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MEDICAL INSURANCE (First of Two Parts)
If you recall, we explained that there are two broad categories of health insurance policies: disability and medical expense. Thus far we have covered disability. Now we’ll take a look at basic medical expense insurance.
Basic medical expense policies provide for medical expenses that
result from accidents and sickness. This is a loose term that refers to various medical, hospital and surgical benefits.
The broad category of medical expense coverage provides a wide
range of benefits for hospital, surgical and medical care. Other benefits may apply as well, such as private nurses, convalescent care, and more.
Policies may be written as such that they may be limited to only one or two types of coverage like hospital or miscellaneous medical costs or surgical expenses. These are known as basic plans.
Other, more broadly written, policies may cover all expenses resulting from accident or illness using some specific exceptions. Medical plans include fee-for-service wherein doctors and other providers receive a payment that does not exceed their billed charge for service provided.
Prepaid plans provide medical or hospital benefits in the form of service rather than dollars. Many things need to be considered when selecting a medical expense plan such as:
- Specified coverage versus comprehensive care. In other words does the plan feature only specific benefits or is the coverage comprehensive
- Any provider versus a limited number of providers. Are you required to choose from a specific list of providers?
- National versus regional operation. Is the plan limited to a specific geographical region or operate nationwide?
- Insured versus subscribers. Are participants considered insureds (the person who receives the benefit) or subscribers (the person who is paying the premium)?
We are going to take a look at the limited coverage for hospital, medical and surgical expenses. Discussing this separately first, will
help you to understand how the components are combined in major
medical and comprehensive policies.
The broad definition of basic medical expense insurance in most states includes hospital, medical and surgical expenses. The purpose of this type of insurance is to cover a broad range of medical, hospital and surgical expenses as well as separate categories of medical expenses.
Let’s explore individual versus group coverage.
No matter how a policy is written, narrowly or broadly, medical expense insurance is designed to reimburse for the cost of care whether it results from injury or illness.
Both individual and group policies are available to consumers. Normally individual policies are more costly along with having limited benefits but generally speaking, both types cover the same medical services.
Hospital expense benefits provide for expenses incurred during hospitalization. Indemnities usually fall under two broad groups:
- Room and board – including nursing care and special dietary requirements
- Miscellaneous medical expenses – including x-rays, lab work, medications, medical supplies and operating and special treatment rooms
In some cases, benefits might be included for certain surgeries and related costs like pain killers given during a hospital stay. Room and board benefits may be paid based on indemnity or reimbursement depending upon the particular policy. When paid on an indemnity basis, the insurer pays a specified rate per day that has been pre-determined and is laid out in a schedule within the policy.
The schedule will spell out the details of the benefit coverage as it pertains to length of stay. Once the length of stay has been exhausted, no more benefits are available. These are sometimes called dollar amount plans and typically the number of days is from 90 up to 365.
More commonly used is a reimbursement basis, also known as an expenses-incurred basis. With this type of coverage the policy will pay in one of two ways – the actual charges for a semi-private room or a percentage of the actual charges. There are no specific dollar amounts but a maximum number of days will still be specified.
Surgical Expense Benefits fall under two plans, scheduled and non-scheduled.
In the scheduled plan, surgical expense policies pay the fees incurred from the surgeons services and related costs incurred when the insured has an operation. Typical related costs include fees for an assistant surgeon, anesthesiologist and can even include the operating room when it is not covered as a miscellaneous item.
Basic surgical coverage can be included in the same policy as basic hospital and medical expense and are normally included in a schedule listing major commonly performed operations and the benefits payable for each.
This gets a bit tricky and you need to be aware of how the insurance company determines the benefit.
Just because a specific surgery is not listed in the schedule does not necessarily mean that there is no benefit for it available. It might mean that the insurer indemnifies that surgery based on absolute value and the relative value of each procedure.
In other words, let’s say that the insurer determines that a certain surgical procedure has a prevailing value of $1500 and indicates that in the schedule included in your policy. That is considered the absolute value. Now, let’s say that there is another procedure not listed in the schedule that is say 50% less complicated as the $1500 procedure. In this case, the relative value would be $750 and that is the benefit amount that will be paid for the less complicated procedure.
