Catastrophe Major Medical Insurance
Product Information
Group Catastrophe Major Medical Insurance is an AICPA-sponsored plan that supplements your basic health insurance by paying up to $2,000,000* in expenses and out-of-network services not covered by your basic insurance. NY residents click here for Plan information and enrollment.
This plan works two ways. Once you have satisfied your deductible for this Plan, it covers your eligible medical expenses that your basic health plan doesn't. Or, if your basic health insurance requires you to use a network, you can go out of the network and this plan will cover those expenses once you reach your deductible.
To find out more about the origins of Catastrophe Major Medical Coverage, read the following white paper
(19k) that includes three sample illustrations of the insurance benefit calculations.
Basic Plan
"Basic Plan" means a plan that provides benefits or services on a primary basis for, or by reason of, hospital, surgical or medical care or treatment. The plan must provide benefits at least as great as the following: semi-private room and board of $300 per day for 70 days; $25,000 for extra services; a $5,000 surgical schedule; and a lifetime maximum benefit of $1,000,000.
Medicare parts A and B qualify as a basic health insurance plan.
Deductible
Once you have satisfied your deductible - the greater of the benefits paid by your basic plan or $25,000 for Plan I, $50,000 for Plan II, or $100,00 for Plan III- this plan will pay up to 100% of the reasonable and customary covered charges until you meet the maximum of $2,000,000 for each benefit period.
You can use covered expenses paid by your basic health insurance or Medicare to meet this deductible. You can use hospital and doctor bills, home health care and other medical expenses.
Exclusions
Charges that result from a war or an act of war; intentionally self-inflicted injury; services given by a member's spouse or his or her spouse's father, mother, son, daughter, brother or sister; or services given by a member's employer or an employee of such employer; treatment after your insurance ends regardless of when the sickness or injury occurred; treatment that is not essential for the necessary care or treatment of the injury or sickness involved; treatment that would be given free of charge if you weren't insured.
Accumulation Period
You have 36 consecutive months to accumulate covered medical expenses in order to satisfy your deductible.
Benefit Period
Benefits are payable starting on the date you incur charges for an injury or sickness in excess of the deductible. The benefit period will begin on the date on which the first covered charge is incurred that is used to satisfy the deductible during the deductible accumulation period.
Once you have satisfied your deductible, this plan will pay benefits until one of the following occurs: the date the applicable maximum benefit has been paid; the end of the benefit period (5 years); or the end of a period of 12 consecutive months during which no charge is incurred for the injury or sickness. A new deductible will be required when the benefit period expires.
Convalescent Home Care
If you need care in a convalescent home (skilled nursing facility) due to a non-job related injury or sickness, you may collect up to $500 a week ($78,000 while insured).
The confinement must begin within 14 days after hospitalization ends and must be due to the injury or sickness which required the hospitalization.
NOTE: CONVALESCENT HOME means a licensed institution that has on its premises: organized facilities to care for and treat its patients, a staff of physicians to supervise such care and treatment, and a registered nurse on duty at all times.
"Convalescent home" does not mean a place, or part of one, which is used mainly for: the aged, alcoholics; drug addicts, persons with mental, nervous or emotional disorders.
Nursing Care
Charges for private duty nursing must be made by a registered nurse or a licensed practical nurse who is not a member of your immediate family or household.
Psychiatric, Mental, Nervous or Emotional Disorder, Alcohol or Drug Abuse Treatment
If you receive care while hospitalized, you will be eligible for benefits up to an amount equal to your deductible, which is either $25,000, $50,000, or $100,000 depending on the plan option you select.
Charges Not Covered
Charges to buy or rent air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, eye glass frames or lenses, hearing aids, swimming pools or supplies for them, general exercise equipment.
Charges for a routine physical exam, except charges for preventive mammography and cytologic screening.
Charges for dental care, treatment or surgery services will be covered only if they result from a non-job related injury to natural teeth, the injury is caused by an accident which occurs while you are insured, and such services are rendered within 12 months of the accident or they are made by a hospital while you are hospitalized. Charges for treatment for temporomandibular joint dysfunction (TMJ) services will be covered, except for those charges for crowns or bridgework. Charges for eye exams to prescribe or fit corrective lenses for eye glasses will be covered only if the charges result from a non-job related injury and the injury is caused by an accident which occurs while you are insured. Charges for cosmetic treatment or surgery services will be covered only if they result from a non-job related injury or sickness or a congenital disease or anomaly of a dependent child resulting in a functional defect.
If you are not covered under a basic plan at time of claim, the following charges will not be covered: hospital charges incurred during the first 70 days of each confinement; the first $10,000 of charges for chemotherapy, radiation therapy, physical therapy or speech therapy that would otherwise be covered; the first $50,000 of charges for physician services that would otherwise be covered; and the first $2,500 of charges for prescription drugs while not hospitalized that would otherwise be covered.
Pre-existing Conditions
A pre-existing condition is any injury or sickness for which you incurred charges, received medical treatment, consulted a physician, or took prescribed drugs during the 12-month period prior to the day your insurance becomes effective.
Pre-existing conditions are not covered unless you have gone 12 continuous months (while insured) without incurring charges, receiving medical treatment, consulting a physician or taking prescribed drugs for such conditions or any complication of it, or until your coverage has been in force for 24 continuous months, whichever comes first.
Filing a Claim
You will file all claims directly with the insurance company. Once they have all the information they need from you, they will take care of all the paperwork, coordination of benefits, etc. You will receive payment for eligible claims directly from the insurance company.
*Subject to New York policy restrictions and coverage limits.
Coverage not available in: AZ, KY, MA, NJ, OR, VT, WA, Puerto Rico and the US Virgin Islands.
Underwritten by The United States Life Insurance Company in the City of New York
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