:: The following are terms related to health insurance. Feel free to call or email us anytime for clarification on any word of subject related to this field. we are here to help!

Accidental Injury means an accidental bodily Injury sustained by an Insured Person which is the direct cause of a loss independent of disease, bodily infirmity, or any other cause.

Age means the Insured Person's attained age.

Alcoholism means a disorder characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning, also termed alcohol abuse or, if tolerance or withdrawal is present, alcohol dependence.

Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It also must meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

Authorization means that the Insurer has approved specific services performed by specific providers as Covered Services prior to the services being rendered. Authorized services are subject to all other limitations and conditions of this Plan. Authorization is required before certain services are eligible for maximum benefits.

Certificate of Coverage is the document issued to each Eligible Participant outlining the benefits under the group Policy.

Co-insurance is the percentage of Covered Expenses the Insured Person is responsible for paying (after the applicable Deductible is satisfied and/or Co-payment paid). Coinsurance does not include charges for services that are not Covered Services or charges in excess of Covered Expenses. These charges are the Insured Person's responsibility and are not included in the Coinsurance calculation.

Complications of Pregnancy are conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from the pregnancy, but are adversely affected by the pregnancy, including, but not limited to acute nephritis, nephrosis, cardiac decompression, missed abortion, pre-eclampsia, intrauterine fetal growth retardation, and similar medical and surgical conditions of comparable severity. Complications of Pregnancy also include termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible. Complications of Pregnancy do not include elective abortion, elective cesarean section, false labor, occasional spotting, morning sickness, physician prescribed rest during the period of pregnancy, hyperemesis gravidarium, and similar conditions associated with the management of a difficult pregnancy not constituting a distinct complication of pregnancy.

Continuing Hospital Confinement means consecutive days of in-hospital service received as an inpatient, or successive confinements for the same diagnosis, when discharge from and readmission to the Hospital occurs within 24 hours.

Co-payment is the dollar amount of Covered Expenses the Insured Person is responsible for paying. Copayment does not include charges for services that are not Covered Services or charges in excess of Covered Expenses.

Cosmetic and Reconstructive Surgery. Cosmetic Surgery is performed to change the appearance of otherwise normal looking characteristics or features of the patient's body. A physical feature or characteristic is normal looking when the average person would consider that feature or characteristic to be within the range of usual variations of normal human appearance. Reconstructive Surgery is surgery to correct the appearance of abnormal looking features or characteristics of the body caused by birth defects, Injury, tumors, or infection. A feature or characteristic of the body is abnormal looking when an average person would consider it to be outside the range of general variations of normal human appearance. Note: Cosmetic Surgery does not become Reconstructive Surgery because of psychological or psychiatric reasons.

Country of Assignment means the country for which the Eligible Participant has a valid passport and, if required, a visa, and in which he/she is working and/or residing.

Course of Treatment is a planned, structured, and organized sequence of treatment procedures based on an individualized evaluation to restore or improve health function, or to promote chemical free status. A Course of Treatment is complete when the patient has finished a series of treatments without a lapse in treatment or has been medically discharged. If the Insured Person begins a series of treatments, it will count as one course of treatment, reducing the available benefits, even if the patient fails to comply with the treatment program for a period of 30 days.

Covered Expenses are the expenses incurred for Covered Services. Covered Expenses for Covered Services received from Participating Providers will not exceed the Negotiated Rate. Covered Expenses for Covered Services received from Non-Participating Providers will not exceed Reasonable Charges. In addition, Covered Expenses may be limited by other specific maximums described in this Plan under Section IV, How the Plan Works and Section V, Benefits - What the Plan Pays. Covered Expenses are subject to applicable Deductibles, penalties and other benefit limits. An expense is incurred on the date the Insured Person receives the service or supply.

Covered Services are Medically Necessary services or supplies that are listed in the benefit sections of this Plan, and for which the Insured Person is entitled to receive benefits.

Creditable Coverage means coverage provided under: a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 101 et seq.); a group health benefit plan provided by a health insurance carrier or health maintenance organization; an individual health insurance policy or evidence of coverage; Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1395c et seq.); Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s); Chapter 55, Title 10, United States Code (10 U.S.C. Section 1071 et seq.); A medical program of the Indian Health Service or of a tribal organization; A state or political subdivision health benefits risk pool; A health plan offered under Chapter 89, Title 5, United States Code (5 U.S.C. Section 8901 et seq.) A public health plan as defined by federal regulations; A health benefit plan under Section 5 (e), Peace Corps Act (22 U.S.C. Section 2504 (e)).

Custodial Care is care provided primarily to meet the Insured Person's personal needs. This includes help in walking, bathing, or dressing. It also includes preparing food or special diets, feeding, administration of medicine that is usually self-administered, or any other care that does not require continuing services of a medical professional.

