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Accident Health ConceptsSeen in 12 questions

Evidence of Coverage (EOC)

The group member's booklet describing benefits, exclusions, and rules under the plan, the analogue of an individual policy contract.

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Under California Insurance Code Section 380, an 'insurance policy' is defined as:

A written contract of insurance, or written evidence of it — Section 380 defines a policy as a written contract of insurance, or written evidence of it. The written instrument is a hallmark of insurance: the policy document contains the insuring agreement, conditions, and exclusions. An application, by contrast, is the offer; a binder is temporary written evidence of coverage; and the policy itself is the complete written contract embodying the parties' agreement.

CA-specific example

In group life insurance, the contract of insurance is between the insurer and the:

Master policyholder, usually the employer — In group life insurance, the insurer issues one master contract to the master policyholder, typically the employer or association, and each covered employee receives a certificate of coverage summarizing the benefits. The employer holds the contract, pays premiums, and administers the plan; the certificate is evidence of coverage but is not the insurance contract itself. This two-tier structure, a master policy plus certificates, is the defining feature that distinguishes group insurance from individual policies. Understanding the master-contract structure is essential because individual employees have rights only through the employer's contract, and disputes are resolved against the terms of the master policy rather than the certificate.

National insurance concept

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