Accidental Injury, Ambulances, Office Visits, Tests
UPDATED: June 19, 2018
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Participating provider services subject to calendar year deductible.
The following is typcial wording seen in health care policies. Click here for specifics on health insurance co-pays and deductibles.
Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for Policy-defined Covered Expenses for the following described services, if they are Medically Necessary:
An "outpatient" is an insured who receives medically necessary medical care, treatment, services or supplies from a provider at:
- a clinic;
- an emergency room of a hospital;
- an ambulatory surgical center;
- an emergency care facility; or
- the surgical facility of a hospital which does not result in an inpatient confinement at that hospital following surgery.
You will note that the expenses of using an air ambulance are not covered unless two requirements are met:
- the insured is transported to a hospital – not a clinic, an ambulatory surgical center or an emergency care facility; and
- the insured's condition was sufficiently acute or severe enough to result in the insured being admitted to the hospital as an inpatient immediately following the insured's treatment in the emergency room of the hospital.
In many policies, office visits are subject to a co-pay. For example, you might pay $20.00 for a routine office visit and the rest of the expense is covered by the insurance company or assumed by the provider under their preferred provider agreement with the insurance company. In this particular policy, there is no co-pay for office visits. The expense of doctor visits is applied to your deducible. If you believe that most of your expenses (not that you can ever know for sure) are going to be of the routine nature, you may wish to purchase a policy with a different plan that has a limited co-pay for routine doctors' visits.
*Wording may vary from contract to contract and from state to state.