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.

How It Works

In health and dental insurance, the claimant who submits the claim is usually the insured person who received the service, though a parent, spouse, or legal guardian can submit on behalf of a covered dependent. The claimant provides documentation such as receipts, treatment details, and provider information to verify eligibility for payment. Health and dental claims can be submitted on paper, online through the insurer's member portal, or directly by a pharmacist, dental office, optical location, or paramedical provider on the member's behalf. When a pay-direct drug card is used at a pharmacy, the member is charged only for amounts not covered by the plan and does not need to submit a separate claim for reimbursement. Once a claim is reviewed and approved, reimbursement is issued either to the claimant or to the healthcare provider if the service was billed through a pay-direct or direct-billing system.

Example:

A member of a Canadian workplace health plan visits the dentist for a cleaning. Because the dental office is set up for direct billing, it submits the claim electronically to the insurer on the member's behalf, and the member pays only the portion the plan does not cover. For a paramedical service like physiotherapy where direct billing isn't available, the member pays up front, keeps the receipt, and submits the claim through the insurer's online portal to be reimbursed for the eligible amount.

What to Watch For:

A claim is not a guaranteed payment. Insurance companies pay only for the specific losses described in the policy, and a claim can still be limited, partly covered, or denied depending on the policy wording and the facts. Policies may also include exclusions, specific claim procedures, and time limits within which a claim must be submitted. These submission time limits typically range from 90 days to 12 months from the date of the loss or event, though insurers set their own deadlines. If a claim is not approved, insurers commonly provide an appeal process.

Related Terms

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.

Reimbursement / Coinsurance

Reimbursement is the amount an insurance company pays back to the insured person or directly to a healthcare provider for eligible expenses covered under a policy. Coinsurance is the portion of the cost that the insurer agrees to pay, expressed as a percentage, with the remaining balance paid by the insured. Together, these terms describe how healthcare costs are shared between you and your insurer once a claim is approved.

Insurer

An insurer is the insurance company or organization that provides financial protection to individuals or groups in exchange for premium payments. The insurer assumes the risk of potential loss and agrees to pay benefits for covered claims according to the terms of the policy. Insurers evaluate applications, determine premiums, issue policies, and manage claims through underwriting and administration processes.

Provider

A provider is a licensed healthcare professional, facility, or service organization that delivers medical, dental, vision, or paramedical care to patients. In the context of insurance, a provider is any individual or entity authorized to perform covered services and submit claims for reimbursement to an insurer. Providers include physicians, dentists, pharmacists, physiotherapists, chiropractors, optometrists, hospitals, and clinics.

Prior Authorization

Prior authorization is the process through which an insurer reviews and approves certain medical treatments, procedures, or prescription drugs before they are performed or dispensed. It ensures that the recommended care is medically necessary, appropriate, and covered under the policy before expenses are incurred. Prior authorization helps manage costs and ensures the use of safe, evidence-based treatments that align with clinical guidelines.

Relevant Plans

Plans that relate to Claim

Alberta Blue Cross - Blue Assured - Basic

Alberta Blue Cross - Blue Assured - Basic

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced

Alberta Blue Cross - Blue Assured - Enhanced

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced+

Alberta Blue Cross - Blue Assured - Enhanced+

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Premium

Alberta Blue Cross - Blue Assured - Premium

Can apply at anytime, at any age.

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