What Do You Mean It's Not Covered: How the Policy Handles Out-Patient Care
The policy will pay 80 percent of covered outpatient services and supplies, subject to the maximum benefit amount shown in the benefit schedule. The insured is required to pay 20 percent of the charges. This proportion is known as a copayment. An example: You incur $300 in charges for emergency room treatment following an accident. Your policy will pay 80 percent ($240) and you must pay 20 percent ($60). Covered outpatient services and supplies include such things as x-rays, lab tests, prescription drugs, casts or splints, artificial limbs, oxygen, emergency room treatments, and tetanus shots. Outpatient benefits are provided for treatment received at a hospital, clinic, doctor's office, or ambulatory surgical center. We will pay benefits for emergency ambulance service which is required as the result of an injury. We will pay up to $25.00 for such service from the accident to the hospital. Hospital confinement is not required. We will not pay more than the fee charged. An ambulance must be a vehicle specifically equipped for, and used exclusively for, the transportation of persons who are sick, injured, or deceased.
Outpatient benefits include coverage for emergency ambulance service required due to an injury. The benefit is limited to the actual fee charges or $25, whichever is less. Coverage applies only to fees charged by an ambulance service that engages in transportation of sick or injured persons. An example: You're injured in an automobile accident. A friend places you in a taxi cab at the accident scene and rushes you to a hospital. The cab fare isn't covered because it is not an ambulance charge. In order for benefits to be paid under this coverage, the service and supply must be rendered: (1) as the result of an injury or sickness (2) while this coverage is in force for the person who incurs the expense (3) at the direction of and under the supervision of a physician or surgeon. This coverage does not include benefits for professional services of a radiologist, pathologist, anesthesiologist, nurse, physician or surgeon.
Outpatient services are covered only when rendered due to injury or sickness, while coverage is in force for the insured person, and at the direction of a physician or surgeon. These outpatient benefits do not include benefits for the professional services of a radiologist, pathologist, anesthesiologist, nurse, physician or surgeon.
