Mélina Lamarche

By Mélina Lamarche

June 2, 2015

Health

Group Insurance Glossary

Article revised on 18 July 2017

Many employees have group insurance coverage through their employers. This insurance covers expenses such as a portion of the cost of prescription drugs they purchase, reimburses certain healthcare expenses such as physiotherapy and chiropractic treatments, and provides a salary insurance benefit in the event of disability.

To help you understand group insurance terms, here are some definitions for nine of the key terms you’re likely to come across.

1- Group Insurance

GROUP INSURANCE is a type of insurance that covers a certain number of people belonging to a specific group under a single contract. Generally speaking, the members of a group are all employees of the same company or belong to the same organization.

Coverage may include, depending on your plan, health insurance (prescription drugs, healthcare expenses, hospitalization, dental treatment and vision care), dental care insurance, life insurance and short-term and long-term disability insurance. Your plan may also include a workplace health and wellness program or an employee assistance program (a confidential service that focuses on prevention, facilitating a return to work and resolving problems).

2- Group Insurance Plan

The GROUP INSURANCE PLAN consists of all of the coverages available for insured members of a group, as determined in the group insurance contract.

3- Plan Member

The PLAN MEMBER (sometimes called the participant) is the person who has enrolled in a group insurance plan as a member of an insured group.

4- Dependent

A DEPENDENT is defined as the plan member’s spouse or dependent child, who may also be eligible under the plan member’s group insurance plan (if he or she has family coverage status).

5- Eligible

Being ELIGIBLE means that a person satisfies all of the conditions for coverage under the plan, but it does not necessarily mean that person is covered.

6- Benefits

BENEFITS refers to the payment or a series of payments of an amount of money to a person under an insurance contract.

7- Claim

A CLAIM is a request for reimbursement of expenses that are covered and payable under a group insurance plan.

Note: In group insurance, we often talk about submitting or filing a claim.

Sometimes you will have to pay the full amount for healthcare services you receive. For instance, when you see a physiotherapist, an optician or other healthcare professional, you will need to pay for your consultation. You will then need to fill out a claim form before the insurer can reimburse you for a certain amount or a percentage of the expenses incurred.

Some expenses that are covered at a certain percentage under your group insurance plan may be automatically reimbursed at the time of purchase (direct payment), meaning you only have to pay out of pocket for the amount not covered by your insurance.

8- Premium

The PREMIUM is the amount a person must pay for coverage under an insurance plan. In exchange, the insurer agrees to cover certain expenses for which claims are submitted.

Under the Quebec Act respecting prescription drug insurance, employers must deduct group insurance premiums directly from their employees’ salary (Source: RAMQ – page available in French only).

9- Disability

DISABILITY means a temporary or permanent limitation of a physical or psychological nature, which partially or totally prevents an insured from carrying out the main duties of his or her regular employment.

Source: Quebec group insurance vocabulary, special 5th anniversary edition, 2005 (translated from the French Vocabulaire de l’assurance collective au Québec, édition spéciale 5e anniversaire, 2005,  Grand dictionnaire terminologique) 

The Viva Workplace health and wellness program is a turnkey program that’s specially designed to meet employers’ needs with regard to health and wellness promotion and prevention.

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