Accidental Injury, Ambulances, Office Visits, Tests

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Jul 16, 2021

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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:

2. Outpatient Treatment of Accidental Injuries: Services Provided by Participating Providers in connection with the Outpatient treatment of Injuries received by an Insured.

3. Emergency Transportation to Hospital by Ambulance: Services Provided in connection with transportation of an Insured by either local ground ambulance or local air ambulance to the nearest Hospital that is a Participating Provider and appropriately staffed, equipped, available and suitable for the Emergency diagnosis, care and treatment of an Insured’s Injury or Sickness. However, expenses charged for transportation to a Hospital by air ambulance are not payable or otherwise considered covered, if such Insured’s medical condition was not sufficiently acute or severe upon arrival at the Hospital to result in Inpatient admission and Confinement in the Hospital immediately following the Insured’s evaluation and treatment in the emergency room of such Hospital.

4. Outpatient Provider Office Visits: Professional services Provided by a Participating Provider during a visit to the professional offices of such Provider for the purpose of evaluation, diagnosis and treatment of Injuries or Sickness.

5. Outpatient Laboratory and Diagnostic Tests: Services Provided by Participating Providers, Hospitals or other medical facilities in connection with the performance and interpretation of laboratory and diagnostic tests received on an Outpatient basis by an Insured due to Injuries or Sickness.

An “outpatient” is an insured who receives medically necessary medical care, treatment, services or supplies from a provider at:

  1. a clinic;
  2. an emergency room of a hospital;
  3. an ambulatory surgical center;
  4. an emergency care facility; or
  5. 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:

  1. the insured is transported to a hospital – not a clinic, an ambulatory surgical center or an emergency care facility; and
  2. 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.

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