Pennsylvania Code
Title 31 - INSURANCE
Part IV - Life Insurance
Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS
MINIMUM STANDARDS FOR BENEFITS
Section 88.165 - Major medical expense coverage
Current through Register Vol. 54, No. 44, November 2, 2024
A policy of "Major Medical Expense Coverage" provides hospital, medical, and surgical coverage as follows:
(1) The aggregate maximum is not less than $10,000 per covered person.
(2) The copayment by a covered person is not more than 25% of covered charges except that the copayment percentage applicable to paragraph (7) of § 88.166 of this title (relating to coverage of each covered person) may not be more than 50%.
(3) The deductible shall be stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of such bases. The deductible shall be not more than 5% of the maximum limit under the coverage unless the policy is written to complement underlying hospital and medical insurance in which case such deductible may be increased by the amount of the benefits provided by such underlying insurance. If the deductible includes benefits provided by underlying hospital and medical insurance, it shall be known as a variable deductible and shall be subject to the following requirements:
Your Major Medical Expense Policy is designed to coordinate its coverage with benefits provided under other medical expense coverage. This is done by a deductible amount' which is the flat amount of the Basic Deductible shown on page _____________ of your policy or the amount of benefits paid under other medical expense coverage if that is greater. If this feature of your policy is not understood contact your agent or the company immediately.
In the application attached to your policy, you were asked to furnish details of any other medical expense coverage applicable to Covered Persons under your policy so that your choice of the flat amount Basic Deductible could be an appropriate one under the circumstances. If the extent of such other coverage changes in the future, it may be that you should consider a change in the Basic Deductible amount in accordance with the provision of your policy entitled Privilege of Changing Basic Deductible.' In such event, we suggest that you get in touch with your agent or company, who will be glad to assist you.
(4) The maximum benefit period for an "each cause" type of policy, where a separate deductible is required for each sickness and accident, is not less than 18 months. The maximum benefit period for an "all cause" type of policy, where separate deductibles are not required for each sickness or accident, is not less than the number of days remaining in the calendar or policy year after the deductible has been met.
(5) The period allowed to satisfy the deductible shall be at least 90 days.
This section cited in 31 Pa. Code § 88.169 (relating to specified disease and specified accident coverage); 31 Pa. Code § 88.171 (relating to supplemental insurance coverage); and 31 Pa. Code § 88.190 (relating to major medical expense coverage form).
