Provision in Policies for Medical or Surgical Services

  1. Law
  2. Georgia Code
  3. Insurance
  4. Individual Accident and Sickness Insurance
  5. Provision in Policies for Medical or Surgical Services

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  1. The benefits on account of medical or surgical services provided by an individual policy of accident and sickness insurance may be limited by its terms to services performed by specifically defined professions, provided that in the absence of such definitions the term "physician" or "surgeon," as used in such policy, shall not be deemed limited solely to medical practitioners licensed under Chapter 34 of Title 43.
  2. When an individual policy of accident and sickness insurance, except policies providing special coverage for limited diseases, accident protection only, or dental policies, provides for hospital care, there may be included within the scope of coverage hospital care rendered on account of mental illnesses and hospital care rendered by any psychiatric hospital duly licensed by this state. If such coverage is not included in the policy, a statement that the policy does not cover mental illnesses shall be printed in the policy in boldface type or stamped on the face of the policy and printed or stamped on any identification card issued pursuant to any such policy.
  3. Any other laws to the contrary notwithstanding, whenever the term "physician" or "surgeon" is used in any policy of health or accident and sickness insurance issued in this state or in any contract for health care, services, or benefits existing under, and by virtue of, any laws of this state, said term shall include, within its meaning, medical practitioners licensed under and in accordance with Chapter 11 of Title 43, relating to dentists, in respect to any care, services, procedures, or benefits covered by said policy of insurance or health care contract which the said persons are licensed to perform, any provisions in any such policy of insurance or health care contract to the contrary notwithstanding. This subsection shall be applicable to all policies in this state, regardless of date of issue.

(Code 1933, § 56-3016, enacted by Ga. L. 1960, p. 289, § 1; Ga. L. 1970, p. 526, § 1; Ga. L. 1974, p. 436, § 1; Ga. L. 1980, p. 1251, § 1; Ga. L. 1981, p. 991, § 2; Ga. L. 1996, p. 6, § 33; Ga. L. 2019, p. 386, § 92/SB 133.)

The 2019 amendment, effective July 1, 2019, in subsection (c), in the first sentence, inserted "and sickness" near the middle, and deleted "issued by any health, medical, or other service corporation" following "services, or benefits" in the middle.

Editor's notes.

- Ga. L. 1970, p. 526, § 3, provides that no provision of Section 1 of Ga. L. 1970 "shall be construed to affect any policy issued prior to July 1, 1970."

OPINIONS OF THE ATTORNEY GENERAL

Limitation on reimbursement.

- Reimbursement mandated by this section is limited to a doctor's professional services and does not include facility costs. 1980 Op. Att'y Gen. No. 80-103.

Reimbursable fees of dentists must be for services performed at listed facilities.

- Reimbursement of the professional fees of dentists licensed pursuant to T. 43, Ch. 11 for medical and surgical procedures is mandated if performed at one of the types of outpatient facilities listed in this section. 1980 Op. Att'y Gen. No. 80-103.

RESEARCH REFERENCES

ALR.

- Infection through boil, or similar condition, as an accident or accidental means within accident policy, 24 A.L.R. 730.

Right of tortfeasor or liability insurer to credit for amounts already disbursed to injured party under medical payments or funeral expense clause in liability policy, 11 A.L.R.3d 1115.

Mental incapacity or disease as constituting total or permanent disability within insurance coverage, 22 A.L.R.3d 1000.

What constitutes a "hospital" within coverage or exclusionary clauses of hospitalization policy, 46 A.L.R.3d 1244.


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