Hassle-Free Health Coverage: How to Buy the Right Medical by Silver Lake Editors

By Silver Lake Editors

Either a primer and a dealers advisor, it bargains up to date details and sensible suggestion.

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56 CHAPTER 4: THE MAJOR MEDICAL APPROACH TO HEALTH CARE For example, a plan with a $250 deductible and an 80/20 percent co-insurance split on the next $2,500 of covered expenses would result in a total out-ofpocket expense to the insured of $750—the $250 deductible plus 20 percent of $2,500. The stoploss provision establishes the maximum out-ofpocket expense to you to be equal to the deductible plus the your co-insurance amount. The out-of-pocket maximum is a major consideration when you are shopping for a policy.

You can also file a complaint with your state’s Department of Commerce (or equivalent agency)—and you don’t have to tell your insurance company first. You will have to fill out a complaint form and supply any information needed to support your position to the Department. Department investigators will usually then contact your insurance company; and, if the problem cannot be resolved within about 10 days, they will investigate whether the insurance company followed the terms of your policy. SUMMARY In today’s business world, employers have come to rely on managed care at the expense of traditional indemnity insurance.

Approved providers (a group slightly less rigidly defined than network providers in a managed care plan) would agree to accept these fees as full payment for each service provided—within the policy’s limits, of course. 40 CHAPTER 3: HOW TRADITIONAL INDEMNITY INSURANCE WORKS This trend has caught on with indemnity companies to the point they are quite common. UCR fees don’t get a lot of attention in the insurance industry—which is curious. They are a big reason that the distinctions between indemnity insurance and managed care are beginning to blur.

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