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Underwritten by
Pan-American Life Insurance Company
Preferred Short Term Medical Plan 2 1K/20/3K/1M Extended
$259.01/month

Overview

Cost breakdown

Monthly Premium

$219.03

Teladoc

$19.99

AFEUSA Association

$19.99

PEP Benefit
(one time payment)

$15.00

Initial total cost

$274.01

Benefits & coverage

Plan Type

PPO - PHCS Practitioner & Ancillary Only Network

Deductible

Individual: $1,000.00

Coinsurance

20% after deductible

Policy maximum benefit

$1,000,000.00

Policy term

3 x 364 days

HIPAA creditable coverage

No

Max out of pocket

$3,000.00

Out-of-network coverage

Yes

Office visit for primary doctor or urgent care

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. After a $25 Copayment for the first 3 visits, the Company will pay 100% of the Coinsurance Percentage for Covered Expenses and the Deductible will not apply. After the first 3 visits, Covered Expenses will be subject to Deductible and Coinsurance. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance. Not to exceed $1,000 per Coverage Period, including all additional services or test performed during the Office Visit. (This maximum will not apply to any services or tests that fall under another Benefit)"

Coinsurance Maximum

Individual: $2,000.00

Does Out of Pocket Maximum Amount include deductible?

No

Out of country coverage

N

Waiting Period for Illnesses

5 days, 30 days for Cancer, 6 months for various covered surgeries

Primary Care Physician (PCP) Required

No

Specialist Referrals Required

No

Network

PPO - MultiPlan PHCS Practitioner & Ancillary Only Network

Periodic Health Exam

$50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period.

Periodic OB-GYN Exam

Yes

Well Baby Care

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. The Deductible will not apply to Immunizations. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance.

OB-GYN Exam Conditions

$50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period.

Generic Prescription Drugs

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided

Brand Prescription Drugs

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided

Non-Formulary Prescription Drugs Coverage

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided

Emergency Room

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses, including the emergency room Doctor charge, 24 hour observation and all miscellaneous medical expenses incurred during the emergency room visit. Covered Expenses are subject to the Deductible and Coinsurance. Covered Expenses will not exceed a maximum benefit of $1,000 per visit.

Outpatient Lab/X-Ray

Included as part of Outpatient Miscellaneous Expense Services

Outpatient Surgery

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed $10,000 per surgery, maximum of $20,000 per Coverage Period

Hospitalization Regular Care

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed the Average Standard Room Rate charged by the Hospital, including all Inpatient Miscellaneous Medical Expenses, maximum $5,000 per day.

Pre & Postnatal Office Visit

Not Covered

Labor & Delivery Hospital Stay

Not Covered

Chiropractic Coverage

Not Covered

Mental Health Coverage

After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Outpatient: Not to exceed $100 per visit, maximum of 10 visits per Coverage Period Inpatient: Not to exceed $100 per day, maximum of 30 days per Coverage Period.

Physician network

One of the popular aspects of short-term medical insurance plans is they do not confine you to a specific network. In other types of major medical plans if a member seeks services outside of the network they either have a higher percentage of cost shares or they have to pay the full claim themselves. The only downside to the open network allowance is that you may get balance billed. To avoid the chance of balance billing, you need to see a network provider. The plan’s network is the Multiplan PHCS network.

The plan’s network is the Multiplan PHCS network.

 

 

Please note: PHCS Network applies to outpatient physicians only. 
Facility Charges (Inpatient and Outpatient) benefit amounts are payable at 150% of the Medicare Rate.

Limitations & Exclusions

We will not pay for loss or expense caused by or resulting from any of the following:

PRE-EXISTING CONDITIONS LIMITATION

We will not provide benefits for any loss caused by, or resulting from, a Pre-Existing Condition. Pre-Existing Conditions means any medical condition or Sickness for which:

  1. Medical advice, care, diagnosis, treatment, Consultation, or medication was recommended by or received from a Doctor within the 24 months immediately prior to  Covered Person’s Effective Date of coverage; or
  2. Symptoms existed within the 24 months immediately prior to the Covered Persons Effective Date of coverage which would cause a reasonable person to seek diagnosis, care or treatment.

