Back to all terms

Claim

A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.

Claims can be submitted electronically by the provider through a direct billing system, or manually by the plan member using an online portal, mobile app, or paper claim form. Most modern health and dental plans support electronic submission, which speeds up processing and reduces the need for manual paperwork. Once a claim is approved, the insurer either reimburses you directly or pays the provider on your behalf, depending on how the plan is set up.

Each claim is assessed based on eligibility, remaining maximums, coinsurance, deductibles, and any applicable exclusions or limitations.

Example:

If you visit a physiotherapist and pay $100 for treatment, you can submit a claim through your insurer’s app with a photo of the receipt. If your plan covers 80 percent, the insurer reimburses $80 directly to your bank account.

What to Watch For:

Always submit claims within your insurer’s time limit, which is usually 12 to 18 months from the date of service. Keep original receipts in case additional documentation is requested. Check that your provider’s name, license number, and service date are clearly listed to prevent delays or denials.

Related Terms

Calendar Year

The calendar year defines a benefit period that runs from January 1 to December 31. Many annual maximums, deductibles, and claim resets follow this schedule. It provides a consistent framework across most insurers and simplifies tax reporting for medical expenses.

Certificate of Insurance

A certificate of insurance is an official document issued by an insurance company that summarizes the key details of your coverage. It serves as proof that you are insured and outlines the essential terms of your policy, including the type of coverage, effective dates, benefit limits, exclusions, and any dependents or beneficiaries listed under the plan.

Claim Submission Deadline

The claim submission deadline is the final date by which an insured person must submit a claim to their insurance company for reimbursement of eligible expenses. After this date, the insurer is not obligated to pay the claim, even if the expense itself would have been covered. This deadline ensures timely processing, accurate recordkeeping, and proper financial reporting for both the insurer and the policyholder.

Claimant

A claimant is the person who submits a request for reimbursement or payment under an insurance policy. In health and dental insurance, the claimant is usually the insured individual who received the service, such as a medical treatment, prescription, or dental procedure. However, a claimant can also be a parent, spouse, or legal guardian submitting a claim on behalf of a covered dependent.

Coinsurance

Coinsurance -sometimes called the *reimbursement rate* - is the percentage of eligible health or dental expenses your plan will pay after any deductible. It’s the insurer’s share of the bill, with the remainder paid by you. Typical plans cover 70–100% of eligible costs; the rest is your out-of-pocket portion.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.

Contact Us