Health Insurance Terms People Misunderstand

A deductible is the amount you pay out of pocket before your insurance starts covering costs. If your deductible is €1,000, you pay the first €1,000 of covered expenses yourself.

Deductibles typically reset annually. Once you meet it, you start over the next year.

Not all services count toward the deductible. Preventive care, for example, may be covered without meeting the deductible first. The specifics depend on your plan.

A copay is a fixed amount you pay for a service. A doctor visit might have a €20 copay regardless of the total bill.

Coinsurance is a percentage. If your coinsurance is 20%, you pay 20% of the bill after your deductible is met.

Many plans use both. You might pay a copay for routine visits and coinsurance for hospital stays. Understanding which applies to which service matters.

The out-of-pocket maximum is the most you pay in a year for covered services. After reaching it, insurance typically pays 100% for in-network covered care.

The catch is in the details. Premiums do not count. Out-of-network care often does not count. Services not covered by your plan do not count.

A high out-of-pocket maximum means significant potential exposure. A €5,000 maximum means you could pay €5,000 in a bad year before full coverage applies.

This is one of the most common misunderstandings. When a service is 'covered,' it means your plan includes it in principle. It does not mean the insurer pays the full cost.

A covered service may still involve deductibles, copays, coinsurance, and cost-sharing. 'Covered' sets the rules. It does not eliminate your share.

Services that are not covered are your full responsibility. For these, insurance provides nothing—no negotiated rates, no partial payment, nothing.

In-network providers have agreements with your insurer. You pay less because the insurer has negotiated rates. Your deductible, copays, and out-of-pocket maximum typically apply.

Out-of-network providers have no agreement. You may pay more—sometimes much more. Some plans cover out-of-network care at reduced rates. Others do not cover it at all.

International plans handle networks differently. Some have global networks. Others have home-country networks with different rules abroad.

A pre-existing condition is a health issue that existed before your coverage started. Insurers define this differently. Some use diagnosis dates. Others use treatment dates. Some look back a specific period.

Exclusions mean the insurer will not cover treatment for that condition. This may be permanent or for a waiting period. The specifics vary widely.

International and expat insurance often has different rules than domestic coverage. Pre-existing condition handling is something to check carefully before choosing a plan.

Some coverage does not start immediately. Waiting periods delay coverage for certain services or conditions. This is common for maternity, dental, and pre-existing conditions.

A 12-month waiting period for maternity means pregnancy expenses are not covered until you have had the plan for 12 months. Claims during the waiting period are denied.

Waiting periods differ from effective dates. Your plan may be 'active' while certain benefits remain in their waiting period.

Pre-authorization means getting insurer approval before a service. Without it, the insurer may deny the claim or reduce coverage.

Common services requiring pre-authorization include hospital admissions, surgeries, expensive diagnostics, and specialist referrals. Emergency care typically has exceptions.

Pre-authorization is not a guarantee of payment. It confirms the service is covered in principle. You may still have cost-sharing obligations.

Exclusion lists are in your policy documents. Reading them before you need care prevents surprises. Assumptions about what is 'obviously' covered often prove wrong.