Consultation means evaluation, diagnosis, or medical advice was given with or without the necessity of a personal examination or visit. This limitation does not apply to a newborn child or newborn adopted child who is added to coverage in accordance with Eligibility provision.

This limitation does not apply to any Covered Expense payable for Pre-Existing Conditions until the Pre-Existing Allowance Maximum benefit shown in the Schedule of Benefits has been reached.

  1. Expenses for the treatment of Preexisting Conditions, as defined in the Preexisting Conditions Limitation provision.
  2. Expenses incurred during the waiting period:
    1. Covered Persons will only be entitled to receive benefits for Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, more than 5 days following the Covered Person’s Effective Date of coverage under the Certificate. 
    2. Covered Persons will only be entitled to receive benefits for Cancer that begins, by occurrence of symptoms or receipt of treatment more than 30 days following the Covered Person’s Effective Date of coverage under the Certificate.
  3. Expenses incurred prior to the Effective Date of a Covered Person’s coverage or incurred after the Expiration Date, regardless of when the condition originated, except in accordance with the Extension of Benefits provision.
  4. Expenses to treat complications resulting from treatment, drugs, supplies, devices, procedures or conditions which are not covered under the Group Policy.
  5. Expenses incurred for Experimental or Investigational services or treatment or unproven services or treatment.
  6. Amounts in excess of the Maximum Allowable Expense for covered services or supplies.
  7. Expenses You or Your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed.
  8. Expenses that do not meet the definition of or are not specifically identified under the Group Policy as Covered Expenses.
  9. Expenses for purposes determined by Us to be educational.
  10. Expenses to the extent that they are paid or payable under another group insurance or medical prepayment plan.
  11. Charges that are eligible for payment by Medicare or any other government program except Medicaid.
  12. Expenses for care in government institutions unless You or Your Covered Dependent are obligated to pay for such care.
  13. Expenses related to Injury or Sickness arising out of or in the course of any occupation for compensation, wage or profit, if the Covered Person is insured, or is required to be insured, by occupational disease or workers’ compensation insurance pursuant to applicable state or federal law, whether or not application for such benefits has been made.
  14. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).
  15. Expenses incurred by a Covered Person while on active duty in the armed forces. Upon written notice to Us of entry into such active duty, the unused premium will be returned to You on a pro-rated basis.
  16. Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection.
  17. Expenses incurred while engaging in an illegal act or occupation or during the commission, or the attempted commission, of a felony or assault.
  18. Expenses for the treatment of normal pregnancy or childbirth, except for Complications of Pregnancy.
  19. Expenses for voluntary termination of normal pregnancy or elective cesarean section.
  20. Expenses incurred for any drug, including birth control pills, implants, injections, supply, treatment device or procedure that prevents conception or childbirth.
  21. Expenses for the diagnosis and treatment of infertility, including but not limited to any attempt to induce fertilization by any method, in vitro fertilization, artificial insemination or similar procedures, whether the Covered Person is a donor, recipient or surrogate.
  22. Expenses for sterilization or reversal of sterilization.
  23. Charges for a Covered Dependent who is a newborn child not yet discharged from the Hospital, unless the charges are Medically Necessary to treat premature birth, congenital Injury or Sickness, or Sickness or Injury sustained during or after birth, and except as state mandates.
  24. Expenses for sex transformation or penile implants or sex dysfunction or inadequacies.
  25. Expenses for physical exams or other services not needed for medical treatment, except as specifically covered.
  26. Expenses for prophylactic treatment, including surgery or diagnostic testing, except as specifically covered.
  27. Expenses for the treatment of mental illness or nervous disorders, including, but not limited to, neurosis, psychoneurosis, psychopathy, psychosis, attention deficit disorder, autism, hyperactivity, or mental or emotional disease or disorder of any kind; unless it is specifically covered.
  28. Expenses for the treatment of alcoholism or alcohol abuse, chemical dependency, substance abuse or drug addiction; unless it is specifically covered.
  29. Expenses incurred for loss sustained or contracted in consequence of the Covered Person being intoxicated or under the influence of any narcotic unless administered on the advice of a Doctor. Intoxication shall be established conclusively by a blood alcohol level of .10 or the legal limit in the state where the incident occurred, whichever is less.
  30. Expenses incurred in connection with programs, treatment, or procedures for tobacco use cessation.
  31. Expenses resulting from suicide or attempted suicide or intentionally self-inflicted Injury, while sane or insane.
  32. Expenses for dental treatment or care or orthodontia or other treatment involving the teeth or supporting structures, except as specifically covered.
  33. Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofacial pain dysfunction or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, unless it is specifically covered.
  34. Expenses of radial keratotomy or correction of refractive error, eye refractions, vision therapy, routine vision exams to assess the initial need for, or changes to prescription eyeglasses or contact lenses, the purchase, fitting or adjustment of eyeglasses or contact lenses, or treatment of cataracts.
