Current through Reg. 50, No. 13; March 28, 2025
(a) "Basic medical-surgical expense coverage"
is a policy of accident and sickness insurance which provides coverage for each
person insured under the policy for the expenses incurred for the necessary
services rendered by a physician for treatment of an injury or sickness for at
least the following:
(1) surgical services:
(A) in amounts not less than those provided
on a fee schedule based on the relative values contained in the 1969 California
Relative Value Schedule or other acceptable value scale of surgical procedures,
up to a maximum of at least $500 for any on e procedure; or
(B) not less than 80% of the usual, customary
and reasonable charges. Surgical schedules shall include a provision
stipulating coverage for procedures not specifically listed in the schedules
and not otherwise excluded by the policy, and benefits therefore shall be
consistent with the benefits for comparable procedures;
(2) anesthetic services, consisting of
administration of necessary general anesthesia and related procedures in
connection with covered surgical services rendered by a physician other than
the physician (or his or her assistant) performing the surgical services:
(A) in an amount not less than 80% of the
usual, customary and reasonable charges; or
(B) 15% of the "surgical services"
benefit;
(3) in-hospital
medical services, consisting of attending physician services rendered to a
person who is a bed patient in a hospital for treatment of sickness or injury
other than that for which surgical care is required, in an amount not less
than:
(A) 80% of the usual, customary and
reasonable charges; or
(B) $5.00
per call, one call per day, for at least 21 such calls during "one period of
confinement";
(4) if
obstetrical-surgical benefits are included within the scope of policy coverage
then the benefits for each covered pregnancy for obstetrical-surgical expenses
incurred shall be based upon the relative value scale of surgical procedures
referred to in paragraph (1) of this section.
(b) Basic medical-surgical expense coverage
must be guaranteed renewable in accordance with §
3.3020 of this title (relating to
Policy Definition of Guaranteed Renewable and Limited Guarantee of
Renewability) and §
3.3038 of this title (relating to
Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical
or Surgical Coverage; Exceptions) of this subchapter, unless such insurance
constitutes short-term limited duration coverage, as defined in §
3.3002(b)(18) of
this title (relating to Definitions).
