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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.

The insured person’s rights and benefits are outlined in the policy or certificate of insurance. These may include coverage for medical, dental, disability, life, or accident-related expenses, depending on the type of plan. The insured person is responsible for providing accurate information during the application process, paying any required premiums, and submitting claims according to the policy’s terms.

Example:

If you are covered under your employer’s group health plan, you are the insured person. Your spouse and children, if listed as dependents, are also insured persons under your family coverage.

What to Watch For:

Ensure that your personal details and those of your dependents are correct on your insurance records, as errors can delay or deny claims. Review your policy to understand your responsibilities, including premium payments and claims submission deadlines. When transitioning between group and individual plans, verify that your insured status continues without interruption.

Related Terms

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.

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.

Policy (Contract)

A policy, also referred to as a contract, is the legally binding agreement between an insurance company (the insurer) and the policyholder that defines the terms, conditions, and obligations of coverage. It outlines what is insured, the benefits provided, the premium amount, exclusions, and the responsibilities of both parties. Once the insurer accepts the application and the first premium is paid, the policy becomes active and enforceable.

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.

Extended Health Care Insurance

Extended health care insurance (EHC) is supplemental coverage that helps pay for medical expenses not covered by your provincial or territorial health plan. It protects you from out-of-pocket costs associated with services such as prescription drugs, vision care, medical equipment, hospital upgrades, emergency travel medical care, and paramedical services like physiotherapy or chiropractic treatments.

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