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DEFINITION OF "ACCIDENT" VS "ILLNESS"

January 1, 2010

Q: Is there a descriptive definition of "accident" available somewhere? For example, if I step badly on a sidewalk and break my leg, is this considered an accident by this plan? Or are only automobile accidents covered?
 

A: Major medical insurance policies group expenses into two broad categories: "Accidents" and "Illnesses". The significant distinction is that illness had some history prior to the need for medical care. For example, a cancer treatment is provided after a history of symptoms emerge over time showing a medical problem. In contrast, an accident occurs suddenly, with no prior medical indication. One simplistic way to describe an "accident expense" is a medical expense that is not the result of an illness.

The distinction is made for legal purposes, particularly for the determination of coverage for "pre-existing medical conditions" since most policies do not automatically begin paying for problems and medical treatment that began before the start of the insurance.

Most automobile accidents are not covered by health insurance. Automobile accidents are primarily covered by automobile insurance, although the health insurance may kick in for catastrophic losses in the rare event that the auto insurance policy limits are exceeded.

All health insurance polices contain a more complete definition of these terms included in the section of the actual policy titled "Definitions". Some sample policies are available online at MedSave.com and health insurance buyers have the limited right to review the wording of their policy contract and cancel the contract, if necessary, without financial obligation. This is known as a "10 day right of refusal".

 


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