Deductible means the amount of Covered Expenses the Insured Person must pay for Covered Services before benefits are available to him/her under this Plan. The Annual Deductible is the amount of Covered Expenses the Eligible Participant must pay for each Insured Person before any benefits are available regardless of provider type.

Dental Prostheses are dentures, crowns, caps, bridges, clasps, habit appliances, and partials.

Drug Abuse means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

Effective Date of the Policy is the date that the Group's or Trust's Policy became active with the Insurer.

Effective Date of Coverage is the date on which coverage under this Plan begins for the Eligible Participant and any other Insured Person.

Experimental / Investigational Procedures. Any medical, surgical, and/or other procedures, services, products, drugs or devices, (including implants) are considered experimental or investigational if; Its use is mainly limited to laboratory and/or research; or it has not been given approval for marketing by the United States Food & Drug Administration at the time it is furnished and such approval is required by law; or reliable evidence shows it is the subject of ongoing phase I, II or III clinical trials or under study to determine if maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the state or means of treatment or diagnosis; or reliable evidence shows that the consensus of the opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the stated means of treatment of diagnosis; or reliable evidence shows that it is not generally approved or used by Physicians in the medical community; or it does not have final approval from the appropriate governmental regulatory body. Reliable evidence means only: the published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility or other facilities studying substantially the same drug, device or medical treatment or procedure; or the medical informed consent used by the treating facility or other facilities studying substantially the same drug, device or medical treatment or procedure.

Full Time Student is a student enrolled at an accredited college, university, or trade school participating in the Federally Guaranteed Student Loan Program. The student must be currently attending classes, carrying at least 12 units per term.

Group refers to the business entity to which the Insurer has issued the Policy.

Group Health Benefit Plan means a group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include: accident-only, credit or disability insurance coverages; specified disease coverage or other limited benefit policies; long-term care, dental care, or vision care coverages; coverage provided by a single service health maintenance organization; insurance coverage issued as a supplement to liability insurance; insurance coverage arising out of a workers' compensation system or similar statutory system; automobile medical payment insurance coverage; jointly managed trusts authorized under 29 U.S.C. Section 141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157; hospital confinement indemnity coverage; or reinsurance contracts issued on a stop-loss, quota share, or similar basis. Home Health Agencies and Visiting Nurse Associations are home health care providers that are licensed according to state and local laws to provide skilled nursing and other services on a visiting basis in the Eligible Participant's home. They must be approved as home health care providers under Medicare and the Joint Commission on Accreditation of Health Care Organizations.

Home Infusion Therapy Provider is a provider licensed according to state and local laws as a pharmacy, and must be either certified as a home health care provider by Medicare, or accredited as a home pharmacy by the Joint Commission on Accreditation of Health Care Organizations.

Hospital is a facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of Physicians. It must: be licensed as a hospital and operated pursuant to law; and be primarily engaged in providing or operating (either on its premises or in facilities available to the hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed physicians) medical, diagnostic, and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and provide 24 hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and be an institution which maintains and operates a minimum of five beds; and have X-ray and laboratory facilities either on the premises or available on a contractual prearranged basis; and maintain permanent medical history records. This definition excludes convalescent homes, convalescent facilities, rest facilities, nursing facilities, or homes or facilities primarily for the aged, those primarily affording custodial care or educational care.

Illness is a sickness, disease, or condition of an Insured Person which first manifests itself after the Insured Person's Effective Date.

Infertility is the inability to: conceive after sexual relations without contraceptives for the period of one year; or maintain a pregnancy until fetal viability. Infusion Therapy is the administration of Drugs (prescription substances), by the intravenous (into a vein), intramuscular (into a muscle), subcutaneous (under the skin), and intrathecal (into the spinal canal) routes. For the purpose of this Plan, it shall also include drugs administered by aerosol (into the lungs) and by feeding tube.

Initial Eligibility Date is the Effective Date for a participant who becomes eligible after the Effective Date of the Policy.

Initial Enrollment Period is the 31 day period during which an Eligible Employee or Eligible Dependent first qualifies to enroll for coverage, as described in the 'Who is Eligible for Coverage' section of this Plan.

Insurance Coverage Area is the primary geographical region in which coverage is provided to the Insured Person

Insured Dependents are members of the Eligible Participant's family who are eligible and have been accepted by the Insurer under this Plan.

Insured Participant is the Eligible Participant whose application has been accepted by the Insurer for coverage under this Plan.

Insured Person means both the Insured Participant and all other Insured Dependents who are covered under this Plan.

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Lifetime Maximum Benefit is the maximum amount of benefits available to each Insured Person during the person's lifetime. All benefits furnished are subject to this maximum amount.

