Merritt Personal Lines Manual: Deductibles, Copayments and Other Matters
DEDUCTIBLE, COPAYMENT, PAYMENT AND ACCUMULATION PERIOD
You pay the deductible, the copayment and the incurred charges not covered by this policy as insured expenses. We pay the insured expenses incurred after the deductible and less the copayment. The schedule of our payment and your copayment for the payment period is shown on page ____. Our payment and your copayment vary with each portion of insured expenses.
The deductibles of this policy that apply to injury and sickness are shown on page ____. When more than one insured person is involved in the same accident, only one deductible will be applied to their combined insured expenses.
Only charges which qualify as insured expenses can be used to satisfy the deductible. You must satisfy the deductible within the accumulation period shown on page ____.
We begin making payments under this policy after you have satisfied the deductible.
You're required to pay deductible and copayment amounts. Since the policy covers "insured expenses," you must also pay any charges which are not covered by the policy (excluded items, such as normal childbirth, elective cosmetic surgery, etc.). Expenses which are not covered cannot be applied toward a deductible. Except for these amounts, the insurance company will pay additional insured expenses up to the maximum payment. As mentioned earlier, the deductible and copayment percentages are shown in the policy schedule and this policy uses a sliding scale for copayments.
If more than one insured person is involved in the same accident, only one deductible will be applied to their combined expenses.
An example: You and your spouse have a major medical policy with a $1,000 deductible applicable to each person and each injury or sickness. After you're both injured in an automobile accident, your medical bills are $1,400 and your spouse's are $2,200. Since only one deductible applies to this accident, $2,600 of the charges are covered by the policy--subject only to copayments.
PAYMENT PERIOD AND MAXIMUM PAYMENT
The payment period begins on the date that the deductible is satisfied. The payment period may not exceed five years of the payment of the maximum payment.
The maximum payment which we will make for any one injury or sickness during a payment period is $500,000. Each injury or sickness is eligible for the maximum payment.
When an insured person incurs less than $100 in insured expenses in any one 90 consecutive day period during the payment period, the payment period will cease at the end of the 90 day period.
The payment period begins on the date the deductible is first satisfied. This policy has a payment period of five years and a maximum payment of $500,000 for each injury or sickness.
An example: You have a major medical policy with a $1,000 deductible. On March 1, you discover that you have a medical condition which requires treatment. Your expenses for doctor visits and medication for this condition do not exceed $1,000 until July 15, so your payment period begins on that date.
If expenses for a given condition are less than $100 in a 90-day period, the payment period ends. Additional expenses related to the same condition would be treated as a new injury or sickness.
An example: You've recovered from your condition to the point where medical expenses fall below $100 in a 90-day period, so your payment period ends. Two months later, you have a relapse and incur more expenses. This is a new sickness and will be subject to a new deductible and payment period.
