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Glossary of terms
Definitions
Any word in the male gender equally applies to the female gender unless a distinction is specified.
“Accident” means a sudden, unexpected and unforeseen, identifiable event producing at the time objective symptoms of an Injury. The Accident must occur while the Insured is covered under this Policy.
“Ambulance” means a ground vehicle which is licensed as required by law, as an Ambulance, and is equipped to transport sick or injured people.
“Authorities” means:
Textbooks:
Cecil Textbook of Medicine, (newest edition, W. B. Saunders Company, Publisher);
Scientific American Medicine, (newest update, Scientific American, Inc., Publisher);
Conn’s Current Therapy, (newest edition, W. B. Saunders Company, Publisher);
Schwartz Principles of Surgery, (Newest edition, McGraw-Hill, Publisher);
Nelson’s Textbook of Pediatrics, (Newest edition, W. B. Saunders Company, Publisher);
Sabiston’s Textbook of Surgery, (Newest edition, W. B. Saunders Company, Publisher).
Periodicals:
Medical Letter;
Journal of American Medical Association;
New England Journal of Medicine;
Disease-a-Month, (Mosby-Yearbook, Inc., Chicago, IL).
"Benefit Maximum" means the maximum amount payable under the Policy for each Covered Person for each benefit as stated in the Benefit Specifications.
[“Child” includes Your natural children. It also includes adopted children, stepchildren and other children provided:
They depend upon You for support; and
They have a parent-child relationship with You.
If both parents of a Child are Insured Persons, the Child will be considered as a Dependent of either parent. The Child may not be considered a Dependent of both parents.]
“Coinsurance” means the shared percentage of Usual and Customary charges that are payable by Us after the Deductible or Co-payment. The Coinsurance we pay is shown in the Benefit Specifications.
“Complications of Pregnancy” means:
Conditions, requiring Hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Examples are acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity. False labor, occasional spotting, Physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy are not considered “Complications”;
Non-elective caesarean section;
Ectopic pregnancy which is terminated;
Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.
“Complications of Pregnancy” as defined above are covered under the policy to the same extent as any other Sickness.
“Co-payment” means the charge, which You are required to pay for certain health services provided under the Plan. You are responsible for the payment of any Co-payment directly to the provider of health services at the time of service.
“Covered Expense” means Usual and Customary Charges for the services, supplies, care or treatment covered under the Policy which are incurred by a Covered Person as a result of Injury or Sickness and for which the Covered Person is legally obligated to pay and are not otherwise excluded or limited herein.
“Covered Person” means an Employee [or Dependent] who is insured under the policy.
“Creditable Coverage” means prior health benefits coverage that may include any of, or a combination of, the following:
A group health plan which means an employee welfare benefit plan as defined in Section 3(1) of ERISA;
A health insurance plan or health maintenance organization (HMO) plan;
An individual health insurance policy;
COBRA continuation of coverage;
A health plan under Chapter 55, Title 10, United States Code pertaining members of the uniformed services of the United States;
Medicare or Medicaid;
A medical care program of the Indian Health Service or of a tribal organization;
A State health benefits risk pool;
A health plan offered under FEHBP (chapter 89 of Title 5, United States Code);
A health plan under section 5(e) of the Peace Corps Act; or
A public health plan.
“Custodial Care” means care which is designed to help a person in the activities of daily living when continuous attention by trained medical or paramedical personnel is not necessary. Such care may involve:
Preparation of special diets;
Supervision over medication that can be self-administered; and
Assisting the person in getting in or out of bed; to walk; to bathe; to dress; to eat; and to use the toilet.
“Customary Charge” means a charge that does not exceed the general level of charges being made by providers of similar training and experience when furnishing customary treatment for a similar Sickness, condition or Injury. The locality where the charge is incurred will also be considered. The term “locality” means a county or such greater area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made.
“Dental Treatment Plan” is a Dentist’s report, on a form satisfactory to Us which:
Itemizes the dental services recommended;
Shows the charge to be made for each dental service; and
Is accompanied by supporting pre-operative X-rays or other diagnostic materials as We may require.
“Dentist” means a duly licensed dentist acting within the scope of his license. It includes a Physician furnishing covered dental services which he is licensed to perform. He may not be a Covered Person or a member of a Covered Person’s Immediate Family. A Dentist is considered a health care provider.
