Accident or Accidental means an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
Administrator shall mean Seven Corners, Inc.
Benefit Period shall mean the allowable time period You have from the date of Injury or onset of Illness to receive Treatment for a Covered Injury or Illness. 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).
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Your responsibility to pay.
Common Carrier shall mean any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passengers for hire.
Company shall mean United States Fire Insurance Company.
Covered Expenses shall mean expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed of ordered by a Physician; Reasonable and Customary charges; incurred while insured under this Policy
Deductible shall mean the amount of eligible Covered Expenses which is Your responsibility to pay before benefits under the plan are payable.
Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician.
Eligible Dependent Child shall mean Your unmarried children over fourteen (14) days and under nineteen (19) years of age.
Eligible Spouse shall mean Your legal spouse.
Hospital shall mean except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision means a place that 1.) is legally operated for the purpose of providing medical care and treatment to sick or injured persons for which a charge is made that the Insured is legally obligated to pay in the absence of insurance 2.) provides such care and treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Doctors. Hospital also means a place that is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Health Care Organizations (JCAHO).
Hospital does not mean:
-a convalescent, nursing, or rest home or facility, or a home for the aged;
-a place mainly providing custodial, educational, or rehabilitative care; or
-a facility mainly used for the treatment of drug addicts or alcoholics.
Home Country shall mean the country where You have Your true, fixed and permanent home and principal establishment.
Illness shall mean sickness or disease of any kind contracted and commencing after the Effective Date of this Policy.
Injury shall mean accidental bodily injury or injuries caused by an accident which occurs after the Effective Date of this policy. The Injury must be the direct cause of the loss, independent of disease or bodily infirmity.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
Insured or Insured Person shall mean a person eligible for benefits under the Policy who has applied for coverage and is named on the application and for whom the Company has accepted premium.
Medically Necessary shall mean services and supplies received while insured that are determined by the Company to be: (1) appropriate and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person’s medical conditions; (2) within the standards the organized medical community deems good medical practice for the Insured Person’s condition; (3) not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider or person; (4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and (5) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person’s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment Medically Necessary or make the charge of a Covered Expense under this Policy.
Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either: 1) utilizing harnesses, ropes, crampons or ice axes; or 2) ascending 4,500 meters or above.
Outpatient shall mean if You receive 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.
Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
Period of Coverage or Policy Period shall mean the Period of Coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Expiration Date or the date coverage is renewed by the Company.
Physician 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.
Pre-existing Condition shall mean any Injury or Illness which meets the following criteria: 1) a condition that would have caused a person to seek medical advice, diagnosis, care, or treatment during the thirty-six (36)* months prior to the Effective Date of coverage under this Policy; 2) a condition for which manifestation, medical advice, diagnosis, care, or treatment was recommended, received, or noticed during the thirty-six (36)* months prior to the Effective Date of coverage under this Policy.
*For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months.
Reasonable and Customary shall mean the maximum amount that the plan determines is Reasonable and Customary for Covered Expenses You receive, up to but not to exceed charges actually billed. The determination considers: 1) Amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) Any usual medical circumstances requiring additional time, skill or experience; and 3) Other factors included but not limited to, a resource based relative value scale.
Treatment means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.
You or Your shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.