“ACCIDENT” or “ACCIDENTAL” shall mean an event,independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
“BENEFIT PERIOD” shall mean the duration of time following an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage). Treatment due to an Injury must be performed by a Physician and meet the following conditions: a) begins within thirty (30) days after date of Injury; and b) is received within 12 months (32 weeks for Insured Persons age seventy (70) and over) after date of Injury; or Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within 12 months (32 weeks for Insured Persons age seventy (70) and over) after the date of first treatment for such Sickness.
“COMPANY” shall mean Certain Underwriters at Lloyd’s, London
“COVERED MEDICAL EXPENSES” means reasonable charges which are: 1) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 2) made for services and supplies not excluded under the policy; 3) made for services and supplies which are a Medical Necessity; 4) made for services included in the Schedule of Benefits; and 5) in excess of the amount stated as a deductible, if any. Covered medical expenses will be deemed “incurred” only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services.
“DISABLEMENT” as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Policy.
“DEDUCTIBLE” means the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Policy are payable by the Company. Such amount will be subtracted from the amount or amounts charged and otherwise payable as Covered Medical Expenses. The deductible will apply per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.
“DEPENDENT CHILD” means a Named Insured’s dependent, unmarried children living with the Named Insured. This includes stepchildren, legally adopted children and children of adopting parents pending adoption procedures. Children shall cease to be dependent on the first occurrence of: (1) the end of the month in which they marry; or (2) the end of the month in which they attain the age of nineteen (19) years. The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both: (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and 2) within thirty-one (31) days of the child’s attainment of the limiting age. Subsequently, such proof must be given to the Company upon request following the child’s attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsection (1) and (2).
“ELIGIBLE BENEFIT” shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under this program and which do not exceed the maximum benefit.
“EMERGENCY” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within 24 hours.
“EXPERIMENTAL/INVESTIGATIONAL” means all services or supplies associated with: 1) treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available; or if less effective than other available treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the device to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devises, or is safer or less costly. The Company will make the final determination as to whether a service or supply is Experimental/Investigational.
“EXCESS PROVISION” means the plan benefits are payable for covered expenses not covered and payable by any other plan providing medical expense benefits. If there is no other valid and collectible benefits available from any other source, this plan will pay the covered expenses up to the limits of the policy.
“HOME COUNTRY” means the country where the Insured Person’s Passport was issued.
“HOSPITAL” means a licensed or properly accredited general Hospital which; 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured person as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating Mental and Nervous Disorders.
“HOSPITAL CONFINED/HOSPITAL CONFINEMENT” means confined in a Hospital for at least eighteen (18) hours by reason of an Injury or Sickness for which benefits are payable.
“ILLNESS” wherever used in this Policy shall mean any medical condition, sickness, disease, disability, birth defect, congenital defect , chronic infirmity or disorder of any kind. Provided, however, that Illness does not include any learning disabilities or attitudinal or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be one Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.
“INJURY” means bodily Injury: 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder or Injury; 2) treated by a Physician within thirty (30) days after the date of accident; and 3) which causes loss during the term of the policy.
“INSURED PERSON” means: 1) the Named Insured; and 2) Dependent Child(ren) of the Named Insured, if: 1) the Dependent Child(ren) is properly enrolled in the program; and 2) the appropriate dependent premium has been paid. The term “Insured” also means Insured Person.
“INTENSIVE CARE” means (1) a specifically designated facility of the Hospital that provides the highest level of medical care; and (2) which is restricted to those patients who are critically ill or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement.
“LOSS” in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight.
“MEDICAL EMERGENCY” means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in: (1) Death; (2) Permanent placement of the Insured’s health in jeopardy; (3) Serious impairment of bodily functions; or (4) Serious and permanent dysfunction of any body organ or part. Expenses incurred for “Medical Emergency” will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor injuries or minor Sicknesses.
“MEDICAL NECESSITY/MEDICALLY NECESSARY” means those services or supplies provided or prescribed by a Hospital or Physician which are: (1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury; (2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury; (3) In accordance with the standards of good medical practice; (4) Not primarily for the convenience of the Insured, or the Insured’s Physician; and (5) The most appropriate supply or level of service which can safely be provided to the Insured. The Medical Necessity of being Hospital Confined means that: 1) the Insured requires acute care as a bed patient; and 2) the Insured cannot receive safe and adequate care as an outpatient. The policy only provides payment for services, procedures and supplies which in the judgement of the Company are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical Necessity, including any or all days of Hospital Confinement.
“MENTAL AND NERVOUS DISORDER” means a Sickness that is a mental, emotional or behavioral disorder.
“NAMED INSURED” means an eligible person who: 1) has completed an application; and 2) that application and the appropriate premium for coverage has been paid and accepted by the Administrator.
“NEWBORN INFANT” means any child born of an Insured while that person is insured under the policy. Newborn Infants will be covered under the policy for the first thirty-one (31) days after birth ONLY IF the Newborn Infant’s mother was both a) insured under the policy when the Newborn Infant was born and b) her pregnancy was a covered condition under the policy. Coverage for such child will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefits will be the same as for the Insured Person who is the child’s parent. The Insured will have the right to continue such coverage for the child beyond the first thirty-one (31) days. To continue coverage the Insured must, within the thirty-one (31) days after the child’s birth:1) submit an application for the Newborn child (ren); and 2) pay the required additional premium for the continued coverage. If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first thirty-one (31) days after the child’s birth.
“OUTPATIENT” shall mean an Insured Person who receives care in a Hospital or another institution, including: ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is confined and is not charged for room and board.
“PHYSICIAN” means a person, other than the Insured or a member of the Insured’s family, who holds a medical license or medical certificate. In this Policy shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.
“PHYSIOTHERAPY” means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a Physician.
“POLICY PERIOD OR PERIOD OF COVERAGE” shall mean the period of coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Termination Date or the date coverage is renewed by the Company. Maximum Period of Coverage is 12 months.
“PRE-EXISTING CONDITION” shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately prior to the Insured Person’s Effective Date under the policy, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury , Illness, disease , Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older)immediately preceding the effective date of coverage under this policy.
“PRESCRIPTION DRUGS” means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin.
“RELATIVE” shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
“SERVICE PROVIDER” shall mean a Hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician, dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
“SICKNESS” means Sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under the policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.
“SOUND, NATURAL TEETH” means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.
“SURGERY” shall mean an invasive diagnostic procedure; or the treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
“TREATMENT(S)” shall mean medical or surgical management of a patient designed to resolve the Illness(es) or Injury(ies) based on standard and accepted medical practice. For purposes of this Certificate, the course of action will only include those scheduled and approved benefits, for which the Insured Person(s) is eligible.