Accident: A sudden, unintentional, and unexpected occurrence caused by external, visible means and resulting in physical Injury to the Participating Member.
Affidavit of Eligibility: The properly completed form provided to the Scheme Administrator that certifies that an applicant is eligible to be covered under this insurance plan because they do not meet the citizenship and/or residency requirements of other insurance companies in the area where they reside.
AIDS: Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.
Amateur Athletics: An amateur or other non-‐professional sporting, recreational, or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. This definition does not include athletic activities that are non-‐contact and engaged in by the Participating Member solely for recreational, entertainment or fitness purposes.
Application: The fully answered and signed individual or Family application/enrollment form submitted by or on behalf of the Participating Member for acceptance into, renewal of coverage under, or Reinstatement in this insurance plan, which by this reference shall be incorporated in and become a part of the Master Policy and/the Evidence of Insurance. Any insurance agent/broker assigned to or assisting with the Application is the representative of the applicant/Participating Member and is not an agent or representative for or on behalf of the Scheme Administrator, Underwriters and/or the Master Policyholder.
ARC: AIDS related complex, as that term is defined by the United States Centers for Disease Control.
Beneficiary: The person(s), executers or administrators entitled to receive payment of Benefits.
Benefit: The amount of Principal Sum payable for Death.
Canada: A federated country in North America made up of ten provinces and three territories, (Canada).
Coinsurance: The payment by or obligations of the Participating Member for payment of Eligible Medical Expenses at the percentage specified in the Schedule of Benefits/Limits contained herein and exclusive of the Deductible.
Complicated Delivery: A delivery in which some condition puts the mother, the developing fetus, or both at higher-‐than-‐normal risk for complications during or after the delivery.
Coverage Period: The period beginning on the Effective Date of Coverage of the Evidence of Insurance and ending on the earliest of the following dates: (i) the termination date specified in the Declaration, or (ii) the termination date as determined in accordance with Section 15 above. The Coverage Period of Insurance can be no more than three hundred sixty five (365) days.
Covered Transplant: A transplant involving the heart, heart/lung, lung, kidney, kidney/pancreas, liver and allogenic or autologous bone marrow.
Custodial Care: Those types of care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual.
Death: Complete and irreversible cessation of life.
Declaration: The Declaration of Insurance issued by the Scheme Administrator to the Participating Member contemporaneously with the Evidence of Insurance (and/or upon renewal or Reinstatement hereof) evidencing the Participating Member’s insurance coverage under the Master Policy as evidenced by the Evidence of Insurance, which Declaration shall be incorporated in and become a part of the Master Policy. The Declaration serves as a descriptive document highlighting the coverage limits, deductible(s), coverage dates, amendments and/ or riders, and names of Participating Members for all Evidence of Insurance issued by the Scheme Administrator on behalf of the Master Policyholder and Underwriters.
Deductible: The dollar amount of Eligible Medical Expenses specified in the Declaration, that the Participating Member must pay per Period of Insurance prior to receiving benefits under this insurance, and exclusive of Coinsurance.
Dental Treatment: Treatment or supplies relating to the care, maintenance or repair of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.
Dependent Child; Children: A Participating Member who is less than eighteen (18) years of age at time of Application and shares your home for at least half the year (if divorced, the child may live with former spouse); and must not provide over one-‐half of his/her own support (scholarships excluded); or must be less than twenty four (24) years of age at time of Application and a full-‐time student and claim your residence as his/her official residence while away at school; and must not provide over one-‐half of his/her own support (scholarships excluded); and must be your biological, step, or legally adopted child/children.
Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body system or the ability to be self-‐sufficient.
Durable Medical Equipment (DME): Durable Medical Equipment consists of the following items: a standard basic hospital bed; and/or a standard basic wheel chair.
Educational or Rehabilitative Care: Care for restoration (by education or training) of a person’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.
Effective Date; Effective Date of Coverage: The date coverage for the Participating Member begins under the Terms of the Master Policy and the Evidence of Insurance, as indicated on the Declaration.
Eligible Medical Expenses: As defined in Section 30 above.
Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Participating Member’s life or limb in danger if medical attention is not provided within twenty four (24) hours.
EST: U.S. Eastern Standard Time.
Evidence of Insurance: The document issued by the Master Policyholder to the Participating Member, which describes and provides an outline and evidence of eligible coverage’s and benefits payable to or for the benefit of the Participating Member under the Master Policy, and which includes the Participating Member’s Application and any Riders attached thereto.
