Emergency Benefits Clause Samples
Emergency Benefits. Benefits are available for Emergency Services received in the emergency room of a Hospital. The Emergency Benefit also includes Hospital admission when inpatient treatment of your Emergency Medical Condition is Medically Necessary. You can access Emergency Services for an Emergency Medical Condition at any Hospital, even if it is a Non-Participating Hospital. If you have a medical emergency, call 911 or seek immediate medical attention at the nearest hospital. Benefits include: • Physician services; • Emergency room facility services; and • Inpatient Hospital services to stabilize your Emergency Medical Condition. Once your Emergency Medical Condition has stabilized, it is no longer considered an emergency. Upon stabilization, you may: • Be released from the emergency room if you do not need further treatment; • Receive additional inpatient treatment at the Participating Hospital; or • Transfer to a Participating Hospital for additional inpatient treatment if you received treatment of your Emergency Medical Condition at a Non- Participating Hospital. Stabilization is medical treatment necessary to assure, with reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, your release from medical care or transfer from a facility. With respect to a pregnant woman who is having contractions, when there is inadequate time to safely transfer her to another Hospital before delivery or the transfer may pose a threat to the health or safety of the woman or unborn child, stabilize means delivery, including the placenta. Post-stabilization care is Medically Necessary treatment received after the treating Physician determines the Emergency Medical Condition is stabilized. If you are admitted to the Hospital for Emergency Services, you should notify your PCP within 24 hours or as soon as possible after your condition has stabilized.
Emergency Benefits. If the Member while covered under this Contract is treated in and/or admitted to a hospital as an emergency case, Kaiser agrees to cover all charges for the Basic Medical Benefits covered herein provided the Member or his representative notifies Kaiser within 24 hours from admission. Failure to do so however, shall not invalidate nor reduce the benefit under this Contract if it can be shown that it was not reasonably possible to do so within such time and that such advise was given as soon as it was reasonably possible. If the emergency treatment is rendered in an Accredited Hospital, Kaiser shall cover expenses up to the maximum amounts indicated in the Schedule of Benefits. If the emergency treatment is rendered in a non-accredited hospital, Kaiser shall cover 80% of expenses up to the maximum amounts indicated in the Schedule of Benefits. If professional services are rendered by a non-accredited physician, KIH shall be liable only for 80% of reasonable professional fees, but not to exceed the amount which Kaiser would have paid to an Accredited Physician. Kaiser reserves the right to transfer the Member to an Accredited Hospital when it is medically safe to do so. If the Member or his representative refuses to do so, Kaiser shall not be responsible for any expenses incurred after the day for which transfer has been recommended. entitled to an annual physical examination to be administered by an accredited service provider. The annual physical examination shall cover the following:
1. Physical examination, chest x-ray, stool examination, routine urinalysis, complete blood count
2. Electrocardiogram for Members above 35 and pap smear for female Members above 35 years old or as required.