some countries and hospitals still require printed hard copy cards.
Member Portal
An online platform (or mobile app) where members can view their benefits, submit claims, find providers, and find information on the insurer’s value-added services.
MGU (Managing General Underwriter)
A company (not an insurer) authorized by an insurer to underwrite, price, and often administer insurance policies.
Did you know? Your plan may be underwritten by an MGU even if the insurer’s brand appears on the card — this can affect claims experience. One World Cover assesses MGU partnerships behind the scenes and advise clients if an MGU-administered plan will meet service expectations.
Moratorium Underwriting
A type of underwriting that excludes pre-existing conditions for a set time (typically 24 months), unless no treatment or symptoms occur.
Did you know? Moratorium underwriting avoids long health questionnaires but delays coverage for past conditions — often misunderstood by staff. It’s commonly used in smaller group or individual plans to speed up onboarding.
Network
The insurer’s list of partnered hospitals, clinics, and doctors offering agreed pricing and usually direct billing. Often members are not restricted in only being covered for medical treatment in the insurer’s network — but often benefit from improved cover or the convenience of direct billing when accessing care ‘in-network’.
Offshore Policy
A policy issued by an insurer licensed outside the country where a policyholder is based — often to access broader coverage or avoid restrictions.
Did you know? Offshore policies can be cost-effective — but may have limitations in claims payment, legal recourse, or tax compliance. One World Cover can guide companies on when offshore policies are appropriate and structure them to minimize compliance risks.
Onshore Policy
A locally licensed insurance policy that complies with regulations and tax requirements in the country where a policyholder is based.
Did you know? Onshore plans may offer fewer benefits or have higher costs — but are often required by regulators or for visa applications. In many countries, “buying onshore” is mandatory.
Out-of-Network Penalty
Higher co-pays or reduced reimbursement applied when members use providers outside of the approved network.
💡 Did you know?
Some plans won’t pay anything for out-of-network care — even in emergencies — unless pre-authorization is obtained.
🧭 OWC Insight:
We help staff understand when and how to seek out-of-network care, and how to minimize the penalty.
Out-of-pocket Maximum
The most a member will ever pay in a policy year for eligible services — after this, the insurer covers 100%.
💡 Did you know?
This is your “safety net” number — crucial in catastrophic situations. Many employees don’t know what theirs is.
🧭 OWC Insight:
We help clients design plans with realistic out-of-pocket caps and ensure they’re communicated clearly at enrollment.
Outpatient
Medical care that doesn’t require an overnight hospital stay — includes GP visits, diagnostics, and minor procedures.
💡 Did you know?
Outpatient services are the most used part of health plans — and a key driver of annual cost increases.
🧭 OWC Insight:
We analyze outpatient utilization data to help clients redesign plans for sustainability while protecting access to primary care.
Policy Wording
The full legal contract that defines the terms, conditions, exclusions, and coverage scope of a health insurance plan.
💡 Did you know?
Marketing brochures often omit or simplify key terms — only the policy wording is legally binding.
🧭 OWC Insight:
We review policy wordings line by line during onboarding and renewals, highlighting risk areas or changes to HR in plain English.
Portability
The ability for a member to retain or transfer their coverage when moving countries or leaving employment.
💡 Did you know?
Some plans offer continuation options or allow transitioning to an individual plan — but only if this is pre-arranged.
🧭 OWC Insight:
We assist departing staff with transition planning, ensuring continuity of cover wherever possible.
Pre-Authorization
Advance approval required from the insurer before certain procedures, tests, or hospital stays can take place.
💡 Did you know?
Skipping pre-auth is a leading cause of denied claims — even when the treatment would otherwise be covered.
🧭 OWC Insight:
We provide pre-auth checklists and escalation paths to make sure members never get caught out.
Pre-existing Condition
Any condition the member had before joining the plan — including symptoms, even if undiagnosed.
💡 Did you know?
In group plans with MHD, pre-existing conditions are covered — but this may not apply to late joiners or dependents.
🧭 OWC Insight:
We audit plan documents to ensure that pre-existing condition terms are properly defined and communicated.
Premium
The amount paid for coverage — by the employer, the employee, or both.
💡 Did you know?
Premiums reflect expected risk, plan generosity, medical inflation, and administrative cost — not just claims.
🧭 OWC Insight:
We help schools understand how their premiums are calculated and what levers they can use to manage future increases.
Provider
A medical facility that delivers medical services — including hospitals, clinics, general practitioners, specialists, laboratories, and pharmacies. Providers may be part of an insurer’s network (in-network) or not (out-of-network).
Provider Co-pay
A co-pay — could be a fixed amount or a percentage of cost — which a member must pay each time they visit a specific medical provider. This type of co-pay is also sometimes known as a ‘High-cost Provider Co-pay’ in plans where the co-pay is structured by provider tier — standard vs. high-cost hospital, for example.
Did you know? Many international health insuarnce plans use tiered provider co-pays to shape member behavior. For example:
- Nil co-pay at a community clinic or public hospital
- $30 or 10% at a private hospital
- $50+ or 20% at designated High-Cost Providers
- This makes costs more predictable while discouraging overuse of expensive facilities for routine care.
