Medical Expense Insurance Questions and Answers Solved 100%

all-cause deductible - with an all-cause deductible, expenses for any number of different or the same type of illness or accidents are accumulated to meet the deductible during a single calendar year. Once enough expenses have been paid by the insured to meet the stated deductible, all other covered charges are paid during the remainder of the calendar year. Under the all-cause deductible arrangement, there is also usually a carryover provision that permits expenses incurred during the last three months of the calendar year to be carried over into the new year if needed to satisfy the deductible for the next year. Aside from group plans as described, many policies exclude maternity benefits but make them available at extra cost. Often, a maternity benefit is a lump sum paid for normal childbirth. The actual amount might be: - usual, customary, and reasonable charges; a specified amount; or a multiple of the daily hospital benefit. The benefit generally includes routine newborn care while the mother is hospitalized. Benefit Periods and Inside Limits - The times during which benefits are paid, known as benefit periods, are generally tied to the deductible and to any inside or internal limits included in the major medical policy. When a deductible must be paid, the benefit period might begin either on the first day of the accident or illness or on the date the insured has satisfied the deductible (if later than the date of the event) and may extend for up to two years. In other cases, the benefit period ceases at the end of the calendar year and begins anew with the new deductible. Chiropractic Services - The treatment rendered by a chiropractor is normally a covered expense subject to a limitation with regard to total benefits (e.g., $10,000 lifetime) or a limitation with regard to the number of visits that will be covered in a given year and/or the amount that may be paid per visit. Common Exclusions and Limitations - Preexisting conditions, as defined in the policy and according to state law (however, some states have no loss/no gain laws that require a replacing health insurance policy to cover any conditions for which there are ongoing claims under existing coverage, thus overriding the preexisting conditions exclusion in the replacing policy); Hernia, although the trend is to cover this condition; Self-inflicted injuries Suicide; War or acts of war resulting in death or injury, whether or not war is officially declared Military duty, usually a suspension of the policy that ends when the insured is released from such duty Noncommercial air travel, which is any air travel other than as a scheduled airline passengerInjury while committing a felony; Injury, illness, or death while under the influence of intoxicants or narcotics; Cosmetic surgery, except for surgery required as the result of an accidental injury or a congenital defect; Dental expense, although some policies cover such expenses resulting from accidental injury; Vision correction, such as eye exams and eyeglasses; Care provided in a government facility, normally paid by the Veterans Administration or by workers' compensation; Sexually transmitted diseases; Experimental procedures; Organ transplants; Infertility services; Alcohol or drug abuse treatment common injury or illness provision - Under this provision, only one deductible must be paid when two or more members of the same family are injured in a common accident or become ill concurrently from the same sickness. Suppose Myra and Rick, wife and husband, are riding in Rick's car when they are both injured in an accident on the freeway. The deductible for each person under their health policy is $200, but their policy requires them to pay only $200 in this case. Comprehensive Major Medical Benefits Coinsurance - means that the insurer and the insured share any expenses above the deductible amount. The insurer always carries the bulk of the expense, usually paying 80% of covered expenses compared with 20% for the insured. Other proportions, such as 75/25%, may be used, so it is important to read the policy. In some areas, coinsurance is referred to as percentage participation. Comprehensive Major Medical Benefits Deductibles - Most major medical benefits begin to be paid after the deductible is satisfied. The policy's deductible is considered satisfied as long as the insured can show evidence of having incurred the necessary expense. There are essentially two types of comprehensive major medical plans: one with first dollar coverage and one without. Comprehensive Major Medical Benefits Stop-Loss Limit and Maximum Benefits - More and more major medical policies include a stop-loss limit, which is a dollar amount beyond which the insured no longer participates in payment of the expenses. The stop-loss limit is sometimes known as the out-ofpocket limit. After the insured's total coinsurance and deductible payments reach that amount, the insurer picks up the entire cost of remaining expenses, up to a stated maximum benefit. Currently, the lifetime maximum limits on health policies might range from $100,000 to $1,000,000, and some policies even have unlimited benefits. Just as the maximum benefit varies considerably, so does the amount of the stop loss limit, depending on the insurer. Comprehensive major medical expense - the more traditional basic coverages and essentially any other type of medical expense are combined into a single comprehensive policyEmergency Accident Benefits - A basic plan may include a specific benefit for expenses incurred as the result of an accident when the insured is taken to the emergency room of a hospital as an outpatient. Typically, this benefit is stated as $300 or possibly $500. The benefit is to cover the cost of treatment in the emergency room including physician expenses, x-rays, stitches, and other services.