Page 12 - AtlasGroup_Specimen
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SPECIMENd. Requires urgent care.
YOU ARE NOT COVERED unless you fulfill the following condition:
1. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.
YOU ARE NOT COVERED IF:
1. The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or
2. The pre-existing condition is a chronic or congenital condition or that gradually becomes worse
over time; or
3. The charges are for known, scheduled, required, or expected medical care, drugs or treatments
existent or necessary prior to the certificate effective date; or
4. Expenses arise directly or indirectly from anything in the General Exclusions.
MEDICAL & REPATRIATION EXPENSES
Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and
restrictions contained in this provision, we will pay the following expenses incurred while this
insurance is in effect.
MEDICAL 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. Emergency treatment of an injury, even if hospital confinement is not required; and
f. 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.
12 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
YOU ARE NOT COVERED unless you fulfill the following condition:
1. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.
YOU ARE NOT COVERED IF:
1. The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or
2. The pre-existing condition is a chronic or congenital condition or that gradually becomes worse
over time; or
3. The charges are for known, scheduled, required, or expected medical care, drugs or treatments
existent or necessary prior to the certificate effective date; or
4. Expenses arise directly or indirectly from anything in the General Exclusions.
MEDICAL & REPATRIATION EXPENSES
Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and
restrictions contained in this provision, we will pay the following expenses incurred while this
insurance is in effect.
MEDICAL 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. Emergency treatment of an injury, even if hospital confinement is not required; and
f. 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.
12 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
