How do I determine what my health care coverage or benefits are?

The most important document is always the health insurance policy or the health plan service agreement; these are the binding contracts between insurers or plans and their insured or members. If you bought your own insurance, you should have a copy of the policy. You might also have a summary or brochure, which is legally known as an”evidence of coverage.”

If you have health insurance or a health plan through an employer or group, you usually do not have a copy of the insurance contract or plan agreement, but rather only has a handbook, summary, brochure or other type of evidence of coverage. In either circumstance, it is the actual insurance policy or plan agreement that controls what the coverage and benefits are, with one important exception. Generally, the law provides that evidences of coverage, whatever their form, may operate to expand or increase the coverage or benefits available, but they may not operate to decrease or limit the benefits and coverage available below that which is provided in the insurance policy or plan agreement. Therefore, if there is any question about whether a benefit or coverage is available, you as an insured or plan member should read and compare the language about the particular benefit or coverage in both the policy or plan and the related evidence of coverage.

Case Studies: Determining Health Care Coverage and Benefits

Case Study 1: John’s Health Insurance Coverage

John recently purchased health insurance on his own. He received a copy of the insurance policy, which serves as the binding contract between him and the insurer. John also obtained a summary or brochure known as an “evidence of coverage.”

However, he is unsure about the extent of his coverage and benefits. To determine the details of his health care coverage, John carefully compared the language about specific benefits in both the insurance policy and the evidence of coverage.

Case Study 2: Sarah’s Employer-Provided Health Plan

Sarah has health insurance through her employer, and she received a handbook that outlines her coverage and benefits. Although she doesn’t have a copy of the insurance contract or plan agreement, the handbook serves as evidence of coverage.

The insurance policy or plan agreement controls the coverage and benefits. However, any evidence of coverage cannot reduce or limit the benefits below what the policy or plan agreement provides.

To clarify any doubts about available benefits or coverage, Sarah referred to both the handbook and the insurance policy or plan agreement.

Case Study 3: Michael’s Conflicting Health Care Information

Michael obtained health insurance through a group plan. He has a summary of coverage but doesn’t possess the actual insurance contract or plan agreement.

While comparing the summary to his specific medical needs, Michael came across conflicting information regarding certain benefits and coverage. He decided to consult with his insurance provider to seek clarification and obtain accurate details about his health care coverage.