Limited Pre-Existing Condition Coverage for Heart Attack/Stroke: $200/night; $3,000 max.
Liaison Majestic includes limited coverage for a heart attack or stroke relating to a pre-existing condition. Knowing what a pre-existing condition is will help you understand what could be covered.
A pre-existing condition shall mean any medical condition, Sickness, Injury, Illness, Disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any Congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or any time during the 36* months prior to the Effective Date of Coverage under this Certificate, whether or not previously manifested , symptomatic, known, diagnosed , treated or disclosed. This specifically includes but is not limited to any medical condition, Sickness, Injury, Illness, Disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or Treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the 36 month period immediately preceding the Effective Date of Coverage under this Certificate.
*For Insured Persons traveling outside the United States, the period is 12 months instead of 36 months.
This $200 per night benefit is only for the admission into the hospital due to a heart attack or stroke caused by pre-existing conditions. It works like an indemnity benefit and is not considered as a covered medical expense. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of the plan. In other words, it does not provide any coverage for heart surgery, heart medicines, blood pressure medicines or complications, routine expenses, emergency room visits due to chest pain, etc. Therefore, there are no network negotiated fees for the rest of expenses.
Limited Pre-Existing Condition Coverage for Heart Attack/Stroke
If you are a non-United States Resident and suffer a Myocardial Infarction or Stroke and are admitted to a Hospital, the pre-existing condition exclusion is waived only in order to pay a $200 per night benefit for each night spent in the Hospital, up to the maximum stated in the SCHEDULE OF BENEFITS. The term “Myocardial Infarction” shall require an acute and emergent onset of the condition. The term “Stroke” shall require an acute and emergent onset of the condition.
Let's assume that you are admitted into the hospital for 3 days because of a heart attack and the medical expense is $25,000/night for a total of $75,000 in medical expenses. Lets assume that the network negotiated fees for the same would be $10,000/night for a total of $30,000. If it were a covered medical expense (not due to pre-existing conditions), insurance company would pay entire $30,000 (subject to your deductible and coinsurance). However, if it is determined that the heart attack was due to pre-existing conditions, the insurance company would pay a total of $600 (Six hundred dollars) and you would have to pay the remaining $74,600.