Page 10 - AtlasEssential
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SPECIMENMEDICAL EXPENSES
YOU ARE COVERED:
1. Charges made by a hospital for:
a. Daily room and board and nursing services not to exceed the average semi-private room rate;
and
b. Daily room and board and nursing services in Intensive Care Unit; and
c. Use of operating, treatment or recovery room; and
d. Services and supplies which are routinely provided by the hospital to persons for use while
inpatients; and
e. Prescription drugs administered while inpatient for treatment of a covered injury or illness;
and
f. Emergency treatment of an injury, even if hospital confinement is not required; and
g. Emergency treatment of an illness; subject to emergency room co-pay as outlined in the
Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to
the hospital as inpatient for further treatment of that illness.
2. Surgery at an outpatient surgical facility, including services and supplies.
3. Charges made by a physician for professional services, including surgery. Charges for an
assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the
primary surgeon, but standby availability will not be deemed to be a professional service and
therefore is not covered hereunder.
4. Dressings, sutures, casts or other supplies which are medically necessary and administered by
or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic
supplies, other supplies for use or application at home, and all devices or supplies for repeat use
at home, except durable medical equipment.
5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric,
intelligence, behavioral and educational testing are not included).
6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the
replacement or repair thereof.
7. Reconstructive surgery when the surgery is directly related to surgery which is covered
hereunder.
8. Hemodialysis and the charges by the hospital for processing and administration of blood or blood
components but not the cost of the actual blood or blood components.
9. Oxygen and other gasses and their administration by or under the supervision of a physician.
10. Anesthetics and their administration by a physician.
11. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
12. Home nursing care in bed by a qualified licensed professional, provided by a home health care
agency upon direct transfer from an acute care hospital and only in lieu of medically necessary
inpatient hospitalization.
13. Emergency local ambulance transport necessarily incurred in connection with injury or illness
resulting in inpatient hospitalization.
14. Emergency dental treatment and dental surgery necessary to restore or replace sound natural
teeth lost or damaged in an accident which was covered under this insurance.
15. Medically necessary rental of durable medical equipment (consisting of a standard basic
hospital bed and or a standard basic wheelchair) up to the purchase prices.
16. Physical therapy while inpatient if prescribed by a physician who is not affiliated with the
physical therapy practice, necessarily incurred to continue recovery from a covered injury or
illness.
17. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded
under this insurance.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
10 Atlas Essential Description of Coverage | Tokio Marine HCC - MIS Group
YOU ARE COVERED:
1. Charges made by a hospital for:
a. Daily room and board and nursing services not to exceed the average semi-private room rate;
and
b. Daily room and board and nursing services in Intensive Care Unit; and
c. Use of operating, treatment or recovery room; and
d. Services and supplies which are routinely provided by the hospital to persons for use while
inpatients; and
e. Prescription drugs administered while inpatient for treatment of a covered injury or illness;
and
f. Emergency treatment of an injury, even if hospital confinement is not required; and
g. Emergency treatment of an illness; subject to emergency room co-pay as outlined in the
Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to
the hospital as inpatient for further treatment of that illness.
2. Surgery at an outpatient surgical facility, including services and supplies.
3. Charges made by a physician for professional services, including surgery. Charges for an
assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the
primary surgeon, but standby availability will not be deemed to be a professional service and
therefore is not covered hereunder.
4. Dressings, sutures, casts or other supplies which are medically necessary and administered by
or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic
supplies, other supplies for use or application at home, and all devices or supplies for repeat use
at home, except durable medical equipment.
5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric,
intelligence, behavioral and educational testing are not included).
6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the
replacement or repair thereof.
7. Reconstructive surgery when the surgery is directly related to surgery which is covered
hereunder.
8. Hemodialysis and the charges by the hospital for processing and administration of blood or blood
components but not the cost of the actual blood or blood components.
9. Oxygen and other gasses and their administration by or under the supervision of a physician.
10. Anesthetics and their administration by a physician.
11. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
12. Home nursing care in bed by a qualified licensed professional, provided by a home health care
agency upon direct transfer from an acute care hospital and only in lieu of medically necessary
inpatient hospitalization.
13. Emergency local ambulance transport necessarily incurred in connection with injury or illness
resulting in inpatient hospitalization.
14. Emergency dental treatment and dental surgery necessary to restore or replace sound natural
teeth lost or damaged in an accident which was covered under this insurance.
15. Medically necessary rental of durable medical equipment (consisting of a standard basic
hospital bed and or a standard basic wheelchair) up to the purchase prices.
16. Physical therapy while inpatient if prescribed by a physician who is not affiliated with the
physical therapy practice, necessarily incurred to continue recovery from a covered injury or
illness.
17. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded
under this insurance.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
10 Atlas Essential Description of Coverage | Tokio Marine HCC - MIS Group
