Major medical coverage is the main coverage that we offer at East Coast Health Insurance. We don’t believe in the other kinds of health insurance unless they are used in tandem with a major medical policy. Major medical is used to cover against catastrophic losses. Back in the 30’s and 40’s this was the only type of health insurance one could buy actually. Though the definition is used more loosely now and the term major medical is used to cover the most comprehensive plan to the highest deductible on the market.
The typical plan that we sell at East Coast Health Insurance provides broad coverage for most expenses relating to a covered sickness or injury, and also includes benefits payable for services performed in the doctor’s office, in a hospital, or at home. Coverage thus includes hospital room and board, physicians and surgeons fees; operating room, medical expenses including lab, transfusions (though you can probably find some small print exclusions on transfusions on some policies), drugs, medicines, x-rays, anesthetics and nursing services.
The major medical policy is usually inclusive of a deductible and coinsurance. They also used to include a maximum of coverage, but since health reform passed, that is no longer the case. Other than that, there should be no other limits on coverage. But because some companies have substandard coverage you might find limits on daily hospital room charges and surgical services. However, most of these fees are already negotiated with the service provider and should be covered fully after the deductible. To be clear however, according to Florida law, Major Medical policies may include deductibles of up to 10% of the maximum limit and coinsurance percentages of 20 or 25%.
So in actual practice if someone has an accident where the insured sustains $5,000 in expenses for one illness, the insured will meet their deductible first and then will pay 10-30% of the rest of the bill in coinsurance. So if the insured has a $1,000 deductible and 20% coinsurance, the insured will pay $1,800 and the insurance company pays the rest of $3,200.
Common Major Medical Exclusions
- Occupation injury or disease if Workers Compensation applies.
- Childbirth, normal pregnancy and elective abortion or elective caesarean.
- Treatment in a government hospital.
- Intentionally self-inflicted injury.
- Dental expenses (except from the result of an accident)
- Mental Illness (may be covered as an option on individual plans)
- Injuries as a crew member of an aircraft
- Cosmetic surgery
Individuals who have had a recurring ailment may still be eligible for major medical coverage at standard rates. Generally the policy is issued with a rider excluding coverage for the specific condition in question.