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RULE §3.3072 Minimum Standards for Basic Medical-Surgical Expense Coverage

Published: 2015

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(a) "Basic medical-surgical expense coverage" is a policy of accident and sickness insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:   (1) surgical services:     (A) in amounts not less than those provided on a fee schedule based on the relative values contained in the 1969 California Relative Value Schedule or other acceptable value scale of surgical procedures, up to a maximum of at least $500 for any on e procedure; or     (B) not less than 80% of the usual, customary and reasonable charges. Surgical schedules shall include a provision stipulating 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;
  (2) anesthetic services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician (or his or her assistant) performing the surgical services:     (A) in an amount not less than 80% of the usual, customary and reasonable charges; or     (B) 15% of the "surgical services" benefit;   (3) in-hospital medical services, consisting of attending 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:     (A) 80% of the usual, customary and reasonable charges; or     (B) $5.00 per call, one call per day, for at least 21 such calls during "one period of confinement";   (4) if obstetrical-surgical benefits are included within the
scope of policy coverage then the benefits for each covered pregnancy for obstetrical-surgical expenses incurred shall be based upon the relative value scale of surgical procedures referred to in paragraph (1) of this section. (b) Basic medical-surgical expense coverage must be guaranteed renewable in accordance with §3.3020 of this title (relating to Policy Definition of Guaranteed Renewable and Limited Guarantee of Renewability) and §3.3038 of this title (relating to Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical or Surgical Coverage; Exceptions) of this subchapter, unless such insurance constitutes short-term limited duration coverage, as defined in §3.3002(b)(18) of this title (relating to Definitions).

Source Note: The provisions of this §3.3072 adopted to be effective January 26, 1977, 2 TexReg 159; amended to be effective January 2, 1978, 2 TexReg 4943; amended to be effective December 22, 1997, 22 TexReg 12503.