What term is used for the circumstances under which a health insurance policy will pay benefits?

The insuring agreement refers to the part of an insurance policy that outlines the circumstances under which the insurer will provide coverage or pay benefits. This section details the specific risks that the policy covers, such as types of medical conditions, services, or treatments that can receive financial assistance. It is the foundation of the contract between the insurer and the insured, clearly defining what is included within the policy's coverage.

In contrast, eligibility criteria determine who is entitled to coverage, coverage limits specify the maximum amount the insurer will pay for particular claims, and policy exclusions highlight situations or conditions that are not covered by the insurance policy. These components serve important functions, but the insuring agreement is specifically focused on the conditions for benefit payment, making it the most relevant term in this context.