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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.

How It Works

The claimant is the person or beneficiary making a request for payment of benefits under the terms of an insurance plan, and they provide documentation such as receipts, treatment details, and provider information to verify eligibility for payment. Once the claim is reviewed and approved, reimbursement is issued either directly to the claimant or to the healthcare provider if the service was billed through a pay-direct or direct-billing system. Under a prepaid PHSP, for example, the claimant submits the claim along with copies of the receipts to the plan administrator, and after the claim is adjudicated for correct coverage the claimant receives the reimbursement. Time limits can also apply. With Ontario Blue Cross extended health care benefits, claims must be submitted no later than 12 months after the expenses are incurred, and the time limit for filing is set out on the Claimant's Statement.

Example:

If a parent submits a dental claim for their child's cleaning under a family plan, the parent acts as the claimant even though the service was for the child. The parent attaches the dentist's receipt and treatment details, and once the insurer approves the claim the reimbursement is issued to the parent.

What to Watch For:

Incorrect claimant details or missing documentation can delay or invalidate payment, so the claimant's information should match the name, member ID, and relationship listed on the policy.

Related Terms

Coordination of Benefits

Coordination of benefits (COB) is the process used by insurance companies to determine the order in which multiple plans will pay for the same claim when a person is covered under more than one policy. The goal is to ensure that combined reimbursements do not exceed 100 percent of the eligible expense, while allowing the insured to receive the maximum possible coverage across all plans.

Benefit

A benefit is the specific financial protection or coverage provided under an insurance policy. In health and dental insurance, a benefit refers to the payment or reimbursement made by the insurer for eligible medical, dental, or wellness expenses. Each benefit category - such as prescription drugs, dental services, vision care, or physiotherapy - outlines what is covered, how much the insurer will pay, and any applicable limits or conditions.

Insured Person

An insured person is the individual covered under an insurance policy who is entitled to receive benefits for eligible claims. In a personal policy, the insured person is typically the policyholder who owns the coverage. In a group insurance plan, the insured person is the employee or member enrolled in the plan, and their eligible dependents may also be covered under the same contract.

Per Person / Per Family

Per person and per family describe how benefit limits, deductibles, or maximums are applied within a health or dental insurance plan. A per person limit means the specified amount applies individually to each insured member, while a per family limit represents the total combined coverage for all members under one policy.

Spouse / Partner

A spouse or partner is the person legally married to or living in a committed relationship with the insured plan member or policyholder. In insurance terms, a spouse includes both legally married and common-law partners who meet the eligibility requirements defined by the insurer. Common-law partners are generally recognized after living together continuously for a specific period, often 12 months or longer, in a relationship similar to marriage.

Relevant Plans

Plans that relate to Claimant

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.

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