  35. Expenses for routine hearing exams to assess the need for or change to hearing aids, or the purchase, fittings or adjustments of hearing aids.
  36. Expenses for cosmetic or reconstructive procedures, services or supplies; except as specifically covered.
  37. Expenses for breast reduction or augmentation or complications arising from these procedures; except as specifically covered.
  38. Outpatient Prescription or Legend Drugs, medications, vitamins, and mineral or food supplements, including pre- natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor, unless it is specifically included as a Covered Expense. This does not include Prescription or Legend Drugs administered by a Doctor in an inpatient or outpatient setting in conjunction with a Covered Expense, unless they are drugs that can be self-administered.
  39. Expenses incurred in connection with any drug or other item used to treat hair loss.
  40. Expenses incurred in the treatment of weak, strained, flat, unstable, or unbalanced feet, metatarsalgia, bunions, spurs, or the removal of corms, calluses or toenails, unless specifically for the treatment of a metabolic or peripheral vascular disease or for the prompt repair of an Injury sustained while coverage is in force for the Covered Person.
  41. Expenses incurred in the treatment of acne, or varicose veins.
  42. Expenses of weight loss programs or diets.
  43. Transportation Expenses, except as specifically covered.
  44. Expenses for rest or recuperation cures or care in an extended care facility, convalescent nursing home, a facility providing rehabilitative treatment, Extended Care Facility, or home for the aged, whether or not part of a Hospital, unless it is specifically covered.
  45. All charges incurred while confined primarily to receive custodial or convalescent care, unless it is specifically covered.
  46. Expenses for services or supplies for personal comfort or convenience, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feeding, routine skin care, bladder care and administration of oral medications or eye drops.
  47. Expenses for services or supplies furnished or provided by a member of Your Immediate Family.
  48. Expenses for diagnosis or treatment of a sleeping disorder.
  49. Expenses incurred in the treatment of Injury or Sickness resulting from participation, instructing, demonstrating, guiding or accompanying others in the following: operation of a flight in an aircraft other than a regularly scheduled flight by an airline; extreme sports: hot-air ballooning; skydiving, scuba diving, hang or ultra-light gliding, base jumping, rock or mountain climbing, bungee jumping, sail gliding, parasailing, para kiting, cave exploration, parkour; riding an all-terrain vehicle such as a dirt bike, snowmobile or go-cart; racing with a motorcycle, boat or any form of aircraft; racing including stunt show or speed test of any motorized or non-motorized vehicle; any participation in sports for pay or profit; participation in rodeo contests; or similar hazardous activities.
  50. Expenses for the purchase of a noninvasive osteogenesis stimulator (bone stimulator).
  51. Expenses for services or supplies of a common household use, such as exercise cycles, air or water purifiers, air conditioners, allergenic mattresses, and blood pressure kits.
  52. Expenses during the first 6-months after the Effective Date of coverage for a Covered Person for:
    1. total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma;
    2. tonsillectomy;
    3. adenoidectomy;
    4. repair of deviated nasal septum or any type of surgery involving the sinus;
    5. myringotomy;
    6. tympanotomy; or
    7. herniorraphy; (subject to all other coverage provisions, including but not limited to, the Pre-existing Conditions exclusion).
  53. Expenses for participating in interscholastic, intercollegiate or organized competitive sports. This does not include dependent children participating in local community sports activities.
  54. Medical care, treatment, service or supplies received outside of the United States, Canada or its possessions, unless specifically covered.
  55. Expenses for private duty nursing services.
  56. Expenses for the repair or maintenance of a wheelchair, hospital-type bed or similar durable mechanical equipment.
  57. Expenses for orthotics, special shoes, spine and arch supports, heel wedges, sneakers or similar devices unless they are a permanent part of an orthopedic leg brace.
  58. Expenses incurred in connection with the voluntary taking of a poison or inhaling gas.
  59. Expenses incurred in connection with obesity treatment or weight reduction including all forms of intestinal and gastric bypass surgery, including the reversal of such surgery even if the Covered Person has other health conditions that might be helped by a reduction of obesity or weight.
  60. Expenses for marital counseling or social counseling.
  61. Expenses for acupuncture.
  62. Expenses for a service or supply whose primary purpose is to provide a Covered Person with (1) training in the requirements of daily living; (2) instruction in scholastic skills such as reading and writing; (3) preparation for an occupation; (4) treatment of learning disabilities, developmental delays or dyslexia; or (5) development beyond a point where function has been demonstrably restored.
  63. Expenses for replacement of artificial limbs or eyes.
  64. Expenses for removal of breast implants.
  65. Chronic fatigue or pain disorders.
  66. Kidney or end stage renal disease.
  67. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.
  68. Biofeedback, acupuncture, recreational, sleep or mist therapy, holistic care of any nature, massage and kinestherapy, excepted as provided for under Home Health Care.
  69. Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and biofeedback and non-medical self-care or self-help programs.
  70. Failure to keep a scheduled appointment.
  71. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  72. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).

