Ambulatory Surgical Center means a facility, licensed as such, that provides outpatient surgical services. It does not include a Hospital, Physician or Dentist's office, a clinic, or any other such location.
<Back To Top>
Coccyx means four fused vertebrae at the bottom of the spine.
<Back To Top>
Common Carrier means a vehicle in which an Insured Person is a passenger at the time of the accident and which vehicle is duly licensed by a proper authority to transport passengers for a fee. Common-carrier vehicles are limited to airplanes, trains, buses, trolleys and boats that operate on a regularly scheduled basis between predetermined points or cities. A taxi is not a common-carrier vehicle.
<Back To Top>
Complications of Pregnancy means any condition which: (1) is diagnosed as being distinct from pregnancy but is adversely affected by or caused by pregnancy and (2) requires a Hospital stay. Such conditions include: acute nephritis, nephrosis, cardiac decompression, missed abortion, ectopic pregnancy, spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible, and similar medical and surgical conditions of comparable severity.
Complications of pregnancy do not include: (1) false labor, occasional spotting, physician prescribed rest during a period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia; (2) any condition similar to those named above, associated with the management of a difficult pregnancy, not constituting a nosologically distinct complication of pregnancy; or (3) non elective cesarean section.
<Back To Top>
Coma means a profound state of unconsciousness that lasts for a period of at least 96 hours and from which the Insured Person cannot be aroused to consciousness, even by powerful stimulation, as determined by a Physician.
<Back To Top>
Concussion means significant blow to the head that may result in unconsciousness.
<Back To Top>
Covered Activity (ies) means those activities set out in the Covered Activities section of the Schedule with respect to which Insured Persons are provided accident and Sickness insurance under the Policy.
<Back To Top>
Dislocation means that one or more bones are out of place, out of joint, or out of position. Dislocation doers not include fingers and toes.
<Back To Top>
Domestic Partner means a same or an opposite sex partner who has met all of the following requirements for at least 12 consecutive months immediately preceding the Effective Date of Coverage: (1) resides with the Insured; (2) shares financial assets and obligations with the Insured; (3) is not related by blood to the Insured to a degree of closeness that would prohibit a legal marriage; (4) is at least the age of consent in the state in which they reside; and (5) neither the Insured or Domestic Partner is married to anyone else, nor has any other Domestic Partner. The Company requires proof of the Domestic Partner relationship in the form of a signed and completed Affidavit of Domestic Partnership.
<Back To Top>
Eligible Dependent means an Eligible Spouse or an Eligible Dependent Child.
<Back To Top>
Eligible Dependent Child(ren) means the Insured’s unmarried children, including natural, step, foster or adopted children from the moment of placement in the home of the Insured, under age 19, (25 if attending an accredited institution of higher learning on a full time basis) and primarily dependent on the Insured for support and maintenance.
Any unmarried Eligible Dependent Children of the Insured covered under the Policy before reaching the age limit specified above, who are incapable of self-sustaining employment by reason of mental or physical incapacity, and who are primarily dependent on the Insured for support and maintenance, may continue to be eligible under the Policy beyond that age limit for as long as the Policy is in force, but only if they remain continuously covered under the Policy. The Company may request that the Insured submit satisfactory proof of the Eligible Dependent Child(ren)'s incapacity and dependency to the Company within 60 days before the Eligible Dependent Child(ren) reach the age limit specified above. If the Insured fails to furnish the requested proof before the Eligible Dependent Child(ren) reach the age limit, coverage for the Eligible Dependent Child(ren) will not be extended past the age limit. If coverage is extended, the Company may request that the Insured submit satisfactory proof of the Eligible Dependent Child(ren)'s continued incapacity and dependency to the Company on an annual basis. If the Insured fails to furnish the requested proof within 31 days of the request, coverage for the Eligible Dependent Child(ren) will terminate at the end of that 31-day period.
<Back To Top>
Eligible Spouse means the Insured's legal spouse or Domestic Partner.
<Back To Top>
Elimination Period means the number of consecutive days that an Insured Person must be confined in a Hospital before a Hospital Confinement Benefit becomes payable.
<Back To Top>
Emergency Treatment means treatment for a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the person (or with respect to a pregnant woman, the health of her unborn child) in serious jeopardy;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
<Back To Top>
Family Coverage means coverage in force under the Policy on an Insured’s Eligible Dependents: 1) whom the Insured has elected to cover under the Policy; and (2) for whom premium has been paid.
<Back To Top>
Fracture means a break or rupture in the continuity of the bone or cartilage and includes, but is not limited to: complete fractures; compound fractures; compression fractures; depressed fractures; open fractures; simple fractures.
<Back To Top>
Hairline Fracture means a break that appears as a narrow crack along the surface of the bone.
<Back To Top>
Hospice means a licensed agency, organization, or unit that provides a centrally administered and autonomous continuum of palliative and supportive care to terminally ill persons and their families. The care must be directed and coordinated by the Hospice organization and received primarily in the patient's home, or on an outpatient or short-term inpatient basis in a Hospice unit.
<Back To Top>
Hospital means a legally operated institution licensed by the state in which it is located that maintains and uses a laboratory, X-ray equipment and an operating room on its premises or in facilities available to it on a prearranged, written, contractual basis. The institution must also have permanent and full-time facilities for the care of overnight-resident bed patients under the supervision of one or more licensed Physicians, provide 24-hour-a-day nursing service by or under the supervision of a registered professional nurse, and maintain the patients' written histories and medical records on the premises. The term "Hospital" does not include any institution or part thereof used as a Rehabilitation Unit; a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders, care for the aged, or care for persons addicted to drugs or alcohol.
