§ 88.190. Major medical expense coverage form.
An outline of coverage, in the form prescribed in this section, shall be issued in connection with policies meeting the standards of § 88.165 of this title (relating to major medical expense coverage). The items included in the outline must appear in the sequence prescribed:
(COMPANY NAME)
(HOME OFFICE ADDRESS)
MAJOR MEDICAL EXPENSE COVERAGE
REQUIRED OUTLINE OF COVERAGE(1) Read Your Policy Carefully—This outline provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provision will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
(2) Major Medical Expense Coverage—Policies of this category are designed to provide, to persons insured, coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, out of hospital care, and prosthetic appliances, subject to any deductibles co-payment provisions, or other limitations which may be set forth in the policy. Basic hospital or basic medical insurance coverage is not provided. (*NOTE: Immediately preceding sentence may be appropriately modified, if necessary, to reflect coverage provided.)
(3) (A brief specific description of the benefits contained in this policy, in the following order:
(a) Daily hospital room and board;
(b) Miscellaneous hospital services;
(c) Surgical services;
(d) Anesthesia services;
(e) In-hospital medical services;
(f) Out of hospital care;
(g) Prosthetic appliances; and
(h) Other benefits, if any.
*NOTE: The above description of benefits shall be stated clearly and concisely, and shall include a description of benefit amounts, durations or limits, elimination periods, inner limits, deductible or co-payment provisions and any other items appropriate to the coverage provided.)
(4) (A description of the exceptions, reductions and limitations contained in the policy or contract, including the pre-existing conditions provisions, if any, and the circumstances under which any reduction becomes operative.)
(5) (A description of the terms and conditions of renewability of the policy or contract, including any limitation by age, time or event, rights to change premium, status requirements and any other matters appropriate to the terms and conditions of renewability (including any right of cancellation reserved to the insured).)
Cross References This section cited in 31 Pa. Code § 88.171 (relating to supplemental insurance coverage).
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