Glossary.

Name: JW Seagon
Address: 1st Floor, Oilibya Plaza, PO Box: 16658 00620, Muthaiga, Nairobi, Kenya
Telephone: +254 (0) 20 405 0008

This section outlines some common/important insurance terms that are used across our website. To make your journey with JW Seagon easier, we have underlined these terms and a simple explanation can be found by hovering your cursor over the term you require.

Word	Meaning
Annual Limit	The total amount your insurer will pay for all covered medical services within a policy year.
All risks	A type of insurance coverage that automatically covers any risk that the contract does not explicitly omit.
Area of cover	The geographic region where your insurance policy is valid. Common options include: Worldwide including USA, Worldwide excluding USA, Africa, India & Europe, Africa & India only
Benefit	The health care items or services covered under a health insurance policy.
Benefit Level	The maximum amount that will be paid for a specific benefit under the policy.
Benefit Package	A description of the services and items that an insurance company covers for members of a specific insurance plan.
Chronic Condition	A long-term condition that requires ongoing management rather than a cure, for example, diabetes and asthma. Coverage terms vary significantly across insurers.
Claim	A request to an insurance company for payment relating to an accident, illness, damage to property, or any other loss that is covered by the policy.
Claims adjuster	A person who settles insurance claims. This typically involves investigation of the loss and a determination of the extent of coverage.
Co-Insurance	Your share of the cost of a covered service, expressed as a percentage, for example, 20% co-insurance means you pay 20%, the insurer pays 80%.
Co-Pay	A fixed amount a health insurance beneficiary pays for medical services with the remaining balance covered by the insurance.
Coverage	Insurance coverage helps you financially recover from sudden, unexpected, and accidental things that may happen.
Deductible	The amount you must pay each policy year before the insurer begins covering eligible expenses. This is not an amount that is applied to each and every claim. Example: Deductible of $750 Bill 1 for $500 – You pay the full amount and do not receive any reimbursement Bill 2 for $500 – As you have already paid $500 in the previous bill, you only cover $250 up to the $750 deductible value and the other $250 is reimbursed to you.
Dependent	A spouse, partner, or child included on your policy and covered under its terms.
Direct Billing	An arrangement where the insurer pays the provider directly, so you don’t need to pay upfront or seek reimbursement.
Emergency Medical Evacuation	Transport to the nearest suitable medical facility if appropriate treatment isn’t available locally.
Exclusions	Exclusions are specific conditions, treatments, or services that your insurance policy will not cover. Exclusions can be ‘general’ or ‘personal’. General exclusions are conditions or treatments that are not* covered at all by your policy, for example, most cosmetic surgery, or experimental treatments. *Personal exclusions are excluded conditions and treatments that are specific to a policy member, based on the medical information declared on the application form. If personal exclusion applies, you will have been told about them before the policy started.
Indemnity	The concept of indemnity is based on a contractual agreement made between two parties in which one party (the indemnitor) agrees to pay for potential losses or damages caused by the other party (the indemnitee).
In-Patient Care	Any medical service that requires admission into a hospital and an overnight stay. Day case treatment is covered under this heading too, where you are admitted to hospital but do not stay overnight.
Insurance Broker	J W Seagon works with its customers best interests at play by offering unbiased advice on different policies from multiple insurers.
Insurance Excess	A pre-agreed amount of money that you need to pay to the insurer in the event of a claim.
Insurance Limit	The maximum amount of money an insurer will pay towards a covered claim.
Insured	The person(s) protected under an insurance contract.
Insurer	The insurance company that undertakes to provide cover for losses and perform other insurance-related operations.
KYC	Know Your Customer, process of verifying a customer’s identity, address, and other details to confirm who they are.
Liability	The obligation to pay a monetary award for injury or damage caused by one’s negligent or statutorily prohibited action.
Medical Necessity	A service or treatment considered necessary by a qualified medical provider and approved by the insurer based on clinical guidelines.
Medical Inflation	Medical inflation is the increase in the cost of healthcare services and products over time, typically at a rate higher than general economic inflation. The biggest drivers of medical inflation are advances in medical technology, and the increased utilisation of treatments.
Out-of-Provider Network	A provider with no direct agreement with your insurer. You may need to pay upfront and claim reimbursement.
Out-Patient Care	Any medical service that does not require admission into a hospital, for example, visiting a family doctor for a consultation or a clinic for some diagnostic tests.
Permanent total disability	This is an individual’s loss of the use of limbs, due to injuries preventing the policyholder from being able to work in the same capacity as they had before the injury.
Policy	A document detailing the terms and conditions of an insurance contract.
Policyholder	The person or company that owns the insurance policy and pays the premiums.
Premium Loading	This is the additional amount added to a base premium due to a higher risk profile of an insured person. It is a way for insurers to manage the risk associated with covering individuals who are more likely to claim.
Pre-authorisation (Pre-certification / Prior Approval)	Formal approval required before certain treatments, surgeries, or high-cost diagnostics to ensure eligibility. It is recommended that all planned treatment is pre-authorised.
Pre-existing conditions	Any health condition that a person has, or has had, prior to enrolling for health insurance.
Premium	The amount of money an insurer charges to provide the coverage described in the policy.
Provider network:	A hospital, clinic, or doctor with a direct billing agreement with your insurer.
Reasonable and Customary Charges	For insurers to pay claims the costs charged by the treatment provider must be no more than they would normally charge and be similar to other treatment providers providing comparable health outcomes in the same geographical region.
Reimbursement	Repayment by the insurer for eligible costs you have already paid. Usually requires submitting a claim with receipts and medical reports.
Renewal	This is the continuation of coverage. The policyholder extends their contract with the insurance company to continue their current coverage for a specified period.
Risk	The chance something harmful or unexpected could happen.
Sum assured	The amount of money that the company will pay out to the policyholder or nominated beneficiary in case of the member’s death.
Underwriter	A professional who evaluates and analyzes the risks involved in insuring a person or asset.
Underwriting	The process used to assess medical history and risk before issuing cover. There are two types of underwriting you can expect: 1. Full Medical Underwriting (FMU) which requires a full medical history declaration on your application form. For any pre-existing condition, the potential outcomes are: the condition is covered; the condition is covered with a premium loading; the condition is excluded from cover; the application is declined. 2. Continuous Personal Medical Exclusions (CPME) which is only an option if you are moving from one international insurer to another international insurer, and where the plan you are moving to has similar cover to the plan you are already on. With CPME you will not be asked to declare your full medical history again but any exclusions on your existing policy will be transferred to the new policy.
Waiting Period	A set time after the policy start date during which certain treatments are not covered. Example: Maternity / Pregnancy – a waiting period of 12 months. This means that you will not be able to claim any maternity or pregnancy costs until you have been on the plan for at least 12 months.
Wellness Benefits / Preventive Care	Coverage for routine health checks, screenings, and vaccinations aimed at early detection and disease prevention.
WIBA	Work Injury Benefits Act (WIBA) is an employee benefit plan enforced by the Kenya law that guarantees your employees get financial compensation when, by accident, they suffer injury, become disabled or die while at work.