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SMC|Enrollment Development|International Education Center|Definitions

Definitions

Medical Insurance 2013-2014

Definitions

The terms shown below shall have the meaning given in this section whenever they appear in the brochure:
 
Accident means the occurrence that: 1) is unforeseen; 2) is not due to or contributed to by Sickness or disease of any kind; and 3) causes Injury.
 
 
Act means the Patient Protection and Affordable Care Act of 2010 (Public Law 111-1148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152)

Allowable C​harges means the charges agreed to by the Preferred Provider Organization for specified covered medical treatment, services and supplies.

Company means the National Union Fire Insurance Company of Pittsburgh, Pa.

Copay means the initial dollar amount payable by the Covered Person for an Eligible Expense at the time service is rendered.

Covered Person means a Covered Student or Covered Dependent while coverage under the Policy is in effect.

Covered Student means a student of the Policyholder who is insured under the Policy.

Deductible means the dollar amount of Eligible Expenses a Covered Person must pay before benefits become payable.

Dependent means: 1) the Covered Student's Spouse residing with the Covered Student; and 2) a the Covered Student's or Spouse's child until the date such child attains age 26.

 
 
Doctor means: 
  1. legally qualified physician licensed by the state in which he or she practices; and 
  2. a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the state of such practitioner; and 
  3. certified nurse midwives and licensed midwives while acting within the scope of that certification. The term Doctor does not include a Covered Person’s immediate family member.
Elective Treatment means medical treatment, which is not necessitated by a pathological change in the function or structure in any part of the body, occurring after the Covered Person’s effective date of coverage.

Eligible Expense means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of a Sickness or Injury: 
  1. not in excess of the Reasonable and Customary charges; or 
  2. not in excess of the charges that would have been made in the absence of this coverage; 
  3. is the negotiated rate, if any and 
  4. incurred while the Policy is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits Provision.
Emergency Medical Condition means a Sickness or Injury for which immediate medical treatment is sought 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 could reasonably be expected to result in any of the following: 
  1. the Covered Person’s life could be in serious jeopardy; 
  2. bodily functions would be seriously impaired; or 
  3. a body organ or part would be seriously damaged; or 
  4. serious disfigurement; or 
  5. serious jeopardy to the health of the fetus.
Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above.

Experimental/Investigational means a drug, device or medical care or treatment that meets the following:
  1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
  2. The informed consent document used 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, if such a consent document is required by law;
  3. The drug, device, medical care or treatment or the patient’s informed consent document used with the drug, device, medical care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, if federal or state law requires such review and approval;
  4. Reliable evidence shows 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, it efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or
  5. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, 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 standard means of treatment of diagnosis. Reliable evidence means: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device, 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, medical care or treatment at the time the expense is incurred.
Hospital means a facility which meets all of these tests:
  1. It provides inpatient services for the care and treatment of injured and sick people; and
  2. It provides room and board services and nursing services 24 hours a day; and
  3. It has established facilities for diagnosis and major surgery; and
  4. It is supervised by a Doctor; and
  5. It is run as a Hospital under the laws of the jurisdiction in which it is located; and
  6. It is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
The term Hospital includes: 
  1. a substance abuse treatment facility during any period in which it provides effective treatment of substance abuse to the Covered Person;
  2. an ambulatory surgical center or ambulatory medical center; 
  3. a mental health hospital if supervised and licensed by the Department of Mental Health; and 
  4. a birthing facility certified and licensed as such under the laws where located. It shall also include rehabilitative facilities if such is specifically for treatment of physical disability. Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.
Hospital does not include a place run mainly: 
  1. as a convalescent home; 
  2. as a nursing or rest home; or 
  3. as a place for custodial or educational care.
Immediate Family Member means a person who is related to the Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild).

Injury means bodily injury due to an accident which: 
  1. results solely, directly and independently of disease, bodily infirmity or any other causes; 
  2. occurs after the Covered Person’s effective date of coverage; and 
  3. occurs while coverage is in force.
All Injuries sustained in any one accident, including all related conditions and recurrent symptoms of these injuries, are considered one Injury.

Medically Necessary means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of a Sickness or Injury based on generally accepted current medical practice in the United States at the time it is provided.

A service or supply will not be considered as Medically Necessary if:
  1. It is provided only as a convenience to the Covered Person or provider; or
  2. It is not the appropriate treatment for the Covered Person’s diagnosis or symptoms; or
  3. It exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or
  4. It is Experimental/Investigational or for research purposes; or
  5. Could have been omitted without adversely affecting the patient’s condition or the quality of medical care; or
  6. It involves treatment of or the use of a medical device, drug or substance not formally approved by the U.S. Food and Drug Administration (FDA); or
  7. It involves a service, supply or drug not considered reasonable and necessary by the Center for Medicare and Medicaid Services Issues Manual; or
  8. It can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or pursuant to a more conservative form of treatment.
The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.

Mental or Nervous Disorder means any nervous, emotional and mental disease, illness, syndrome or dysfunction classified in the most recent edition of the International Classification of Diseases as a Mental Disorder (other than those conditions deemed Severe Mental Illness) on the date the medical care or treatment is rendered to a Covered Person.

Pre-Existing Condition means a Sickness or Injury for which medical care, treatment, diagnosis or advice, including use of prescription drugs, was received or recommended within the six (6) months prior to the Covered Person’s effective date of coverage under the Policy.

Reasonable and Customary (R&C) means the charge, fee or expense which is the smallest of: 
  1. the actual charge; 
  2. the charge usually made for a covered service by the provider who furnishes it; 
  3. the negotiated rate, if any; and 
  4. the prevailing charge made for a covered service in the geographic area by those of similar professional standing.
Severe Mental Illness means 
  1. schizophrenia; 
  2. schizo-affective disorder; 
  3. bipolar disorder (manic-depressive illness); 
  4. major depressive disorders; 
  5. panic disorder; 
  6. obsessive-compulsive disorder; 
  7. pervasive developmental disorder or autism; 
  8. anorexia nervosa; 
  9. bulimia nervosa; and 
  10. treatment of a child under age 18 who: a) is suffering from one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms; and b) meets the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and Institutions Code.
Sickness means disease or illness of the Covered Person which causes loss while the Covered Person is insured under the Policy. All Sicknesses due to the same or a related cause are considered one Sickness. Sickness also includes pregnancy and complications of pregnancy.


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