The Plain-English Benefits Glossary: Every Term on Your Booklet, Decoded

Benefits booklets are written by people who do this for a living, for people who don't. The result is a document full of words like coordination of benefits and reasonable and customary that sound like they mean something obvious and absolutely do not.

So here's your decoder ring. I've grouped the terms the way you'll actually meet them — the people involved, the money, the using-it part, and the fine print. Keep this open the next time you read your booklet and it'll suddenly make sense.

Who's who

• Plan sponsor — your employer. They choose the plan and pay for most of it.
• Insurer / carrier — the company that actually pays the claims (Sun Life, Canada Life, Manulife, and so on).
• Plan administrator — usually someone in your HR team who manages enrolment and answers your questions.
• Plan member — you, the employee who's covered.
• Dependant — your spouse or common-law partner and your eligible children, if you've enrolled them.
• Beneficiary — the person who receives your life insurance benefit. Name one. Keep it current.

The money words

• Premium — the monthly cost of the plan. On a group plan your employer typically pays a big share, and your portion comes off your pay.
• Deductible — what you pay before the plan starts paying (covered in depth in Lesson 1).
• Co-insurance — the percentage split between you and the plan, like 80/20.
• Co-pay — a small flat fee each time you use a benefit.
• Maximum — the most the plan pays for something in a year (or sometimes per lifetime, like orthodontics).

Michelle's tip: When a benefit shows two numbers — say "80% to a maximum of $500" — read it as the plan pays 80% of each bill, and stops once it has paid out $500 total this year. Both limits apply.

Using-it words

• Claim — your request to be paid back for an eligible expense.
• Direct billing / assignment of benefits — when the provider bills the insurer directly so you don't pay the full amount up front (more in Lesson 4).
• EOB (Explanation of Benefits) — the summary the insurer sends showing what they paid and why. Not a bill — a receipt for the claim.
• Coordination of benefits (COB) — when you're covered by two plans (say, yours and a spouse's), the rules for combining them so more of the bill gets paid. Used well, two plans can cover close to 100%.
• Paramedical — practitioners outside the doctor/hospital system: physiotherapists, massage therapists, psychologists, chiropractors, and the like.

Fine-print words

• Eligible expense — something your plan actually covers. If it's not eligible, no percentage applies — it's simply not paid.
• Reasonable and customary (R&C) — a cap on how much the plan considers a "normal" price for a service in your area. Get charged above R&C and you cover the difference.
• Formulary — the list of drugs your plan covers (the subject of Lesson 5).
• Prior authorization — pre-approval the insurer requires before covering certain higher-cost drugs or services.
• Pre-existing condition — a health issue you had before coverage started; relevant mostly for certain optional or individual policies, rarely for standard group health.
• Waiting period — the time you wait after starting a job before coverage begins.
• Coordination with government plans — how your plan fits around public coverage like OHIP (the subject of Lesson 3).

How to actually use this

You don't need to memorize any of it. You need to recognize a word when it appears on your statement and know where to look. Bookmark this page, and when something on your EOB looks off, come back, find the term, and you'll usually solve it yourself in two minutes.

And when you can't? That's exactly what a real advisor is for. No term in your booklet should ever be a wall between you and the coverage you're paying for.