Medical Emergency means a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity including without limitation sudden and unexpected severe pain for which the absence of immediate medical attention could reasonably result in:

Medically Necessary services or supplies are those that the Insurer determines to be all of the following: Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition. Provided for the diagnosis or direct care and treatment of the medical condition. Within standards of good medical practice within the organized community. Not primarily for the patient's, the Physician's, or another provider's convenience. The most appropriate supply or level of service that can safely be provided. For Hospital stays, this means acute care as an inpatient is necessary due to the kind of services the Insured Person is receiving or the severity of the Insured Person's condition and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting. The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Policy.

Mental, Emotional or Functional Nervous Disorders are neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.

Negotiated Rate is the rate of payment that the Insurer has negotiated with a Participating Provider for Covered Services.

Newborn is a recently born infant within 31 days of birth.

Non-Participating Hospital (out of network) is a Hospital that has not entered into a Participating Hospital agreement with the Insurer at the time services are rendered.

A Non-Participating Physician (out of network) is a Physician who does not have a Participating Provider agreement in effect with the Insurer at the time services are rendered.

Non-Participating Provider (out of network) is a provider who does not have a Participating Provider agreement in effect with the Insurer at the time services are rendered.

Office Visit means a visit by the Insured Person, who is the patient, to the office of a Physician during which one or more of only the following three specific services are provided: History (gathering of information on an Illness or Injury).

Examination. Medical Decision Making (the Physician's diagnosis and plan of treatment). This does not include other services (e.g. X-rays or lab services) even if performed on the same day.

Other Plan is an insurance plan other than this Plan that provides medical, repatriation of remains, and/or medical evacuation benefits for the Insured Person.

Out-of-Pocket Maximum is the amount of Coinsurance each Insured Person incurs for Covered Expenses in a Year. The Out-of-Pocket Maximum does not include any amounts in excess of Covered Expenses, the Deductible and/or any Copayments, Prescription Drug Deductible and Copayments, any penalties, or any amounts in excess of other benefit limits of this Plan.

A Participating Hospital (in network) is a Hospital that has a Participating Hospital agreement in effect with the Insurer at the time services are rendered. Participating Hospitals agree to accept the Negotiated Rate as payment in full for Covered Expenses. Participating Physician (in network) is a Physician who has a Participating Physician agreement in effect with the Insurer at the time services are rendered. Participating Physicians agree to accept the Negotiated Rate as payment in full for Covered Services.

A Participating Provider (in network) is a Participating Physician, hospital, or other health care provider that has a Participating Provider agreement in effect with the Insurer at the time services are rendered. Participating Providers agree to accept the Negotiated Rate as payment in full for Covered Expenses.

Physical and/or Occupational Therapy/Medicine is the therapeutic use of physical agents other than drugs. It comprises the use of physical, chemical and other properties of heat, light, water, electricity, massage, exercise, spinal manipulation and radiation.

Physician means a physician licensed to practice medicine or any other practitioner who is licensed and recognized as a provider of health care services in the state and/or country the Insured Person resides or is treated; and provides services covered by the Plan that are within the scope of his/her licensure.

Plan is the set of benefits described in the Certificate of Coverage booklet and in the amendments to this booklet (if any). This Plan is subject to the terms and conditions of the Policy the Insurer has issued to the Group. If changes are made to the Policy or Plan, an amendment or revised booklet will be issued to the Group for distribution to each Insured Participant affected by the change.

Policy is the Group Policy the Insurer has issued to the Group.

Pre-existing Condition means a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months immediately preceding the Eligibility Date

A Primary Plan is a Group Health Benefit Plan, an individual health benefit plan, or a governmental health plan designed to be the first payer of claims for an Insured Person prior to the responsibility of this Plan.

Reasonable Charge, as determined by the Insurer, is the amount it will consider a Covered Expense with respect to charges made by a Physician, facility or other supplier for Covered Services. In determining whether a charge is Reasonable, the Insurer will consider all of the following factors:

Special Care Units are special areas of a Hospital that have highly skilled personnel and special equipment for acute conditions that require constant treatment and observation.

Special Enrollment Period is the 31-day period during which an Eligible Participant or Eligible Dependent qualifies to enroll for coverage, as described in the "Who is Eligible for Coverage" section of this Plan.

Totally Disabled or Total Disability means: As applied to Insured Participant, any period of time during the Insured Participant's lifetime in which he/she is unable to perform substantially all the duties required by his/her usual occupation, provided the disability commences within twelve (12) months from the date the disabling condition occurred; As applied to a Dependent, not being able to perform the normal activities of a like person of the same age and sex. The patient must be under the care of a Physician.

U.S. means the United States of America.

Utilization Review means those functions performed by the Insurer to evaluate whether the services provided, or to be provided, are Medically Necessary and are being provided in a medically appropriate setting.

The Waiting Period is a required period of continuous, full time group participation that must be completed before an Eligible Participant is eligible for the Insurer's coverage.

Year is a 12-month period beginning each January 1 at 12:01 a.m. Eastern Time.