The male pronoun includes the female whenever used.
For the purposes of the Policy the capitalized terms used herein are defined as follows:
Additional terms may be defined within the provision to which they apply.
Accident or Accidental means a sudden, unforeseeable, external event that result in Injury to the Plan Participant and occurs while the coverage is in effect.
Acute Onset of a Pre-Existing Condition(s) shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a congenital condition or that gradually becomes worse over time will not be considered Acute Onset. A Pre-existing Condition will not be considered an Acute Onset if during the 30 days prior to the acute event You had a change in prescription or treatment for a diagnosis related to the acute event. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of coverage.
Administrator shall mean Seven Corners, Inc.
Airworthiness Certificate means the “Standard” Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.
Benefit Period shall mean the one hundred and eighty (180) days following the onset of an eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If the Plan Participant’s plan terminates during the Plan Participant’s Benefit Period, the Plan Participant will still be eligible to receive Treatment so long as the Treatment is within the Benefit Period and outside the Home Country (except as provided under the Home Country Coverage).
Child means the Plan Participant’s natural Child, adopted Child (or Child placed in the Plan Participant’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Plan Participant has legal guardianship (proof will be required). A Child must reside with the Plan Participant in a parent-Child relationship. NOTE: In the event the Plan Participant shares physical custody of the Child with another parent, the requirement that the Child reside with the Plan Participant will be waived.
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Plan Participant’s responsibility to pay.
Common Carrier means any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire.
Company means Advent, Lloyd’s Syndicate 780. Also hereinafter referred to as Underwriter, We, Us and Our(s).
Complications of Pregnancy means a condition which:
When pregnancy is not terminated, requires Medical Treatment and whose diagnosis is distinct from pregnancy but is adversely affected by or are caused by pregnancy, such as: (a) acute nephritis; (b) nephrosis; © cardiac decompensation; (d) missed abortion; (e) eclampsia; (f) puerperal infection; (g) R.H. Factor problems; (h) severe loss of blood requiring transfusion; and (i) other similar medical and surgical conditions of comparable severity related to pregnancy.
When pregnancy is terminated: (a) non-elective cesarean section; (b) ectopic pregnancy that is terminated; and ©spontaneous termination of pregnancy during a period of gestation in which a viable birth is not possible;
Complications of Pregnancy will not include:
Physician prescribed rest during the period of pregnancy;
Similar conditions associated with the management of a difficult pregnancy but which are not a separate Complication of Pregnancy.
Delivery by cesarean section is considered a complication of pregnancy if the cesarean section is non-elective. A cesarean section will be considered non-elective if the fetus or mother is determined to be in distress and is in immediate danger of death, Sickness or Injury if a cesarean section is not performed. A cesarean section beyond one performed in any previous pregnancy will also be considered non-elective if vaginal delivery is medically inappropriate, or a vaginal delivery is attempted but discontinued due to immediate danger of death, Sickness or Injury to the Child or mother.
Congenital means a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.
Covered Expense shall mean “Eligible Benefit”.
Deductible means the dollar amount of Eligible Expenses which must be incurred and paid by the Plan Participant before benefits are payable under the Policy or Plan Document. It applies separately to each Plan Participant.
Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating Medical Treatment by a Physician.
Dependent means a Plan Participant’s:
1) lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Union Partner.
2) unmarried Children over 14 days and under 19 years of age.
The age limitations will not apply to a Plan Participant’s unmarried Child who is dependent on the Plan Participant or other care providers for lifetime care and supervision, and incapable of self-sustaining employment by reason of mental or physical handicap that occurred before age 19. Proof of such dependence and incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation. Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.
Eligible Benefit(s) shall mean benefits payable by the Underwriter 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 Plan Participant under this program and which do not exceed the maximum benefit.
Eligible Expenses means the Reasonable and Customary charges for services or supplies which are incurred by the Plan Participant for the Medically Necessary treatment of an Injury or Sickness. Eligible Expenses must be incurred while the Policy is in force.