Disclaimer: Preferred STM limitations, exclusions, terms, and conditions may vary by state law. Please check the product certificate or master policy for complete details.

RTBs

Definitions

This section provides the meaning of special terms used in this Certificate.  Whenever the following terms appear capitalized in this Certificate, these definitions apply. 

Accident means an act or event which: (1) is unforeseen, unexpected and unanticipated and is the direct cause of a loss covered under the Policy;  (2) is definite as to time and place; (3) is not a Sickness; and (4) occurs on or after the Certificate Effective Date and while insurance is in effect for a Covered Person.

Ambulatory Surgical Center means a licensed health care facility whose main purpose is the diagnosis or treatment of patients by surgery. It must (1) admit and discharge the patient within the same working day; (2) be supervised by a Doctor; (3) require a licensed anesthesiologist or licensed Certified Registered Nurse Anesthetist to administer anesthesia and remain during the surgery; (4) provide a post-anesthesia recovery room; and (5) have a written agreement with at least one Hospital for immediate acceptance of patients who develop complications.

“Ambulatory surgical center” does not include: (1) a facility whose main purpose is performing terminations of pregnancy; (2) an office maintained by a Doctor for the practice of medicine; or (3) an office maintained for the practice of dentistry.

Coinsurance Percentage means the applicable percentage amount the Company will pay for Covered Expenses incurred by the Covered Person after satisfaction of the Deductible and any Copayments have been met. 

Coinsurance Maximum means the maximum amount of Covered Expenses that the Covered Person will pay before the Company will begin paying benefits at 100% of Covered Expenses for the remainder of the Coverage Period, not to exceed the Coverage Period Maximum Benefit Amount and any applicable maximum benefit amounts. The Coinsurance Maximum does not include Deductibles, Copayments, Pre-Authorization penalties, amounts in excess of the Maximum Allowable Expense and amounts in excess of the maximum benefit amounts. 

