This article continues the discussion of miscellaneous benefits not subject to any co-pays, deductibles or coinsurance percentage unless otherwise indicated. The insurance company promises to pay these benefits on behalf of each applicable insured for the amount of professional fees and other applicable diagnostic or treatment expenses that are covered expenses. (Typical wording*) 2. Mental and Emotional Disorders, Alcoholism and Drug Addiction/Abuse: a. Services Provided by participating Providers and Non-Participating Providers to each Insured for Outpatient treatment of Mental and Emotional Disorders, Alcoholism and Drug Addiction/Abuse. Covered Expenses Provided in any Calendar Year, per Insured will be: i. 100% of the first $100;
ii. 80% of the next $100; and
iii. 50% of the next $1,800.
b. Covered Expenses will include treatment at a facility primarily for the treatment of Mental or Emotional Disorders, Alcoholism or Drug Addiction/Abuse and for treatment by a licensed psychologist. c. Covered Expenses Provided for all Outpatient Mental and Emotional Disorders, Alcoholism and Drug Addiction/Abuse services are limited to a lifetime maximum of $7,500 per Insured. |
"Mental and emotional disorders" are disorders listed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. They do not include conditions that are not attributable to a mental disorder that may also be a focus of attention or treatment. "Alcoholism" is the chronic and habitual use of alcoholic beverages by any person to the extent that such person has lost the power of self-control with respect to the use of such beverages.
"Drug Addiction/Abuse" is a disease that is characterized by a pattern of pathological use of a drug with repeated unsuccessful attempts to control its use, and with significant negative consequences in at least one of the following areas of life: medical, legal, financial or psycho-social.
Note that this is fairly limited benefit considering the potential seriousness and lengthy treatment period for these conditions. (Typical wording*) 3. Childhood Immunizations: Services Provided by Participating Providers and Non-Participating Providers to each Insured under seventy-two (72) months of age for the following routine childhood immunizations: at least four(4) doses of rubella, rubeola, and mumps; five (5) doses of vaccine against tetanus, pertussis and diphtheria; three (3) doses of vaccine against hepatitis B; one (1) dose of vaccine against varicella; and such vaccines as may be prescribed by the Department of Health of the state in which the Insured child resides. | This benefit provides some basic coverage for necessary childhood immunizations. *Wording may vary from contract to contract and from state to state.
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