“Deductible” means the amount of Covered Expenses that a Covered Person must pay for each Covered service before benefits will be paid. Deductible does not include non-Covered Expenses.
[“Dependent” means:
Your spouse;
Unmarried children who are under 19 years of age; and
Unmarried children who are 19 years of age through 25 years of age if the child:
Is attending an accredited school full-time; and
Is financially dependent upon You for support.]
“Durable Medical Equipment” means medical equipment that:
is prescribed by the Physician who documents the necessity for the item including the expected duration of its use;
can withstand long term repeated use without replacement;
is not useful in the absence of an Injury or Sickness; and
can be used in the home without medical supervision.
“Emergency” means the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which is severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following:
The patient’s health would be placed in serious jeopardy;
Bodily function would be seriously impaired;
There would be serious dysfunction of a bodily organ or part.
“Emergency Care” means medical care and treatment provided after the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following:
The patient’s health would be placed in serious jeopardy;
Bodily function would be seriously impaired;
There would be serious dysfunction of a bodily organ or part.
“Experimental/Investigational Treatment” includes:
Medical devices;
Drugs and/or pharmaceutical agents; and
Procedures or treatments;
as defined below:
Medical device if any of the following applies:
It does not have FDA approval to be marketed; or
It has a 510K number, and its use is other than for the purpose or in the manner for which the original FDA approval was received. Final determination of the similarity of use per the original approval will be made by Us; or
It has FDA approval to be marketed or has a 510K number, and its use is not in accordance with the FDA approval guidelines/instructions; or
The device, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician’s supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the device is being used;
Drugs and pharmaceutical agents if any of the following applies:
It does not have FDA approval to be marketed; or
Its use does not conform to FDA licensing; or
The drug or pharmaceutical agent, alone or in combination with any other drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician’s supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which such drug or pharmaceutical agent is being used;
Procedures or treatments performed or rendered by a Physician or under a Physician’s supervision if any of the following applies:
It requires the use of a medical device, drug or pharmaceutical agent which would be considered experimental/investigational under this policy; or
It is not currently reported to be safe and effective by one of the Authorities listed; or
The use of such procedure or treatment, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed or rendered by a Physician or under a Physician’s supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the procedure or treatment is performed or rendered.
“Employee” means a person who is:
Employed by an Employer contributing to the Holder; and
Eligible for insurance according to the Holder’s Rules of Eligibility which have been agreed to by Us.
“Experimental/Investigational Treatment” includes:
Medical devices;
Drugs and/or pharmaceutical agents; and
Procedures or treatments;
as defined below:
Medical device if any of the following applies:
It does not have FDA approval to be marketed; or
It has a 510K number, and its use is other than for the purpose or in the manner for which the original FDA approval was received. Final determination of the similarity of use per the original approval will be made by Us; or
It has FDA approval to be marketed or has a 510K number, and its use is not in accordance with the FDA approval guidelines/instructions; or
The device, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician’s supervision, is not currently Reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the device is being used;
Drugs and pharmaceutical agents if any of the following applies:
It does not have FDA approval to be marketed; or
Its use does not conform to FDA licensing; or
The drug or pharmaceutical agent, alone or in combination with any other drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician’s supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which such drug or pharmaceutical agent is being used;
Procedures or treatments performed or rendered by a Physician or under a Physician’s supervision if any of the following applies:
It requires the use of a medical device, drug or pharmaceutical agent which would be considered experimental/investigational under this policy; or
It is not currently reported to be safe and effective by one of the Authorities listed; or
The use of such procedure or treatment, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed or rendered by a Physician or under a Physician’s supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the procedure or treatment is performed or rendered.
“FDA” means the United States Food and Drug Administration.
[“Formulary” means the schedule of prescription drugs approved for use which will be covered by the plan and dispensed through participating pharmacies.]
“Home Health Care Services” means Necessary Treatment prescribed by a Physician and provided to the Covered Person in the home in lieu of Hospital confinement.
