§ 88.163. Basic medical-surgical expense coverage.
A policy which provides ‘‘Basic Medical-Surgical Expense Coverage’’ is defined as providing coverage for each person insured under the policy for the expense incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:
(1) Surgical services on a fee schedule basis with a maximum of $350 based on an acceptable relative value scale of surgical procedures.
(2) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician other than the physician or his assistant performing the surgical services, to a minimum of 15% on an expense incurred basis of the surgical service benefit provided.
(3) In-hospital medical services, consisting of 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 $5.00 per call, one call per day, for at least 21 such calls during ‘‘one period of confinement.’’
(4) Surgical schedules contained in the policy shall include a provision providing 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.
(5) Two or more surgical procedures performed on the same surgical occasion and through the same incisions shall be covered to the extent that payment is provided for the most expensive procedure. Operations performed during the same surgical session, but not through the same incision, shall be covered to the extent that 100% payment is provided for the most expensive operation and 50% payment for the remaining total.
(6) Whenever a policy is written that provides at least the coverages required for both basic hospital expense coverage and basic medical-surgical expense coverages, the allowable deductible may be applied to the combined coverage.
Cross References This section cited in 31 Pa. Code § 88.169 (relating to specified disease and specified accident coverage); 31 Pa. Code § 88.171 (relating to supplemental insurance coverage); 31 Pa. Code § 88.187 (relating to basic medical-surgical expense coverage form); and 31 Pa. Code § 88.188 (relating to basic hospital and medical-surgical expense form).
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