Additional terms which may be applicable to this Plan may be found at www.healthcare.gov/glossary/.
Accident is a happening arising from identifiable, extrinsic sources that is not expected, foreseen, or intended resulting in an injury, loss or damage.
Calendar Year means January 1st through December 1st of the same year.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Cosmetic Procedure is a procedure performed solely for the improvement of a person's appearance rather than for the improvement or restoration of bodily function. Generally such procedures are not covered under the Plan.
Elective Procedure is a medical procedure which is not provided within 72 hours does not cause a life-threatening situation for the Covered Person.
Eligible Procedure is a medical expense for which a health benefit plan will provide eligible benefits.
Emergency Care is initial treatment given in a hospital's emergency room directly following:
(1) The sudden and unexpected acute medical condition that, without medical care within 48 hours of onset, could result in death or cause serious impairments of bodily functions;
(2) An accident causing injuries which are severe enough to require immediate hospital level care. Hospital care will be deemed to be required only if safe and adequate care could not have been provided elsewhere.
Employer is a legal entity which currently is under contract with the Fund through a Participation Agreement, whose contributions to the Fund are current and is otherwise in good standing.
ERISA is the Employee Retirement Income Security Act of 1974, as amended.
Experimental care and treatment that which is not approved or accepted as essential to the treatment of Injury or Sickness by The American Medical Association, The United States Surgeon General, The United States Department of Public Health, The American Dental Association or The American Osteopathic Association.
Extended Care Facility is an institution, or a distinct part of an institution, which is licensed to provide inpatient care to persons convalescing from Injury or Illness including, but not limited to:
Professional nursing services rendered by a Registered Nurse (RN) or by a Licensed Practical
Physical restoration services assisting patients in reaching a degree of bodily function
permitting self-care in essential daily living activities;
Providing 24 hour per day nursing services by licensed nurses, under the direction of a
full-time Registered Nurse;
Maintaining a complete medical record on each patient.
It is not, other than incidental, a place for rest, the aged, drug addicts, alcoholics, mentally handicapped, custodial or educational care, or care of mental disorders.
Facility refers to facilities such as general hospital, surgi-center, mental illness/substance abuse facility, hospice facility, nursing home, half-way house, and other facilities of confinement when used in the treatment of any illness, injury, mental or nervous condition, drug abuse or alcoholism.
Illness is a bodily disorder, disease, physical sickness, mental infirmity, or functional nervous disorder for a Covered Person. A recurrent illness will be considered one illness. Concurrent Illnesses are totally unrelated. All such disorders existing simultaneously which are due to the same or related causes shall be considered one illness.
Injury is an accidental bodily injury.
In-Patient is a person who is a resident patient using and being charged for room accommodations and board by a Hospital, but shall not include any such person for any day on which he is on leave or otherwise absent from the facility where he is a resident patient, irrespective of whether a room and board charge is made.
Intensive Care Unit is defined as separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a "coronary care unit" or an "acute care unit." It has:
Facilities for special nursing care not available in regular rooms and wards of the
Special life saving equipment which is immediately available at all times;
At least two (2) beds for the accommodation of the critically ill; and
At least one (1) Registered Nurse (RN) in continuous and constant attendance 24 hours a
Leave of Absence means that an application for a leave of absence from the Employer has been filed and approved.
Medically Necessary means those services or supplies which are required to identify or treat Covered Member's or Eligible Dependent's sickness or injury and which are:
with the symptoms or diagnosis and treatment of the condition, disease, ailment or injury;
Appropriate with regards to standards of good medical practice;
for the convenience of a Covered Member, Eligible Dependent, Physician or Hospital;
optional nor cosmetic
appropriate supply or level of service which can safely be provided to the Covered Member or Eligible Dependent;
applied to the care of inpatient, unable to be safely provided on an outpatient basis;
recommended or approved by a Physician; and
conducted for research purposes.
Furthermore, "Medically Necessary" shall not mean those services or supplies which will not
significantly improve the health of the Covered Member or Eligible Dependent.
All services and supplies for which the Fund is responsible to pay for must be determined Medically Necessary.
Medicare is the Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as amended.
Mental Disorder is neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.
Physician Therapy is the treatment by physical means, including hydrotherapy, heat, or similar modalities, physical agents, biochemical, and neurophysiological principles and devices, to relieve pain, restore maximum function, and prevent disability following disease, injury or loss of body part.
Physician is a person who is licensed to practice and who is practicing within the scope of that license as a Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of Podiatry, Doctor of Optometry, Doctor of Chiropractic, a Licensed Optician or a Licensed Psychologist.
Prescription Drugs means any of the following:
A drug or
medicine which, under federal law is required to bear the legend: "Caution: Federal law prohibits dispensing without prescription."
medicines of which at least prohibits one ingredient is included under item (1) above.
needles or syringes, but only when dispensed upon a written prescription.
Provider is a legally qualified physician, dentist, nurse, certified nurse midwife, chiropractor, physical therapist, podiatrist, psychologist, speech therapist, home health care agency or facility legally licensed to perform a covered service. Also included is a certifies and legally recognized person who has been certified by a state to render outpatient psychotherapy is an individual state mandates that a person is certified and legally qualified person to render outpatient psychotherapy.
Schedule of Benefits is established by the Trustees of the Fund, as amended from time to time and incorporated herein.
Semi-Private is a class of accommodations in a hospital, in which at least two patient beds are available per room.
Sickness is a person's illness, disease or Pregnancy (including complications). For a newborn child after birth, but before release from a medical facility, sickness also includes a congenital defect, a birth abnormality or premature birth.
Skilled Nursing Facility is a facility which primarily provides 24-hour inpatient skilled care and related services to patients requiring convalescent and rehabilitative care. Such care must be provided by either a registered nurse, licensed practical nurse or physical therapist performing under the supervision of a Physician.
Subrogation is the right of the Plan to succeed to a member's right of recovery against third party for benefits paid by the Plan to, or on behalf of, a member for services incurred for which the third party is, or may be legally liable.
Substance Abuse is physical dependence on drugs. This includes (but not limited to) dependence on tobacco and ordinary caffeine-containing drinks. Addiction must be predetermined by an individual who has received specialized training and is licensed in the state in which that individual performs such services before entry into an approved program.
Terminal Illness is an illness not responsive to treatment currently available, and which is expected to result in death of a Member or Dependent within six (6) months or less.
Urgent Care Facility is a freestanding facility that is engaged primarily in providing minor emergency and episodic medical care and that has a board certified physician, a registered graduate nurse (RN), and a registered x-ray technician in attendance at all times, and x-ray and laboratory equipment and a life support system. An urgent care facility does not include a clinic located at, operated in conjunction with, or in any way made apart of a regular hospital.
Usual, Customary and Reasonable Charge (UCR) is a charge which is the usual, customary and reasonable charge for the treatment, supply or service, determined by comparison with the charges customarily made for similar treatments, supplies or services to individuals with similar medical conditions within a given geographical area.