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Further, there are a number of provisions that apply only or primarily to group policies. These provisions: Describe who is eligible for the group plan, Describe when individuals become eligible for the plan. Specify minimum number of participants and minimum participation by eligible people necessary to sustain the plan, Specify amount of insurance that individual group members are entitled, Describe the responsibilities of the master policy owner.
In other policies this benefit could be for non-surgical services performed by a physician whether the patient is in or out of the hospital. Once again there are limits such as $100 per visit up to 50 visits per year depending on the policy.
Supplemental major medical benefits supplement a basic policy that includes hospital, surgical and medical with an additional policy that covers the broader range of medical expenses.
Using a non-scheduled scenario, when surgical benefits are not listed by a specific dollar amount in a schedule, the policy will pay based on what is considered usual, customary and reasonable in a certain geographical area and is also known as UCR. This non-scheduled type of indemnity is found most often in major medical and comprehensive policies which we will discuss further along. As you might imagine, under this type of arrangement the UCR is determined by the amount that physicians in the local area usually charge for the same procedure.
Are lab fees and x-rays included? Can you choose your own physician or select from a list of providers? What is most important to you? Does the coverage include dental, vision, maternity, well-baby care, etc.
The portion of the covered medical expenses you pay is called "coinsurance." Although there are variations, fee-for-service policies often reimburse doctor bills at 80 percent of the "reasonable and customary charge." (This is the prevailing cost of a medical service in a given geographic area.) You pay the other 20 percent—your coinsurance. However, if a medical provider charges more than the reasonable and customary fee, you will have to pay the difference. For example, if the reasonable and customary fee for a medical service is $100, the insurer will pay $80. If your doctor charged $100, you will pay $20. But if the doctor charged $105, you will pay $25.
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