Health Insurance Terms
1. Accident means an occurrence which: (a) is
unforeseen; (b) is not due to or contributed to by sickness or disease
of any kind; and, (c) causes injury.
2. Covered Person means a covered student while coverage under the Policy is in effect.
3. 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.
4. 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 that is: (a) not in excess of the
Reasonable and Customary charges; (b) not in excess of the charges that
would have been made in the absence of this coverage; (c) is the
negotiated rate, if any, and (d) 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.
5. "Emergency Medical Condition" means
a medical condition that manifests itself by acute symptoms of
sufficient severity, including, but not limited to, severe pain or by
acute symptoms developing from a chronic medical condition that would
lead a prudent lay person, possessing an average knowledge of medicine
and health, to reasonably expect the absence of immediate medical
attention of the Injury or after onset of sickness to result in any of
the following: (a) placing the health of an individual, or with respect
to a pregnant woman, the health of the woman or her unborn child, in
serious jeopardy; (b) serious impairment to such person's bodily
functions; (c) serious dysfunction of any bodily organ or part; and, (d)
6. Injury means
bodily injury due to an accident which: (a) results solely, directly and
independently of disease, bodily infirmity or any other causes; (b)
necessary for and appropriate to the diagnosis, treatment, cure, or
relief of a health condition, illness, Injury, or disease, or its
symptoms; (c) the negotiated rate, if any; and, (d) the prevailing
charge made for a covered service in the geographic area by those of
similar professional standing.
7. Medical Necessity/ Medically Necessary means
the covered services or supplies: (a) provided for the diagnosis,
treatment, cure or relief of a health condition, illness, Injury, or
disease; and except as allowed for Clinical Trials, not for
experimental/investigational or cosmetic purposes; (b) necessary for and
appropriate to the diagnosis, treatment, cure or relief of a health
condition, illness, Injury, or disease, or its symptoms; (c) within
generally accepted standards of medical care in the community; and, (d)
not solely for the convenience of the Covered person, his or her
immediate family, or the provider.
8. Pre-Existing Condition*
means a Sickness, Injury, or pregnancy for which medical care,
treatment, diagnosis, or advice was received or recommended within the 6
months prior to the Covered Person's effective date of coverage under
9. Reasonable and Customary (R&C)
means the charge, fee, or expense which is the smallest of: (a) the
actual charge; (b) the charge usually made for a covered service by the
provider who furnishes it; (c) the negotiated rate, if any; and, (d) the
prevailing charge made for a covered service in the geographic area by
those of similar professional standing.
10. Sickness means
disease, illness, or complications of pregnancy including related
conditions and recurrent symptoms of the Sickness which begins after the
effective date of a Covered person's coverage. All Sicknesses due to
the same or a related cause are considered one Sickness.
11. *Pre-Existing Conditions Limitation
incurred by a Covered Person as a result of a Pre-Existing Condition
will not be considered Eligible Expenses for a period of 12 months of
continuous coverage while covered under the Policy. This limitation will
not apply if, during the period immediately preceding the Covered
Person's effective date of coverage under the policy, the Covered Person
was covered under prior creditable coverage for 12 consecutive months.
Prior Creditable Coverage of less than 12 months will be credited toward
satisfying the Pre-existing Condition limitation. This waiver of
Pre-existing Condition limitation will apply only if the Covered Person
becomes eligible and enrolls for coverage within 63 days of termination
of his or her prior coverage. Pre-existing Conditions limitations does
not apply to: (a) a newborn Dependent child; (b) a child adopted by the
covered Student or placed with the Covered Student for adoption, if
adoption or placement for adoption occurs while covered under the
Policy; or, (c) a foster child placed with the Covered Student while
covered under the Policy.