Complications of Pregnancy means: (1) conditions (when pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by or caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, hyperemesis gravidarum, preeclampsia, and similar medical and surgical conditions of comparable severity; and (2) non-elective Cesarean section, ectopic pregnancy which is terminated and spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.

“Complications of Pregnancy” does not include false labor, occasional spotting, Doctor-prescribed rest during the period of pregnancy, morning Sickness, elective Cesarean section, and similar conditions associated with the management of a difficult pregnancy but not constituting a nosologically distinct complication of pregnancy.

Confined/Confinement means the time in which a Covered Person is a Registered Bed-Patient in a Hospital, on the order of a Doctor, for Medically Necessary medical treatment.

Copayment means the amount required to be paid by a Covered Person each time a specific service is provided, as shown in the Schedule of Benefits.  Copayments are deducted before any applicable Deductible or Coinsurance Percentage is applied. Copayments do not apply toward the Coinsurance Maximum.

Covered Dependent means Eligible Dependents who have become Covered Person(s) under the Group Policy.

Covered Expenses means Expenses for treatments, services and supplies which a Doctor recommends (1) as Medically Necessary to treat a Sickness or Injury; (2) which are not in excess of the Maximum Allowable Expense; and (3) which are not otherwise excluded by this Certificate or exceed any amount payable under the terms of this Certificate.  The Company reserves the right to interpret and determine coverage for Covered Expenses.

Coverage Period means the length of time coverage is in force under this Certificate, as shown in the Schedule of Benefits. 

Coverage Period Maximum Benefit Amount means the total aggregate amount of benefits payable under the Certificate for all Covered Expenses which are incurred for Sickness or Injury by each Covered Person during such person's Coverage Period. 

Covered Person(s) means You and Your Covered Dependents.

Deductible means the amount of Covered Expenses, up to the Maximum Allowable Expense, that each Covered Person must pay before benefits will be payable.  The Deductible is shown in the Schedule of Benefits and does not include any Copayment amounts. The Deductible does not apply towards the Coinsurance Maximum.

Doctor means a licensed practitioner of the healing arts who is practicing and treating within the scope and limitations of that license.  “Doctor” does not include You, a Covered Dependent, Immediate Family, or a Covered Person’s employer.

Domestic Partner means a person of the opposite or same sex with whom the Covered Person has established a Domestic Partnership. In no event, will a person's legal spouse be considered a Domestic Partner.

Domestic Partnership means a relationship between the Covered Person and one other person of the opposite or same sex. The following requirements apply to both persons:

  1. They share the same permanent residence and the common necessities of life;
  2. They are not related by blood or a degree of closeness which would prohibit marriage in the law of state in which they reside;
  3. Each is at least 18 years of age;
  4. Each is mentally competent to consent to contract;
  5. Neither is currently married to, or Domestic Partner of, another person under either a statutory or common law;
  6.  They are financially interdependent and have furnished at least two of the following documents evidencing such financial interdependence:
    1.  have a single dedicated relationship of at least 6 months duration;
    2.  joint ownership of residence;
    3. at least two of the following:
      1. joint ownership of an automobile;
      2.  joint checking, bank or investment account;
      3. joint credit account;
      4. lease for a residence identifying both partners as tenants;
      5. a will and/or life insurance policies which designates the other as primary beneficiary.
  7. The Covered Person and Domestic Partner must jointly sign an affidavit of Domestic Partnership.

Effective Date means the date coverage under the Group Policy begins for a Covered Person. The Covered Person’s Effective Date is shown on the Schedule of Benefits.

Emergency means the sudden onset or sudden worsening of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possess an average knowledge of health and medicine, to result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. 

Evidence of Insurability means an Eligible Person will satisfy the insurability requirement on the day the Company agrees in writing to accept the person as insured for that amount.  To determine a person’s acceptability for coverage, the Company will require evidence of good health and may require it to be provided at the Insured Person’s expense. 

