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.

For example, if your plan offers 80 percent coinsurance, the insurer reimburses 80 percent of the eligible expense, and you are responsible for the remaining 20 percent. Coinsurance helps manage healthcare costs by encouraging shared responsibility while still providing substantial financial protection. Reimbursement may occur automatically through direct billing or manually when you submit a claim with receipts and documentation.

Example:

If your physiotherapy session costs $100 and your plan covers 80 percent, your insurer reimburses $80. You pay the remaining $20 directly to the clinic.

What to Watch For:

Understand how your plan calculates reimbursement, as it is often based on the lower of the provider’s actual fee or the insurer’s reasonable and customary rate. Some plans include annual or per-visit maximums that further limit reimbursement. Always review your plan’s coinsurance percentages and consider the impact of out-of-pocket costs, especially if you frequently use health or dental services.