<Back To Top>
Immediate Family Member means a person who is related to the Insured 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).
<Back To Top>
Injury means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that is external to the body and that occurs while the injured person's coverage under the Policy is in force, and (2) which directly (independent of sickness, disease, mental incapacity, bodily infirmity or any other cause) causes a covered loss [and (3) which occurs while such person is participating in a Covered Activity].
<Back To Top>
Inpatient means confined overnight as a registered bed patient in a Hospital or other medical facility where at least one day’s room and board is charged. The confinement must be on the advice of a Physician.
<Back To Top>
Insured means a member of an eligible class of persons as described in the Schedule and for whom premium has been paid while covered under the Policy.
<Back To Top>
Insured Dependent means an Insured Spouse or an Insured Dependent Child.
<Back To Top>
Insured Dependent Child(ren) means the Insured’s Eligible Dependent Child(ren): (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy.
<Back To Top>
Insured Person means an Insured or an Insured Dependent.
<Back To Top>
Insured Spouse means the Insured’s Eligible Spouse: (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy.
<Back To Top>
Intensive Care Unit (ICU) means a specifically designated facility of the Hospital that provides the highest level of medical care and that is restricted to those patients who are critically ill or injured. Such facilities must be separate and apart from the surgical recovery room and from rooms, beds, and wards customarily used for patient confinement. The ICU must be permanently equipped with special lifesaving equipment for the care of the critically ill or injured, and the patients must be under constant and continual observation by nursing staffs assigned exclusively to the ICU on a full-time basis. These units must be listed as Intensive Care Units in the current edition of the American Hospital Association Guide or be eligible to be listed therein. This guide lists three types of facilities that meet this definition: (1) Intensive Care Units, (2) Cardiac Intensive Care Units, and (3) Infant (Neonatal) Intensive Care Units.
<Back To Top>
Limb means entire arm or entire leg.
<Back To Top>
Loss of a hand or foot means complete severance through or above the wrist or ankle joint.
<Back To Top>
Loss of sight or an eye means total and irrecoverable loss of the entire sight in that eye.
<Back To Top>
Osteoporosis means the thinning of bone with reduction in bone mass due to depletion of calcium and bone protein. <Back To Top>
Pathological Fracture means any Fracture in an area where pre-existing disease has caused weakening of the bone.
<Back To Top>
Period of Confinement means a time period of continuous confinement as an Inpatient in a Hospital or other medical facility. If the confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless the later confinement is the result of an entirely unrelated Injury or Sickness or the confinements are separated by 30 days or more.
<Back To Top>
Physician means a licensed practitioner of the healing arts acting within the scope of his or her license who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder.
<Back To Top>
Pregnancy means childbirth, miscarriage, abortion or any complications thereof.
<Back To Top>
Prosthetic Device/Prosthesis means a removable artificial substitute or replacement of a part of the body. It does not include:
- Dental aids, including false teeth,
- Eyeglasses,
- Cosmetic prosthesis such as hair wigs,
- Other types of prosthesis devices that are permanently implanted such as artificial hip or tooth,
- Any experimental prosthesis,
- Any auditory prosthesis (a device that substitute for or enhances ability to hear).
<Back To Top>
Quadriplegia means the complete and irreversible paralysis of both upper and both lower limbs.
<Back To Top>
Rehabilitation Facility means an institution whose primary purpose is to provide restorative therapy to disabled persons. Such facility must be licensed as such in the state in which it operates. "Rehabilitation Facility" does not include places for custodial care or places for confinement of drug addicts or alcoholics.
<Back To Top>
Rehabilitation Unit means a unit of a Hospital providing coordinated multidisciplinary physical restorative services to inpatients under the direction of a Physician who is knowledgeable and experienced in rehabilitative medicine. Beds must be set up and staffed in a unit specifically designated for this service.
<Back To Top>
Reduction means restoration to a normal position, of a dislocated bone or joint.
<Back To Top>
Schedule means the schedule found in the beginning of this certificate.
<Back To Top>
Severe Burn/Severely Burned means cosmetic disfigurement of at least 20% of the surface of a body area due to an Injury that is a third-degree, full-thickness burn, as determined by a Physician. The Company has a right, at its own expense, to have the Physician’s determination verified by a Physician of the Company’s choice. (A third degree, full-thickness burn is the destruction of the skin through the entire thickness or depth of the dermis and possibly into underlying tissues, with loss of fluid and sometimes shock, by means of exposure to fire, heat, caustics, electricity or radiation).
<Back To Top>
Sickness means an illness or disease that requires treatment by a Physician. Sickness includes pregnancy.
<Back To Top>
Skilled Nursing Facility means a lawfully operating institution or a distinct part thereof. Such facility must be engaged mainly in providing skilled nursing care and treatment for people convalescing from an injury or sickness. It must: (1) have organized facilities for medical services; (2) provide 24 hour a day nursing services under the full-time supervision of a Physician or a registered nurse; (3) have available the services of a Physician at all times; (4) maintain daily clinical records on each patient; and (5) provide appropriate methods for dispensing and administering drugs and medicines.
A Skilled Nursing Facility shall include the following facilities that are operating within the scope of their lawful licenses: (1) a rehabilitation center; (2) a transitional care unit; (3) an intermediate nursing facility; (4) an extended care facility; and (5) a nursing home.
A Skilled Nursing Facility does not mean a home or facility, or part of home or facility, that is used primarily for: (1) rest; (2) the aged; (3) alcoholics or drug addicts; (4) mental illness or disorders; (5) custodial care; or (6) educational care.
<Back To Top>
|
