A policy which provides "Basic Medical-Surgical Expense
Coverage" is defined as providing coverage for each person insured under the
policy for the expense incurred for the necessary services rendered by a
physician for treatment of an injury or sickness for at least the
following:
(1) Surgical services on a
fee schedule basis with a maximum of $350 based on an acceptable relative value
scale of surgical procedures.
(2)
Anesthesia services, consisting of administration of necessary general
anesthesia and related procedures in connection with covered surgical service
rendered by a physician other than the physician or his assistant performing
the surgical services, to a minimum of 15% on an expense incurred basis of the
surgical service benefit provided.
(3) In-hospital medical services, consisting
of physician services rendered to a person who is a bed patient in a hospital
for treatment of sickness or injury other than that for which surgical care is
required, in an amount not less than $5.00 per call, one call per day, for at
least 21 such calls during "one period of confinement."
(4) Surgical schedules contained in the
policy shall include a provision providing coverage for procedures not
specifically listed in the schedules and not otherwise excluded by the policy,
and benefits therefore, shall be consistent with the benefits for comparable
procedures.
(5) Two or more
surgical procedures performed on the same surgical occasion and through the
same incisions shall be covered to the extent that payment is provided for the
most expensive procedure. Operations performed during the same surgical
session, but not through the same incision, shall be covered to the extent that
100% payment is provided for the most expensive operation and 50% payment for
the remaining total.
(6) Whenever a
policy is written that provides at least the coverages required for both basic
hospital expense coverage and basic medical-surgical expense coverages, the
allowable deductible may be applied to the combined coverage.
