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Generally, each individual member of a group who purchased
insurance from petitioner could elect the type of insurance
benefit and the type of insurance coverage that would be
applicable.
We use the word “benefit” herein to distinguish between
insurance that was applicable to an individual only, to an
individual as a parent with one or more dependents, or to an
individual as a parent with a spouse and children (family).
We use the word “coverage” herein to distinguish between the
different types of medical costs that, as of January 1, 1987,
were reimbursable by petitioner under the various group contracts
as follows.
Under basic medical, the costs of basic medical services
performed by “professional providers” (e.g., doctors, dentists,
optometrists, and physical therapists) were covered.
Under basic hospital, the costs of basic hospital services
such as inpatient and outpatient services obtained in hospitals
or in surgical centers were covered.
Under major medical, major medical services not covered
under basic medical and basic hospital were covered. Major
medical also covered a portion of the costs of prescription
drugs.
2(...continued)
individual members of each group.
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