Emergency means a Sickness or Injury for which the Plan Participant seeks immediate Medical Treatment at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are sufficiently severe (including severe pain) that without immediate medical care a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would cause:
His life or health would be in serious jeopardy, or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn Child;
His bodily functions would be seriously impaired; or
A body organ or part would be seriously damaged.
Experimental/Investigational means that a drug, device or medical care or treatment will be considered experimental/investigational if:
The drug or device cannot be lawfully marketed without approval of the Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; 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.
The informed consent document utilized with the drug, device, medical care or treatment states or indicates that the drug, device, medical care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;
The drug, device, medical care or treatment or the patient informed consent document utilized with the drug, device or medical care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval;
Reliable Evidence show that the drug, device or medical care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or
Reliable Evidence show that the prevailing opinion among experts regarding the drug, device or medical care or treatment 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 a standard means of treatment of diagnosis.
Reliable evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical care or treatment or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical care or treatment. Eligible Expenses will be considered in accordance with the drug, device or medical care at the time the expense is incurred. Management staff in Our Claims Department or a claims payor acting on Our behalf will make the determination if the drug, device or medical care is Experimental/Investigational based on the above criteria.The Company will make the final determination as to whether a service or supply is Experimental/Investigational
Expatriate means (1) a person working or living outside their country of citizenship; (2) a person working outside their country of citizenship and outside the employer’s country of domicile; or (3) non-U.S. citizens working in the United States.
He, His and Him includes “she”, “her” and “hers.”
Home Country means the country where a Plan Participant has his or her true, fixed and permanent home and principal establishment.
Hospital means an institution licensed, accredited or certified by the State that:
1) Operates as a Hospital pursuant to law for the care, treatment and providing in-patient services for sick or injured persons;
2) Is accredited by the Joint Commission on Accreditation of Healthcare Organizations;
3) Provides 24-hour nursing service by registered nurses (R.N.) on duty or call;
4) Has a staff of one or more licensed Physicians available at all times;
5) Provides organized facilities for diagnosis, treatment and surgery, either
a) on its premises; or
b) in facilities available to it, on a pre-arranged basis;
6) Is not primarily a nursing care facility, rest home, convalescent home or similar establishment, or any separate ward, wing or
section of a Hospital used as such; and
7) Is not a place for drug addicts, alcoholics or the aged.
Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.We will not deny a claim for services solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability, and the Hospital is accredited by any one of the following:
1) the Joint Commission of Accreditation of Hospitals; or
2) the American Osteopathic Association; or
3) the Commission on the Accreditation of Rehabilitative Facilities.
Hospital does not include a place, special ward, floor or other accommodation used for: custodial or educational care; rest, the aged; a nursing home or an institution mainly rendering treatment or services for mental illness or substance abuse, except as specifically stated.
Hospital Stay means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.
Host Country shall mean any country other than the country where an Plan Participant has his or her true, fixed and permanent home and principal establishment.
Illness shall mean a Sickness, disorder, Illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap, deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind, or any other medical, physical or health condition, provided, however, that Illness does not include 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. Any complication or any condition arising out of an Illness for which the Plan Participant is being treated or has received Treatment will be considered as part of the original Illness.
Immediate Family means a Plan Participant’s Spouse, domestic partner, civil union partner, parent (includes Step-parent), Child(ren) (includes legally adopted or step Child(ren), brother, sister, step-Child(ren), grandchild(ren), or in-laws). A Member of the Immediate Family includes an individual who normally lives in the Plan Participant’s household.
Injury means bodily harm resulting, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same person sustained in one Accident, including all related conditions and recurring symptoms of injuries will be considered on Injury.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
Intensive Care shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units
Insurance means the coverage that is provided under the Policy.
Master Application means the Application for the Master Policy.
