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Merritt Personal Lines Manual: Other Terms and Definitions that Affect Coverage

These are definitions that specifically apply to the coverage provided by the Basic Hospital Expense Policy, in addition to the general definitions (hospital, physician, etc.) that we reviewed before.

ADDITIONAL DEFINITIONS

expense

The usual and customary charge for medical services and supplies for which this policy provides coverage.

The policy covers qualified "expenses," which means the usual and customary charges for covered medical services and supplies. This is a slightly more limited term than the term "loss" we considered before.

one period of confinement

(1) one continuous hospital confinement; or

(2) several hospital confinements for the same or related cause which are separated by less than 180 days.

Each hospital confinement must begin while the coverage is in force.

The term "one period of confinement" is defined because basic hospital expense policies usually limit the maximum benefit for each period of confinement to a number of days and a total dollar amount. In addition to a continuous period of confinement, multiple confinements due to related causes and separate by less than 180 days will be treated as a single confinement.

An example: You have an appendectomy and spend three days in a hospital. After release, the incision becomes infected and you're readmitted 20 days later for care and treatment. For benefit purposes, both periods in the hospital related to the appendectomy are treated as a single period of confinement.

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