Question

Zach Carey was approximately week. One day, while cleaning windows on the eighth floor of the Second National Bank Building, I have tripped and fell from the scaffolding to the pavement below. He has suffered severe multiple injuries but miraculously survived the accident. I was immediately rushed to the local hospital for surgery. I have remained there for 60 days of treatment, after which I was allowed to go home for further recovery. During his hospital stay, I incurred the following expenses: surgeon, $ 2,500; physician, $ 1,000; hospital bill for room and board, $ 250 per day; nursing services, $ 1,200; anesthetics, $ 600; wheelchair rental, $ 100; ambulance, $ 150; and drugs, $ 350. Zach has a major medical policy with Medical Benefits Corporation that has a $ 3,000 deductible clause, an 80 percent co-insurance clause, internal limits of $ 180 per day in hospital room and board, and $ 1,500 as a maximum surgical fee. The policy provides no disability income benefits. Your assignment is to Zach Carey's medical insurance program. After reading his situation there are four questions. I want to answer question 4. However, the type of information requested in questions 1-3 is what should be considered in answering question 4.

1. Explain the policy provisions as they relate to deductibles, co-insurance, and internal limits.

2. How much should Zach recover from the insurance company? How much must I pay out of his own pocket?

3. Would any other policies have offered Zach additional protection? What about his inability to work while recovering from his injury?

4. Based on the information presented, how would you assess Zach's health care insurance coverage? Explain

Answer 1

1.   Explain the policy provisions as they relate to deductibles, co-insurance, and internal limits.

Ans.Deductibles are the cost that the insured person must pay before insurance covers the rest of the expenses. Co-Insurance is a provision that the insurer will pay a portion of the excess of the deduction. Internal limits are limits for certain expenses which the insurance will not pay.

2.   How much should Zach recover from the insurance company? How much must he pay out of his own pocket?

Ans.Insurance: $15,700, Out-of-Pocket: $5,200

3.   Would any other policies have offered Zach additional protection? What about his inability to work while recovering from his injury?

Ans.Comprehensive major medical coverage, disability income coverage, and rehabilitation coverage.

4.   Based on the information presented, how would you assess Zach’s health care insurance coverage? Explain.

Ans.It is coverage, but it is not the best. He should go for something that will allow him to use any services that are out-of-network.