What Do You Mean It's Not Covered: The Other Common Kind of Health Coverage
ADDITIONAL DEFINITIONS -- accumulation period: The continuous period of time during which insured expenses must be incurred which satisfy the deductible.
An "accumulation period" is a specified period of time during which expenses are charged against the deductible before benefits begin. The period is usually specified in the policy schedule. An example: Your policy shows a $500 deductible and an accumulation period of six months. If you have $450 of medical expenses during a six-month period, no benefits are paid. If you have $750 of medical expenses during a six-month period, your policy will provide benefits for the amount above $500 (minus any copayment). In either case, you will have to pay the first $500 of expenses during the next six-month period. copayment: After the deductible is paid by you, that part of continuing insured expenses which you pay. The copayment varies with each level of insured expenses.
Covered expenses above the deductible are subject to a copayment. This policy has copayment percentages that change with each level of covered expenses. These are shown in the policy schedule. To illustrate, let's assume that an insured's deductible is $500 and the policy shows the following copayments: 20 percent for the first $500 of covered expenses, 15 percent for the next $500, 10 percent for the next $1,500, 5 percent for the next $2,500, and 0 percent for covered expenses above $5,000. At this point, the insured's "stop loss" is reached and the insurance company will pay 100 percent of additional expenses. An example: You incur $17,500 in medical expenses due to an accidental injury. You have to pay the deductible ($500) and the above copayment amounts ($100 + $75 + $150 + $125 + $0 = $450). Your "stop loss," the maximum expense you must pay, is $950. The insurance company pays $16,550 for this injury. deductible: The insured expenses for any one injury or sickness which must be incurred during the accumulation period before we make any payments. You pay the insured expenses satisfied by the deductible. You elect the deductible when you purchase this policy.
Each insured person must satisfy the deductible during the accumulation period before any benefits are paid. A deductible applies to each injury or sickness. Separate deductibles may apply to injury and sickness. These are shown in the policy schedule.
Insured expenses: A charge which results from injury or sickness which is covered by this policy: is medically necessary; and is authorized by a physician or surgeon.