Maximum Benefit means the largest total amount of Eligible Expenses that the Company will pay for the Plan Participant as found on the ID card.
Medically Necessary means a treatment, drug, device, service, procedure or supply that is:
1) Required, necessary and appropriate for the diagnosis or treatment of a Sickness or Injury; and
2) Prescribed or ordered by a Physician or furnished by a Hospital; and
3) Performed in the least costly setting required by the condition; and
4) Consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered;
5) Not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment.
When specifically applied to Hospital confinement, it means that the diagnosis or Treatment of symptoms or a condition cannot be safely provided on an outpatient basis.
The purchasing or renting air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them, and general exercise equipment are not considered Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may consider the cost of the alternative to be the Eligible Expense.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
A Treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:
Is Experimental/Investigational or for research purposes;
Is provided for education purposes or the convenience of the Plan Partic ipant, the Plan Participant’s Immediate Family, Physician, Hospital or any other provider;
Exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate and appropriate diagnosis or Treatment and where ongoing treatment is merely for maintenance or preventive care;
Could have been omitted without adversely affecting the person’s condition or the quality of medical care;
Involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration;
Involves a service, supply or drug not considered Reasonable and Customary by the Healthcare Financing Administration Medicare Coverage Issues Manual; or
It can be safely provided to the patient on a less cost effective basis such as out-patient, by a different medical professional, or pursuant to a more conservative form of treatment.
Medical Treatment means examination, treatment, and/or consultation by a Physician for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or Treatment.
Mental Illness and Mental and Nervous Disorder shall mean any 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; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other Mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. Mental Illness and Mental and Nervous Disorder does not mean or include learning disabilities, attitudinal disorders or disciplinary problems.
Mountaineering means 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.
Natural Disaster means a flood, hurricane, tornado, earthquake, mudslide, tsunami, avalanche, landslide, volcanic eruption, fire, wildfire or blizzard that is due to natural causes.
Occupational Disease means an Illness or Injury resulting from or in the course of any employment for wage or profit by the Plan Participant. Occupational Disease is not a contagious disease resulting from exposure to fellow employees or from a hazard to which the workman would have been equally exposed outside of his employment. An Occupational Disease is also not an ordinary disease of life to which the general public is equally exposed, unless such disease follows as a complication and a natural incident of an Occupational Disease or unless there is a constant exposure peculiar to the occupation itself that makes such disease a hazard inherent in such occupation.
Outpatient means a Plan Participant who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for a Sickness or Injury, but who is not confined and is not charged for room and board.
Outpatient Surgical Facility means a surgical or medical center which has (1) permanent facilities for surgery; (2) organized medical staff of Physicians and registered graduate Registered Nurses; (3) is authorized by law in the jurisdiction in which it is located to perform surgical services and is licensed (if no license is required, officially approved) under law.
Out-of-Pocket Maximum means the maximum dollar amount the Plan Participant is responsible to pay during a Benefit Period. After the Plan Participant has reached the Out-of-Pocket Maximum, the Policy pays 100% of Eligible Expenses for the remainder of the Benefit Period. The Out-of-Pocket Maximum is met by accumulated Deductible, Coinsurance . Penalties and amounts above the Reasonable and Customary expenses do not count toward the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is shown on the Schedule of Benefits.
Parachuting means an activity involving the breaking of a free fall from an airplane using a parachute.
Participation/Subscription Agreement means the agreement completed by a Plan Participant for insurance under the Master Policy.
Period of Coverage shall mean the Period of Coverage issued by the Underwriter to the Plan Participant Person, typically beginning with the effective date and ending with the expiration Date or the date coverage is renewed by the Underwriter.
Physician or Legally Qualified Physician or Surgeon means a person who is a qualified practitioner of medicine. As such, He or She must be acting within the scope of his/her license under the laws in the jurisdiction in which He or She practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include a Plan Participant, a Plan Participant’s Spouse, son, daughter, father, mother, brother or sister or other relative.
