YOUR SOURCE FOR HEALTH INSURANCE AND WELLNESS INFORMATION

Comprehensive - Major Medical Health Policies

 (Download Free Healthy Living Guide)

What expenses are covered under major medical policies?  Regardless of whether they are supplemental or comprehensive both will generally cover the following with slight variations from policy to policy:

Hospital inpatient room and board including intensive and cardiac care Nursing services including private duty outside a hospital
Hospital medical, surgical services and supplies
Physicians’ diagnostic, medical and surgical services
Anaesthesia and anaesthetist services
Other medical practitioners’ services
Outpatient services
Ambulance service to and from a hospital
xRays, diagnostic and lab tests
Radiological and other types of therapy
Prescription drugs
Blood and blood plasma
Oxygen including administering
Dental services that are a result of injury to natural teeth
Convalescent nursing home care
Home health care services
Prosthetic devices when initially purchased
Casts, splints, trusses, braces and crutches
Rental of durable equipment like hospital style beds and wheelchairs

Major Medical Deductibles  vary depending on your policy:

A per-cause deductible applies to each sickness or injury.  Other policies may have a deductible known as all-cause which is sometimes called cumulative or calendar-year deductible.  If your policy is per-cause you will pay a single deductible for all expenses you incur for the same injury or illness.  Your benefit period for each cause begins when deductible has been met for that injury or illness.  This can sometime run as long as two years.

Example of the per-cause stipulation - If you become ill in May and then are injured in an accident in July, these are counted as two causes and the deductible must be met for each of them separately.

In some cases the all-cause method will have a carryover provision that allows you to carry over expenses from the last three months of one calendar year to the next.

If your policy covers the entire family, then a family deductible will apply rather than individual deductibles.  If a policy’s individual deductible is $250, a family deductible might be $500.  This can be very advantageous because a four member family would only have to meet  a $500 deductible rather than $1,000 on an individual basis.

The common injury or illness provision deductible could be beneficial for a family.  If two or more family members are injured in a common accident or become sick from the same illness, only one deductible amount will be required.

The benefit period is the time during which benefits are paid.  These times are generally linked to the deductible as well as any inside or internal limits in the major medical policy.  

Benefit payment determination:

First day of an injury or illness
or
Date that the insured meets the deductible and can extend to two years.  Or, the benefit period may cease at the end of a calendar year and begins with a new deductible.

The Benefit limitations placed on the various coverage in a major medical policies are considered to be inside or internal limits.  The policy may limit both room and board and number of days that will be paid.  Then the period for hospital room and board will be whatever number of days that are specified in the policy.  Other internal limits might be restrictions on convalescent care days, mental health, x-rays and similar items.

Restoration of benefits is the time at which you can expect your benefits to resume after policy limits have been met.  For instance, a lifetime level might be as much as $500,000 and an insured might use up half or more of that in a single year.  This leaves only $250,000 left for the remainder of his life.  Some policies allow the maximum to be restored if the insured can prove that he is once again insurable.  Other policies may have an automatic reset provision which restores a specified amount the first of the year.