Expenses Incurred: Expenses rendered by a Participating Member that have or may not yet have been paid by the responsible parties.
Experimental: Any Treatment that includes completely new, untested drugs, procedures, or services, or the use of which is for a purpose other than the use for which they have previously been approved; new drug procedure or service combinations; and alternative therapies which are not generally accepted standards of current medical practice.
Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state or country in which it operates; is regularly engaged in providing twenty four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; maintains a daily record on each patient; provides each patient with a planned program of observation prescribed by a Physician; provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.
Family: A Participating Member and his/her spouse who is covered as a Participating Member under this insurance plan and his/her natural Child or Children (see definition of Dependent Child; Children) who are under the age of eighteen (18) and covered as Participating Members under this insurance plan.
HIV +: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human Immunodeficiency Virus infection.
Home Country: The country of which the Participating Member is a citizen or national; or maintains his/her residence or usual place of abode; or the country of which the Participating Member is the possessor of a validly issued passport. US citizens always have the US as their Home Country regardless of where they are.
Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.
Home Nursing Care: Services, provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient, provided always that such care is in lieu of Medically Necessary Inpatient care.
Hospice: An institution which operates as a hospice; and is licensed by the state or country in which it operates; and operates primarily for the reception, care and palliative control of pain for terminally ill persons who have, as certified by a Physician, a life expectancy of not more than one hundred eighty days (180).
Hospital: An institution which operates as a hospital pursuant to law; is licensed by the state or country in which it operates; operates primarily for the reception, care, and treatment of sick or injured persons as Inpatients; provides twenty four(24)hour nursing service by Registered Nurses on duty or call; has a staff of one or more Physicians available at all times; provides organized facilities and equipment for diagnosis and treatment of acute medical, surgical or mental/nervous conditions on its premises; and is not primarily a long-‐term care facility, Extended Care Facility, nursing, rest, Custodial Care, or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Hospitalization; Hospitalized: Confined and/or treated in a Hospital as an Inpatient.
Illness: A sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, or attitudinal or disciplinary problems.
Initial Effective Date: The date (most recent, if more than one) the Participating Member first obtains coverage under the Beacon/Axis Series Family of Insurance plans and maintains continuous unbroken coverage thereafter.
Injury: Bodily injury resulting from an Accident.
Inpatient: A person who is an overnight resident patient of a Hospital, using and being charged for room and board.
Intensive Care Unit: A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.
Investigational: Treatment that includes drugs, procedures, or services which are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.
Master Policyholder: The Beacon/Axis Series Group Insurance Trust (Anguilla).
Maximum Limit: The cumulative total dollar amount of benefit payments and/or reimbursements available to a Participating Member under this insurance during the Participating Member’s period of coverage. When the Maximum Limit is reached, no further benefits, reimbursements or payments will be available under this insurance.
Medically Necessary; Medical Necessity: A Treatment or supply which is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice as determined by the Scheme Administrator. By way of example but not limitation, a Treatment or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Participating Member or his/her provider; and/or if it is not necessary or appropriate for the Participating Member’s Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate, and appropriate diagnosis or Treatment.
Mental or Nervous Disorders: A mental, nervous, or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without limitation: psychosis; depression; schizophrenia; bipolar affective disorder; and those psychiatric Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association. Mental or Nervous Disorder does not include learning disabilities, or attitudinal or disciplinary problems. For purposes of this insurance, Mental or Nervous Disorder does not include Substance Abuse.
Mortal Remains: The bodily remains or ashes of a Participating Member.
Newborn: An infant from the moment of birth through the first thirty one (31) days.
Normal Delivery: A Vaginal delivery with no unexpected complications before or after delivery.
Other Insurance: As defined in Section 14 above.
Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider that does not require an overnight stay in a Hospital.
Participating Member: The person(s) named as the Participating Member(s) on the Declaration.
Period of Insurance: The period beginning on the Effective Date of Coverage of the Evidence of Insurance and ending on the earliest of the following dates: (i) the termination date specified in the Declaration, or (ii) the termination date as determined in accordance with Section 15 above. The Period of Insurance can be no more than three hundred sixty five (365) days.
Physician: A duly licensed practitioner of the medical arts. A Physician must be currently licensed by the state or country in which the services are provided, and the services must be within the scope of that license.
