What Do You Mean It's Not Covered: The Main Coverage Section

When we receive proof of injury or sickness of an insured person, and subject to the terms of this policy, we will pay insured expenses incurred during the payment period after the deductible and less the copayment up to the maximum payment. Insured expenses must be medically necessary and must be authorized by a physician or surgeon. Preexisting conditions are not covered. These conditions are any injury, sickness, or mental disorder which had existed within the two year period before the effective date. Coverage begins at 12 noon on the effective date and ends at 12 noon on the termination date shown in the application. A child born to you while this policy is in force will have immediate coverage from the date of birth to the end of the policy term. Coverage for the newborn child includes coverage for congenital defects, birth abnormalities, injury and sickness. Coverage is not provided for premature birth or routine well-baby care.

Coverage applies only to charges which are made for injury or sickness, are medically necessary, and are authorized by a doctor. The insurance company agrees to pay up to the maximum payment for covered expenses incurred during the payment period. It will only pay expenses above the deductible amount and minus the insured's copayments. Preexisting conditions which existed in the two-year period before the effective date are not covered by this policy. (Notice that this is different from the "limitation" found in the basic hospital expense policy, which only delays coverage for a preexisting condition for two years following the effective date unless it is specifically excluded by an endorsement. This major medical policy "excludes" preexisting conditions completely and there is no need to attach an endorsement to do so.) Coverage begins and ends at 12 noon on the effective date and termination date shown in the policy schedule. A newborn child will be automatically covered until the end of the policy term shown in the schedule. Coverage for a newborn child includes coverage for congenital defects, birth abnormalities, and injury or sickness. But no benefits are provided for premature birth (where no defects or abnormalities are involved) or well-baby care. Notice that this differs from the newborn child provision found in the basic hospital expense policy. That policy provides automatic coverage for newborns only for 31 days and requires a request for continued coverage.