“Hospital” means an establishment which:
Holds a license as a Hospital (if required in the state);
Operates primarily for the reception, care and treatment of sick or injured persons as inpatients;
Provides around the clock nursing service;
Has a staff of one or more Physicians available at all times;
Provides organized facilities for diagnosis and surgery;
Is not primarily a clinic, nursing, rest or convalescent home or a Skilled nursing facility or a similar establishment; and
Is not, other than incidentally, a place for treatment of drug addiction.
The nursing service must be by registered or graduate nurses on duty or call. The surgical facilities may be either at the Hospital or at a facility with which it has a formal arrangement.
Confinement in a special unit of a Hospital used primarily as a nursing, rest or convalescent home or skilled nursing facility will not be deemed to be confinement in a Hospital.
“Hospital” also includes a licensed ambulatory surgical center. The center must have permanent facilities and be equipped and operated primarily for the purpose of performing surgical procedures. The types of procedures performed must permit discharge from the center in the same “‘working day.” The center will not qualify as a “Hospital” if:
Its primary purpose is performing abortions;
It is maintained as an office by a Physician for the practice of medicine; or
It is maintained as an office for the practice of dentistry.
“Hospital” also includes a licensed emergency treatment center. The center must have permanent facilities and:
A Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) present at all times;
An M.D. specialist representing each of the major specialties available within minutes;
Ancillary services, including laboratory and X-ray, staffed at all times; and
A pharmacy staffed, or on call, at all times.
“Immediate Family” means the spouse, children, brothers, sisters or parents of a Covered Person.
“Individual” means an Employee.
“Injury” means bodily injury caused by an Accident. The Accident must occur while coverage is in force as to the Covered Person. It must also result directly and independently of all other causes in loss covered by the policy.
“Insured Person” or “You” means an Employee who is insured under the policy.
“Intensive Care Unit (ICU)/Cardiac Care Unit (CCU)” means that part of a Hospital which
Is segregated from the rest of the hospital facilities;
Is exclusively reserved for critically ill patients who require audio-visual observation and/or cardiac monitoring as prescribed by the attending Physician; and
Provides room and board, specialized registered graduate professional nurses (RN), and special life saving equipment and supplies.
"Lifetime Benefit Maximum" means the maximum amount paid for benefits during the entire period of time that the Covered Person is covered under this Policy or any Policy issued by the Us to the Holder or Employer that replaces this Policy. The Lifetime Benefit Maximum is stated in the Benefit Specifications.
“Medicare” means benefits under Title XVIII of the Social Security Act of 1965, as amended.
“Necessary Treatment” means a service or supply that is necessary and appropriate for the diagnosis or treatment of an Injury or Sickness based on generally accepted current medical practice. A service or supply will not be considered Necessary Treatment if:
It is provided only as a convenience to the Covered Person or provider;
It is not appropriate treatment for the Covered Person’s diagnosis or symptoms;
It exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or
It is Experimental/Investigational Treatment.
The fact that a Physician may prescribe, order, recommend or approve a service or supply does not, of itself, make the service or supply Necessary Treatment.
“Nurse Midwife” means a licensed Registered Nurse who is certified as a Nurse Midwife by the American College of Nurse-Midwives and is authorized to practice as a Nurse Midwife under state regulations.
“Occupational Therapy” means the use of purposeful activities to restore and maximize independence, prevent associated disability, and maintain health. The practice encompasses assessment, treatment and consultation for individuals and groups in healthcare, educational, and community settings.
“Occurrence” means a period of Injury or Sickness. An Occurrence is deemed to have ended when [60] consecutive days have passed during which the Covered Person:
Received no medical treatment, services, or supplies for an Injury or Sickness; and
Neither took any medication, nor had any medication prescribed, for an Injury or Sickness.
“Open Enrollment Period” means the number of days each year during which Employees [and their Dependents] may enroll for health coverage under this plan. The Open Enrollment Period is shown in the Benefit Specifications.
“Outpatient Surgery Facility” means a licensed or certified public or private medical facility:
With an organized staff of Physicians;
Which is permanently equipped and operated primarily for the purpose of performing surgical procedures;
Which does not provide accommodations for overnight stays; and
Which provide continuous Physician services and registered professional nursing services whenever a patient is in the facility.