Pre-‐certification; Pre-‐certify: A general determination of Medical Necessity, only, made in reliance and based upon the completeness and accuracy of the information provided at the time thereof. Pre-‐ certification is not an assurance, authorization, or verification of coverage, a verification of benefits, or a guarantee of payment. See Section 24 above, for further details.
Pre-‐existing Condition: Any Illness, Injury or Mental or Nervous Disorder that, with reasonable medical certainty, existed on or at any time prior to the Initial Effective Date of this insurance, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed on the Application or on any Claim Form or otherwise, including any chronic, subsequent or recurring complications or consequences associated therewith or arising or resulting therefrom.
Premium: The premium payments required to effectuate and maintain the Participating Member’s insurance coverage and benefits under this insurance, in the amounts and at the times (“Due Dates”) established by the Scheme Administrator in its sole discretion from time to time.
Pregnancy; Pregnant: The process of growth and development within a woman’s reproductive organs of a new individual from the time of conception through the phases where the embryo grows and fetus develops to birth.
Primary Beneficiary: The Beneficiary(ies) named by the Participating Member as the first party entitled to Benefits.
Principal Sum: The Benefit based upon the attained age of the Participating Member.
Professional Athletics: A sport activity, including practice, preparation, and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization, is directly supported or sponsored by a professional team or professional sports organization, is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization; or has any athlete receiving for his or her participation any kind of payment or compensation, directly or indirectly, from a professional team or professional sports organization.
Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters “R.N.” after his or her name.
Relative: A parent, guardian, spouse, son, daughter, or immediate Family member of the Participating Member.
Rider: Any exhibit, schedule, attachment, amendment, endorsement, or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, the Evidence of Insurance, or the Application, as the case may be.
Routine Physical Exam: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the Treatment of any Illness or Injury.
Scheme Administrator: The “Scheme Administrator”, as referred to herein; Azimuth Risk Solutions, LLC, acts solely as the disclosed and authorized agent and representative for and on behalf of the Master Policyholder and Underwriters, and has and shall have no direct, indirect, joint, several, separate, individual, or independent liability or obligation of any kind under the Master Policy or the Evidence of Insurance to the Participating Member or to any other person or entity. Azimuth Risk Solutions, LLC, 1 North Pennsylvania Street Suite 600 Indianapolis, Indiana 46204, USA. Telephone Number 317-‐644-‐6291 or 888-‐201-‐8050, Fax Number 317-‐423-‐9620 or 888-‐201-‐8851, Website: www.azimuthrisk.com Email: email@example.com.
Sports Diving: Recreational underwater diving activities requiring the use of underwater or artificial breathing apparatus, and carried out in strict accordance with the guidelines, codes of good practice, and recommendations for safe diving practices as laid down by an Authoritative Diving Body.
Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency.
Sudden Onset of a Pre-‐Existing Condition: An unexpected outbreak or recurrence of a Pre-‐existing Condition, which occurs unexpectedly and without advance warning, either in the form of Physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the outbreak or recurrence. Treatment must be obtained within twenty four (24) hours of the sudden and unexpected occurrence of pain.
Surgery or Surgical Procedure: An invasive diagnostic or surgical 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.
Terms: Terms, provisions, conditions, definitions, limits, sub-‐limits, limitations, wordings, restrictions, qualifications and/or exclusions.
Terrorism: An act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear. All other Terms, clauses and conditions remain unchanged.
Third party Liability: Third party liability insurance coverage is the portion of an insurance policy that covers loss to others, caused by the policyholder, whether it is personal injury or property damage. Subject to the Benefits and Limits set forth in the SCHEDULE OF BENEFITS AND LIMITS in Section 21.
Treatment: Any and all services and procedures rendered in the management and/or care of a patient for the purpose of identifying, diagnosing, treating, curing, preventing, controlling and/or combating any Illness or Injury, including without limitation: verbal or written advice, consultation, examination, discussion, diagnostic testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.
Unexpected: Sudden, unintentional, not expected, and unforeseen.
U.S.: The United States of America and or any of its territories.
Usual, Reasonable and Customary: The most common charge for similar services, medicines, or supplies within the area in which the charge is incurred, so long as those charges are reasonable. The Scheme Administrator reserves the right to determine, in the reasonable exercise of its discretion, whether charges are Usual, Reasonable and Customary. In determining whether a charge is Usual, Reasonable and Customary, the Scheme Administrator may consider one or more of the following factors, without limitation: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or service as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; and such other factors as the Scheme Administrator, in the reasonable exercise of its discretion, determines are appropriate.