Only such expenses incurred as a result of and within 52 weeks from a Disablement, which shall mean an Illness or an accidental bodily Injury necessitating medical treatment, and which are specifically enumerated in the following list of charges:
- Charges made by a Hospital for room and board, floor nursing and other services, including charges for professional services, except personal services of a non-medical nature, provided, however, that expenses do not exceed the Hospital's average charge for semi-private room and board accommodation, or two (2) times the average semi-private room charge if confinement to an intensive care unit is required, or the actual charge for an intensive care unit made by the servicing Hospital, whichever is less;
- Charges made for diagnosis, treatment and surgery by a Physician;
- Charges made for the cost and administration of anesthetics;
- Charges for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs, and medical treatment;
- Charges for physiotherapy, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist;
- Hotel room charge, when the Insured, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond the control of the Insured;
- Dressings, drugs, and medicines that can only be obtained upon written prescription of a Physician.
With regard to chiropractic care, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed chiropractor, 80% of eligible charges up to $35.00 per visit, with a maximum of 10 visits per Injury or Illness is allowable. The charges enumerated above shall in no event include any amount of such charges which are in excess of regular and customary charges. A charge incurred by an Insured shall be deemed a regular and customary charge for the services and supplies for which the charge is made if it is not in excess of the average charge for such services and supplies in the locality where received, considering the nature and severity of the Illness or bodily Injury in connection with which such services and supplies are received. If the charge incurred is in excess of such average charge such excess amount shall not be recognized as Covered Expenses. All charges shall be deemed to be incurred on the date such services or supplies which give rise to the expense or charge are rendered or obtained.