Using a non-scheduled scenario, when surgical benefits are not listed by a specific dollar amount in a schedule, the policy will pay based on what is considered usual, customary and reasonable in a certain geographical area and is also known as UCR.
This non-scheduled type of indemnity is found most often in major medical and comprehensive policies which we will discuss further along.
As you might imagine, under this type of arrangement the UCR is determined by the amount that physicians in the local area usually charge for the same procedure.
Regular medical expense benefit is another category that is sometimes known as physician’s non-surgical expense. This coverage is for non-surgical services a physician provides and can sometimes be narrowly applied to physician visits while the patient is in the hospital.
If this is the case the benefit will most likely pay for a specified maximum number of visits per day, a specified maximum dollar amount per visit and a specified number of days coverage applies.
In other policies this benefit could be for non-surgical services performed by a physician whether the patient is in or out of the hospital. Once again there are limits such as $100 per visit up to 50 visits per year depending on the policy.
Other medical expense benefits fall into a category in addition to the hospital, surgical and medical benefits previously discussed. These
optional benefits vary from insurer to insurer and may or may not include as part of their standard policies. Separate policies can sometimes be written to include these benefits. Some of them are:
- Maternity
- Convalescent – Nursing home
- Emergency first-aid
- Home health care
- Mental infirmity
- Hospice care
- Prescription drugs
- Dread disease
- Outpatient treatment
- Dental
- Private duty nursing
- Vision
We will not cover all of these options, but will let’s take a look at
the most common.
Maternity benefits are sometimes included in policies subject to certain conditions and limitations. The most usual limitation is a 10 month waiting period designed to prevent the purchase of health insurance just to cover pregnancy and childbirth expenses.
Interesting to note, however, group policies for employee groups of 15 or more are required by law to provide maternity benefits on the same basis as non-maternity benefits. This means that in a case such as this, the waiting period would not apply unless non-maternity benefits also required a 10 month waiting period.
Aside from the group scenario above, many policies just exclude maternity benefits totally but make them available at extra cost.
Where maternity benefits do apply, the benefit usually includes newborn care while the mother is in the hospital.
Other benefits that are sometimes available under the same maternity coverage might include cesarean deliveries, natural abortions and elective abortions.
Emergency First Aid Coverage applies to an accident that may call for immediate first-aid on the scene. This applies when a medical professional who just happens on the scene provides first-aid service he/she might bill the insured. Sometimes treatment like this must be performed without the knowledge or assent of the insured.
Some policies offer coverage for such contingencies and normally must incur within a very short time after an accident.
Mental Infirmity historically has been excluded from most policies. However, in recent years more and more policies include this type of coverage but with limitations. The benefits are usually much lower than physical ailments and a stated percentage of the benefit paid for other types of medical care is included.
Common exclusions and limitations. Both disability income and medical expense policies limit or exclude coverage for certain types of injuries or illness.
There is a difference between limitations and exclusions. The mental infirmity policy limitations we discussed above is an example, whereas an exclusion is completely omitted from any coverage.
It is important that you deal with a knowledgeable agent because state laws and policies may differ on specific items. Some items that fall into the common exclusions and limitations might be:
- Pre-existing conditions as defined by your policy and dictated by state law.
- Hernia however the growing trend is to cover the condition.
- Self-inflicted injuries
- Suicide
- War and/or acts of ware that result in injury or death
- Military duty
- Non-commercial air travel
- Injury while committing a felony
- Injury, illness or death incurred while under the influence of alcohol or narcotics
- Cosmetic surgery unless for surgery required as a result of an accidental injury or a congenital defect
- Dental expense, unless resulting from accidental injury
- Vision correction such as eye exams, eyeglasses and contact lenses
- Care provided by governmental facility which is normally covered by the Veterans Administration or by workers compensation
- Sexually transmitted diseases
- Experimental procedures
- Organ transplant
- Infertility treatment and services
- Alcohol and drug abuse treatment
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