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How do I determine what my health care coverage or benefits are?
The primary insuring 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 the insurance or plan is obtained by an individual directly, the individual usually has a copy of the policy or plan agreement. In addition, or sometimes instead of the policy or plan, the insured may 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. |
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