The term “Outpatient Surgery Facility” will include surgical suites, and facilities operated by a Hospital, which provide scheduled, non-emergency outpatient surgical care.
The term “Outpatient Surgery Facility” does not include:
Hospital emergency room;
Trauma center;
Physician’s office (except as shown above); or
Clinic; or
Any facility that an insured Person is admitted to as an overnight bed-patient and charged for room and board.
“Physical Therapy” means physical or corrective rehabilitation or corrective treatment of any bodily or mental condition of any person by the use of physical, chemical, and other properties of heat, light, water, electricity, sound, and active, passive, and resistive exercise, and shall include evaluation, treatment planning, instruction and consultative services. Physical Therapy does not include spinal manipulations.
“Physician” means a licensed practitioner of the healing arts acting within the scope of his license. He may not be a Covered Person or a member of a Covered Person’s Immediate Family.
“Physician” includes a duly Certified Nurse Midwife with respect to treatment, service or care rendered by such Nurse Midwife within the lawful scope of practice of a duly Certified Nurse Midwife.
“Policy Year” means a consecutive 12-month period or any part of such period, beginning on the Certificate Effective Date and ending on the Certificate Anniversary Date.
“Policy Year Benefit Maximum” means the maximum amount of benefits available under the plan during a Policy Year.
“Reported” means an article which has been published or accepted for publication in a textbook or peer reviewed periodical.
“Sickness” means Sickness or disease which causes loss covered by the policy. The loss must commence while the Covered Person is insured. Pregnancy is considered a Sickness.
“Special Enrollee” means an Employee [or Dependent] who previously declined health coverage under the plan, but has experienced one of the following events:
Loses other health insurance coverage[;
Becomes a Dependent, or acquires a Dependent, due to marriage;
Becomes a Dependent, or acquires a Dependent, due to a birth, adoption or placement for adoption in the Employees home; or
Has a court order requiring coverage be provided for a spouse or Dependent Child]; or
Any other event as defined under ERISA.
Special Enrollees may join the plan if any of the above events should occur. In order to be eligible for coverage, the Special Enrollee must submit a request for enrollment and pay any required premium within 31 days of the event. Any Special Enrollee who does not request coverage within 31 days will not be able to enroll until the plan’s next Open Enrollment Period.
“Specialist” means a Physician who has advanced education and training in one clinical area of practice specific to individual diseases or systems of the body.
“Speech Therapy” means the application of principles, methods, and procedures for measurement, testing, identification, prediction, counseling, or instruction related to the development and disorders of speech, voice, or language for the purpose of identifying, preventing, managing, habilitating, or rehabilitating, ameliorating, or modifying such disorders and conditions in individuals or groups of individuals.
"Surgery" means the performance of generally accepted operative and cutting procedures, including surgical diagnostic procedures, specialized instrumentation's, endoscopic examinations, and other invasive procedures; the correction of fractures and dislocations; and any of the procedures designated by Current Procedural Terminology codes as Surgery. Surgery may be performed in a Hospital or Outpatient Surgery Facility.
“Totally Disabled” means, for an Insured Person, inability to perform the substantial and material duties of his occupation or employment. The inability must be as a result of Injury or Sickness.
“Totally Disabled” means, for a retired person, [and a Dependent spouse,] inability to engage in the substantial and material activities engaged in prior to the start of disability. The inability must be as a result of Injury or Sickness.
[“Totally Disabled” means, for a child, confinement to the house or a Hospital. The confinement must be as a result of Injury or Sickness.]
“Urgent Care Facility” means a non-Hospital-based facility which provides Necessary Treatment which is required in order to prevent serious deterioration of a Covered Person’s health and that is required as a result of an unforeseen Sickness, Injury, or onset of threatening symptoms.
“Usual and Customary” means the lesser of the actual charge or the fee regularly charged and received for a given service by the health care provider that does not exceed the general level of charges being made by providers of similar training and experience when furnishing customary treatment for a similar Sickness, condition or Injury. The locality where the charge is incurred will also be considered. The term “locality” means a county or such greater area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made.
“Visit” means a physical meeting between a Covered Person and a Physician where the Covered Person is medically diagnosed, treated, or seeks advice.
“We,” “Our” or “Us” means CIGNA HealthCare .
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