Traditional Indemnity Insurance Plans

Regardless of the terminology you may hear, the three terms used to indicate this type of insurance are usually referencing the same type of plan. Traditional health care insurance plans reimburse a patient (the enrollee or a covered dependent or spouse) according to the provider's bill based on UCRs, that is, usual, customary and reasonable fees.

For example: A patient sees a physician and pays the charge for the office visit. The patient then files a claim to be reimbursed for the fees paid. (Often, the provider will submit the claim on behalf of the patient as a courtesy.) When the service is covered under the terms of the policy, the patient may expect to receive partial reimbursement for the expenses, usually contingent on the co-insurance being paid by the patient and the policy deductible amount being met. Typically, there are no limits or restrictions on your choice of a medical service provider.

Hospital-Surgical, Major Medical and Comprehensive Coverage

The primary forms of traditional indemnity insurance plans available generally are fee-for-service plans that offer

You will find that the benefits offered under each type of coverage vary. Comprehensive plans-as their name implies-will more typically offer a wider range of benefits. Any of these plans may be offered as group coverage or as individual coverage. In fact, some national forms of group health coverage-for example, some portions of Medicare-are essentially made available singly or as a fee-for-service plan that offers combined coverages. These indemnity or fee-for-service plans are designed primarily to help cover costs related to illnesses that:

  • require medical and/or surgical treatment in a hospital (inpatient care) and
  • the medical costs associated with illnesses requiring care out of the hospital (outpatient care)

The variations you may expect to find in time and dollar coverages under these plans are generally called limits and may include but are not limited to the

  • lifetime and/or per occurrence (dollar limit)
  • inpatient length of stay allowed per occurrence (time limit)
  • deductible (some plans provide coverage without a deductible requirement)
  • co-payment per benefit or occurrence
  • stop-loss provision if applicable

Updated on: 3/8/2019