Plan Participant means a person and Dependent eligible for coverage as identified in the Enrollment/Application, for whom proper premium payment has been made when due, and who is therefore a Plan Participant under the Policy.
Policy means this document, the Master Application of the Policyholder and any end endorsements, riders or amendments that will attach during the Period of Coverage.
Policy Period means the period of time following the Policy’s Effective Date, as shown on the Schedule of Benefits.
Policyholder means the entity shown as the Policyholder in the Schedule of Benefits.
Pre-Existing Condition means 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 any time during the thirty-six (36) months prior to the effective date of coverage under this 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 thirty-six (36) month period immediately preceding the effective date of coverage under this policy.
*For U.S. and Canadian residents traveling outside the United States and Canada, the Pre-existing Condition period is twelve (12) months instead of thirty-six (36) months.
Pregnancy means the physical condition of being pregnant, including Complication of Pregnancy.
Reasonable and Customary means the most common charge for similar professional services, drugs, procedures, devices, supplies or Treatment within the area in which the charge is incurred. The most common charge means the lesser of:
The actual amount charged by the provider;
The negotiated rate; or
The charge which would have been made by the provider (Physician, Hospital, etc) for a comparable service or supply made by other providers in the same Geographic Area, as reasonable determined by Us for the same service or supply.
Reasonable and Customary Charges, Fees or Expenses as used in the Policy to describe expense will be considered to mean the percentile of the payment system in effect at Policy issue as shown on the Schedule of Benefits.
Registered Nurse means a licensed registered professional Registered Nurse (R.N.).
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 Plan Participant.
Scheduled Departure Date means the date on which the Plan Participant is originally scheduled to leave on the Plan Participant’s trip.
Scheduled Return Date means the date on which the Plan Participant is originally scheduled to return to the point of origin or the original final destination of the Plan Participant’s trip.
Service Provider means 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, Registered Nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
Sickness means Illness, malady or disease which requires treatment by a Physician while covered by this Policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness.
Skilled Nursing Facility means a facility that provides skilled nursing 24 hours a day, seven days a week, under the supervision of a Registered Nurse, and/or skilled rehabilitative services at least five days per week. The emphasis is on skilled nursing care, with restorative, physical, occupational, and other therapies available. A Skilled Nursing Facility provides services that cannot be efficiently or effectively rendered at home or in an intermediate care facility. The service provided must be directed towards the patient achieving independence in activities of daily living, improving the patient’s condition, and facilitating discharge.
Sound Natural Tooth is a tooth that is whole or properly restored; is without impairment, periodontal or other conditions; is not more susceptible to Injury than a virgin tooth, and is not in need of the Treatment provided for any reason other than Accidental Injury. A tooth previously restored with a crown, inlay, or porcelain restoration, or Treated by endodontics is not a Sound Natural Tooth.
Spouse means lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Partner.
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means an invasive or diagnostic procedure; or the treatment of Sickness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Terrorism or Terrorist Activity shall mean an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).
Third Party means a person or entity other than the Plan Participant, the Policyholder or the Company.
Transportation Expense means the cost of Medically Necessary conveyance, personnel, and services or supplies.
Traveling Companion means a person or persons whose names appear with the Plan Participant’s on the same Travel Arrangements and who, during the Trip, will share accommodations with the Plan Participant in the same room, cabin, condominium unit, apartment unit or other lodging
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.
Trip means a scheduled trip for which coverage for travel arrangements is requested and the premium is paid prior to the Plan Participant’s actual or Scheduled Departure Date of the Plan Participant’s Trip.
Underwriter or We, Our, Us means Advent, Lloyd’s Syndicate 780 underwriting this insurance.
You, Your, Yours, He or She means the Plan Participant and the Plan Participant’s Spouse or Dependents who meets the eligibility requirements of the Policy and whose insurance under the Policy is in force.