§ 2220.25. Major Medical Expense Benefits.

MAJOR MEDICAL EXPENSE BENEFITS

A policy, or rider, shall be deemed to provide major medical expense benefits and shall be deemed to be of real economic value and not subject to Section 2220.15 through 2220.24 if:

(a) The aggregate maximum benefit is not less than $10,000 per covered person.

(b) The coinsurance percentage applicable to expenses covered under Items (f), (g), (h), (i) and (j) below is not more than 25 percent, and the coinsurance percentage applicable to Item (k) and any other covered expense not referred to in this section is not more than 50 percent.

(c) The deductible amount (other than as specified below in this section) is not more than 10 percent of the maximum benefit.

(d) The maximum benefit period for an “each cause” type of policy (where a separate deductible is required for different sicknesses and accidents) is not less than 18 months and the maximum benefit period for an “all cause” type of policy (where separate deductibles are not required for different sicknesses or accidents) is not less than the number of days remaining in the calendar or policy year after the deductible has been met.

(e) The period allowed to satisfy the deductible is not less than 90 days if the deductible is $500 or less, or is not less than 90 plus an additional 30 days for each additional $500, or fraction thereof, of deductible.

(f) Hospital room and board expenses are covered, prior to application of the coinsurance percentage, for not less than $50.00 daily (or in lieu thereof the cost of a semi-private room rate in the area where the insured resides), and is not less than either the cost or double the daily amount during confinement in the hospital's intensive care unit for up to 10 days.

(g) Miscellaneous hospital services are covered, prior to application of the coinsurance percentage, for an aggregate maximum of not less than $1,500.

(h) Surgical fees are covered, prior to application of the coinsurance percentage, to a maximum of not less than $750 for the most severe operation in accordance with a surgical schedule which otherwise meets the requirements of Section 2220.21; and anesthesia services are covered, prior to application of the coinsurance percentage, for a maximum of not less than 15 percent of the covered surgical fees, or, alternatively, if the surgical schedule is based on a California Relative Value Schedule, not less than the amount provided therein for anesthesia services at the same unit value as used for the surgical schedule.

(i) Doctors visits are covered, in or out of the hospital, with minimum dollar amounts per visit, prior to application of the coinsurance percentage, equal to not less than $8.00 per visit, covering not less than one visit per day and for an aggregate maximum of such covered charges of not less than $500.

(j) Out-of-hospital diagnostic X-rays and tests are covered, prior to application of the coinsurance percentage, for an aggregate maximum of not less than $500.

(k) Not fewer than three of the following additional benefits are covered, prior to application of the coinsurance percentage, for an aggregate maximum of not less than $1,000:

(1) In-hospital private duty registered nurse services.

(2) Convalescent nursing home care.

(3) Diagnosis and treatment by a radiologist or physiotherapist.

(4) Rental of special medical equipment, as defined by the insurer in the policy.

(5) Artificial limbs or eyes; casts, splints, trusses or braces.

(6) Treatment for functional nervous disorders, and mental and emotional disorders.

(7) Out-of-hospital prescription drugs and medications.

The deductible amount may be expressed as either: (1) a fixed dollar amount; or (2) the higher of a fixed dollar amount of basic deductible or the policy's covered charges paid by medical expense insurance; or (3) not more than $500 plus the policy covered charges paid by other medical expense insurance.

Notwithstanding the terminology of either this section, or any other section of this Article, this section shall not be interpreted in any manner which is or would be inconsistent with the provisions of any applicable section of the Insurance Code. A benefit under this section shall not be of real economic value to an insured person if any coinsurance percentage factor of the policy is applied as a reduction in benefits prior to application of any deductible.

If a policy, or rider, provides a fixed benefit (a benefit not subject to a coinsurance percentage) for any of the medical expenses referred to in (f), (h) or (i) above, a fixed benefit of 75 percent of the minimum covered charge specified in (f), (h) or (i) shall be acceptable; and, if coinsurance percentages of less than 25 percent are applicable, a lower covered charge will be acceptable if at least as much as 75 percent of the minimum covered charge specified in (f), (h) or (i).