Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-350 - Major medical expense coverage

Current through Register Vol. 24-14, July 15, 2024
(1) "Major medical expense coverage" is a
				disability insurance policy which provides hospital, medical and surgical
				expense coverage, to an aggregate maximum of not less than $10,000; copayment
				by the covered person not to exceed 25% of covered charges; a deductible stated
				on a per person, per family, per illness, per benefit period, or per year
				basis, or a combination of such bases not to exceed 5% of the aggregate maximum
				limit under the policy, unless the policy is written to complement underlying
				hospital and medical insurance in which case such deductible may be increased
				by the amount of the benefit provided by such underlying insurance, provided
				the policy containing such deductible meets the criteria of subsection (3) of
				this rule.
(2) The coverage for
				each covered person shall be for at least:
(a)
				Daily hospital room and board expenses, prior to application of the copayment
				percentage, for not less than $50 daily (or in lieu thereof the average daily
				cost of semiprivate room rate in the area where the insured resides) for a
				period of not less than 31 days during continuous hospital
				confinement;
(b) Miscellaneous
				hospital services, prior to application of the copayment percentage, for an
				aggregate maximum of not less than the greater of $1,500 or 15 times the daily
				room and board rate if specified in dollar amounts;
(c) Surgical services, prior to application
				of the copayment percentage, to a maximum of not less than $600 for the most
				severe operation with the amounts provided for other operations reasonably
				related to such maximum amount;
(d)
				Anesthesia services, prior to application of the copayment percentage, for a
				maximum of not less than 15% of the covered surgical fees or, alternatively, if
				the surgical schedule is based on relative values, not less than the amount
				provided therein for anesthesia services at the same unit value as used for the
				surgical schedule;
(e) In-hospital
				medical services, prior to application of the copayment percentage, as defined
				in WAC 284-50-340(3).
(f) Out of hospital care, prior to
				application of the copayment percentage, consisting of physicians' services
				rendered on an ambulatory basis where coverage is not provided elsewhere in the
				policy for diagnosis and treatment of sickness or injury, and diagnostic X ray,
				laboratory services, radiation therapy, and hemodialysis ordered by a
				physician; and
(g) Not fewer than
				three of the following additional benefits, prior to application of the
				copayment percentage, for an aggregate maximum of such covered charges of not
				less than $1,000:
(i) In-hospital private
				duty graduate registered nurse services;
(ii) Convalescent nursing home
				care;
(iii) Diagnosis and treatment
				by a radiologist or physio-therapist;
(iv) Rental of special medical equipment, as
				defined by the insurer in the policy;
(v) Artificial limbs or eyes, casts, splints,
				trusses or braces;
(vi) Treatment
				for functional nervous disorders, and mental and emotional disorders;
(vii) Out-of-hospital prescription drugs and
				medications.