One World Cover helps our clients implement tiered co-pay structures that gently steer staff toward cost-effective care — without restricting choice. This can encourage smarter decisions around where (and when) to seek treatment. We help clients model how different co-pay structures affect both cost and behavior. Small co-pays encourage smarter healthcare usage without discouraging essential visits, helping control outpatient claims in a positive way.
Rate Guarantee
A commitment by the insurer to hold premiums steady for a set period (typically 12–24 months).
💡 Did you know?
Two-year rate guarantees don’t always mean long-term savings — if they result in a large correction at the next renewal.
🧭 OWC Insight:
We advise on when to accept rate guarantees — and when a transparent, year-by-year model might offer better value.
READ MORE >> Two-Year Rate Guarantees in Health Insurance: A Good Deal or a Risky Shortcut?
Reasonable & Customary Charges
The maximum amount the insurer will reimburse for a service based on local pricing norms.
💡 Did you know?
If a provider’s bill exceeds this benchmark, the member may be left paying the difference — even for in-network care.
🧭 OWC Insight:
We advocate for fair benchmarking, challenge low limits where necessary, and guide staff to avoid inflated billing.
Reinsurance
A type of insurance that insurers themselves buy to protect against high-cost claims or unusually high overall loss ratios.
💡 Did you know?
Reinsurance allows insurers to offer multi-million-dollar annual maximums — especially useful for catastrophic or cancer care coverage.
🧭 OWC Insight:
We work with insurers who have solid reinsurance partners to ensure stability in coverage and pricing, especially for schools with high benefit caps.
READ MORE >> How Reinsurance Protects Large Employer Health Plans from Massive Premium Hikes
Second Medical Opinion
An expert review of a diagnosis or treatment plan by a different medical specialist.
💡 Did you know?
Studies show that 10–15% of second opinions result in a completely different diagnosis — and over 60% recommend different treatment plans.
🧭 OWC Insight:
We help schools promote this underused benefit — especially useful in markets where overtreatment or misdiagnosis is a concern.
Self-Insured Plan
A funding arrangement where the employer pays for claims out-of-pocket and hires a TPA or insurer to administer the plan.
💡 Did you know?
In the right conditions, self-insurance can cut costs and increase transparency — but it requires strong claims oversight.
🧭 OWC Insight:
We help employers explore self-insurance as a long-term cost-control strategy and build in reinsurance protections where needed.
READ MORE >> Self-Funding Out-patient Benefits vs. Insurance: A Costly Gamble
Sub-limit
A cap on a specific benefit within a broader coverage area. For example: “USD 5,000 for physiotherapy under a USD 100,000 outpatient limit.”
💡 Did you know?
Sub-limits are how many insurers “hide” restrictions in generous-looking plans — even when the overall benefit looks unlimited.
🧭 OWC Insight:
We audit sub-limits line by line and compare them across providers to ensure plans meet staff needs without unexpected denials.
Telemedicine or Telehealth
Remote consultations with a doctor via phone or video — often used for minor illness, mental health, or follow-up care.
💡 Did you know?
In many regions, telemedicine use increased 20x during the pandemic — and most insurers now include it at no additional cost.
🧭 OWC Insight:
We help schools integrate telemedicine into staff communications, making it the first port of call for non-urgent issues.
READ MORE >> How Telehealth and Virtual Care Can Reduce Health Insurance Costs and Boost Employee Wellbeing
Third Party Administrator (TPA)
A company that handles claims, provider payments, and policy admin on behalf of the insurer or self-funded employer.
💡 Did you know?
Your insurer might outsource all claim handling to a TPA — but you’d never know unless you ask.
🧭 OWC Insight:
We evaluate TPAs behind the scenes and provide feedback to insurers — ensuring your staff gets high-quality service even when it’s outsourced.
Underwriter
The person or team responsible for assessing insurance risk and setting pricing.
💡 Did you know?
Underwriters use algorithms, data models, and sometimes medical judgment to predict future costs — and your group’s renewal depends on their view.
🧭 OWC Insight:
We present your school’s data in a favorable way, contextualizing claims to avoid over-penalization and helping secure better renewal terms.
Underwriting Margin
The portion of premiums the insurer retains after paying claims — covering admin costs and profit.
💡 Did you know?
Insurers typically aim for a 15–25% underwriting margin — understanding this helps when negotiating renewals.
🧭 OWC Insight:
We help clients push for transparency in underwriting performance and benchmark insurer margins to ensure fair pricing.
Waiting Period
A set time after enrollment during which certain benefits (like maternity or dental) are not available.
💡 Did you know?
Waiting periods are often waived for full group enrollment or when switching from another comparable plan.
🧭 OWC Insight:
We negotiate waiting period waivers for new schools or staff transfers whenever possible to ensure continuity of care.
Wellness Benefit
Coverage for preventive care and health promotion services — such as checkups, vaccinations, screenings, and mental health tools.
💡 Did you know?
Many insurers include wellness perks (telehealth, coaching, EAPs) that go unused — even though you’re paying for them.
🧭 OWC Insight:
We create school-specific wellness engagement plans to boost utilization of value-added services without increasing cost.
