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Merritt Personal Lines Manual: Conditions of Surgical Coverage

When more than one surgical operation or diagnostic procedure is performed as the result of an accident or sickness, we will pay benefits a follows:

For Sickness

We will pay only the procedure which provides the larger benefit:

(1) when two or more surgical procedures are performed,

(2) when two or more diagnostic procedures are performed and

(3) when both a surgical and diagnostic procedure are performed.

For Accident

If as the result of one accident multiple injuries are sustained which require more than one operation to be performed in separate operative fields and through separate incisions:

(1) we will pay up to the stated percent of the maximum for the most severe operation performed and

(2) we will also pay 50% of the stated percent of the maximum for each additional operation or diagnostic procedure performed.

We will not pay for more than 3 operations (which includes diagnostic procedures). If an operation or procedure is not listed in the Schedule of Operations, we will determine the amount to be paid based on other procedures of like severity.

Benefits will be adjusted when multiple procedures are performed as a result of the same accident or sickness.

For sickness, the policy will pay only for the procedure that provides the largest benefit when two or more surgical or diagnostic procedures are performed.

For an accident that causes multiple injuries requiring more than one operation on different areas of the body, the policy will pay the percentage benefit for the most severe operation plus 50% of the percentage benefit for each additional operation or procedure.

The insurance company will not pay for more than three operations or diagnostic procedures related to the same accident or sickness.

If a particular operation or procedure is not listed in the Schedule of Operations, the insurance company will determine the benefit to be paid based on benefits for other procedures of similar severity.

We will pay up to 15% of the amount that is paid for an operation or diagnostic procedure toward the cost of anesthetic service. If more than one surgical operation is performed as the result of one accident or sickness, we will pay 15% of the greater benefit. We will not pay more than the amount charged or more than the expense.

The insured person need not be confined in the hospital for a benefit to be paid for this expense. In order for benefits to be paid:

(1) the surgery must be for an injury or sickness

(2) this coverage must be in force for the person undergoing the surgery

(3) the surgery must be performed by a physician or surgeon.

In addition to the surgical expense benefit, the policy will pay up to 15 percent of the amount paid for an operation for anesthetic services. If more than one operation is performed, it will pay 15 percent of the greater benefit. In no case will the policy pay more than the actual charges for anesthetic services.

Benefits for surgical and diagnostic procedures do not depend upon hospitalization. An insured does not need to be confined in a hospital to be entitled to these benefits.

Benefits for surgical and diagnostic procedures or treatment of fractures will be paid only if the surgery is due to an injury or sickness, coverage is in force for the person when the surgery is performed and the surgery is performed by a physician or surgeon.

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