Key Terms and Definitions

These are some of the terms used in your booklet.  Some other terms are described where they are used.  Please read them carefully.  It can help you to better understand your benefits.

Whenever a personal pronoun in the masculine gender is used, it includes the feminine, unless the context clearly indicates otherwise.

"Covered Charges" means the reasonable and customary charges which are incurred for the medically necessary treatment of conditions that are covered under this Plan.

"Day of Hospital Confinement" means a period of twenty-four (24) hours or less for which the hospital makes a full daily room and board charge.

"Dependent" means your spouse, and each of your unmarried children less than nineteen (19) years of age, excluding individual who is a full-time military, naval or air service.  A child who has attained age nineteen (19) will continue to be eligible as a dependent until the child's twenty-third (23rd) birthday if unmarried, a full-time student at an accredited college or technical school, and not eligible under any other plan.

The word "child" includes the following:

1. Your biological child;

2. A legally adopted child, including a child placed with you for the duration of the probationary period, without regard to whether the adoption becomes final;

3. A stepchild residing with you for whom you provide sole support (evidenced by federal income tax returns) where the applicable divorce decree does not obligate the other biological or legal parent to provide health care or health insurance coverage;

4. A child permanently residing in your household for whom you provide sole support, provided you are related to the child by blood or marriage and you have been granted legal custody by a court of record; and

5. Any child named in a Qualified Medical Child Support order satisfying all conditions outlined in the Omnibus Budget Reconciliation Act of 1993.

While your Dependent Coverage is in affect, newly acquired dependents automatically become Covered Individuals on the date they meet this definition of "dependent," subject to the effective date.  If you die, the eligibility of your dependents shall continue to the end of the normal termination date, as outlined in "Termination of Coverage".

"Dependent Coverage" means coverage under the Plan with respect to your dependents.

"Hospital" means an institution which:

1. is primarily engaged in providing, by or under the supervision of Physicians, inpatient diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation of injured, disabled or sick persons; and

2. maintains clinical records on all patients; and

3. has bylaws in effect with respect to its staff of Physicians; and

4. has a requirement that every patient be under the care of a Physician; and

5. provides twenty-four (24) hour nursing service rendered or supervised by a registered professional nurse; and

6. has in effect a hospital utilization review plan; and

7. is licensed pursuant to any state or agency of the state responsible for licensing Hospitals; and

8. has accreditation under on of the programs of the Joint Commission on Accreditation of Hospitals.

"Hospital" does NOT mean any institution, or part thereof, which is used principally as a rest facility, nursing facility, convalescent facility or facility for the aged.  It does NOT mean any institution that makes a charge that you or your dependents are not required to pay.  However, the term shall include any rehabilitative facility which is licensed by the state for the treatment of alcoholism or drug abuse.

"Illness" means a bodily sickness, disorder or disease.  The Plan treats pregnancy as if it were an illness for you or your eligible dependents.

"Injury" means all damage to you or your eligible dependent's body which is caused by an accident while this Plan is in force and which results directly and independently of all other causes in a loss covered under this Plan.

"Inpatient" is a Covered Individual who incurs a hospital charge for a day of hospital confinement in other than the outpatient department of the hospital.

"Medically Necessary" means the services, supplies, treatment and confinement must be generally recognized in the physician's profession as effective and essential for treatment of the injury or illness for which it is ordered and that they must be rendered at the appropriate level of care in the most appropriate setting based on diagnosis.  To be considered "Medically Necessary", the care must be based on generally recognized and accepted standards of medical practice in the United States and it must be the type of care that could not have been omitted without an adverse effect on the patient's condition or the quality of medical care.  In addition, services, treatment, supplies or confinement shall not be considered "Medically Necessary" if they are an Experimental Procedure, or if investigational or primarily limited to research in their application to the injury or illness; or if primarily for scholastic, educational, vocational or developmental training; or if primarily for the comfort, convenience or administrative ease of the provider or the patient or his or her family or caretaker.

The definition and determination of Medically Necessary shall not apply to any services which are covered under the Plan as preventive services.  Preventive services means those services and supplies used for routine physical examinations and any such other services which are not for the treatment of an injury or illness, but which are for prevention of disease and for maintenance of good health which may otherwise be covered under the Plan.

"Participant Coverage" means coverage under the Plan with respect to yourself.

"Physician" means a duly licensed doctor of medicine authorized to perform medical or surgical service within a lawful scope of his practice, and shall also include any other health care provider or allied practitioner   as mandated by State Law.

"Totally Disabled" when used in reference to the Health coverage means, with respect to you, that you, due solely to Injury or Illness, are prevented from engaging in your regular or customary occupation and you receive no remuneration for any other work or service.  With respect to a dependent, this means that he, due solely to Injury or Illness, is prevented from engaging in substantially all of the normal activities of a person of like age and like sex who is in good health.  This definition does NOT apply to Life Insurance.

"Usual, Reasonable and Customary" means the usual charge made by a person, a group or an entity which renders or furnishes the services, treatment or supplies that are covered under this Plan.  In no event does it mean a charge in excess of the general level of charges made by others who render or furnish such services, treatments or supplies to persons; (a) who reside in the same area and (b) whose illness is comparable in nature and severity.  The term "area" means a county or such greater area that is necessary to obtain a representative cross section of the usual charges made.