Expenses means the amounts billed for treatments, services and supplies rendered to a Covered Person.  An expense shall be considered to have been incurred on the date the treatment, service or supply was provided. 

Experimental or Investigational means a treatment, drug, device, procedure, supply or service and related services (or any portion thereof, including the form, administration or dosage) for a particular diagnosis or condition when any one of the following exists:  (1) It cannot be legally marketed without the approval of the United States Food and Drug Administration (FDA) and such approval has not been granted at the time of its proposed use; (2) It is not yet recognized as acceptable medical practice throughout the United States to treat that Illness or Injury; (3) It is the subject of either: (a) a written investigational or research protocol; or (b) a written informed consent or protocol used by the treating facility in which reference is made to it  being experimental, investigative, educational, for a research study, or posing an uncertain outcome, or having an unusual risk; or (c) an ongoing phase I, or phase II  clinical trial or as the experimental or research arm of a phase III clinical trial, as the phases are defined in regulations and other official actions and publications issued by the FDA and the Department of Health and Human Services (HHS); or (d) an ongoing review by an Institutional Review Board (IRB); (4) It does not have either: (a) the positive endorsement of national medical bodies or panels, such as the American Cancer Society; or (b) multiple published peer review medical literature articles, such as the Journal of the American Medical Association (J.A.M.A.), concerning Health Care Service and reflecting its recognition and reproducibility by non‑affiliated sources the Claims Administrator determines to be authoritative; or (5) It is regarded within a Doctor's profession as appropriate only when provided in a clinical research setting.

We may also determine whether a treatment, drug, device, procedure, supply or service is experimental or investigational by using the following evaluations:  (1) Reports in peer review medical literature; (2) Scientific evaluations published by organizations that conduct health care research such as the Agency for Health Care Policy and Research, the National Institutes of Health, the American Medical Association, and the American College of Physicians; (3) Opinions of independent medical consultants; (4) Listings in drug correspondence, including the American Medical Association's Drug Evaluations, the American Hospital Formulary Service Drug Information, and the United States Pharmacopoeia Drug Information; (5) Use of a written informed consent addressing the experimental or investigational nature of the service or supply.  This applies whether consent is used by the Covered Person's Doctor or by any other Doctor studying the same or similar service or supply;  (6) Any requirement that the use of the service or supply be subject to Institutional Review Board ("IRB") approval; or  (7) Written protocols used by the health care provider.

Extended Care Facility means an institution, other than a Hospital, operated and licensed pursuant to law, that provides:

  1. permanent and full-time facilities for the continuous skilled nursing care of three or more sick or injured persons on an Inpatient basis during the convalescent stage of their Sicknesses or Injuries;
  2. full-time supervision of a Doctor;
  3. twenty-four (24) hour a day nursing service of one or more nurses; and
  4. is not, other than incidentally, a rest home or a home for custodial care or for the aged. Extended Care Facility does not include an institution that primarily engages in the care and treatment of drug addiction or alcoholism. 

Group Policy means the contract issued to the Group Policyholder providing the benefits described herein.

Home Health Care Agency means an entity licensed by state or local law operated primarily to provide skilled nursing care and therapeutic services in an individual’s home and:

  1.  Which maintains clinical records on each patient;
  2. Whose services are under the supervision of a Doctor or a licensed graduate registered nurse (RN); and
  3. Which maintains operational policies established by a professional group, including at least one Doctor and one licensed graduate registered nurse (RN).

Home Health Care Plan means a program for continued care and treatment of an individual established and approved in writing by the individual’s attending Doctor. As part of the plan, an attending Doctor must certify that proper treatment of the Injury or Sickness would require continued confinement in a Hospital in the absence of the services and supplies.

Hospital means an institution which is legally constituted and operated in accordance with the laws pertaining to Hospitals in the jurisdiction where it is located, which meets all of the following requirements:

  1. It is engaged primarily in providing medical care and treatment to sick and injured persons on an inpatient basis at the patient's expense;
  2. It provides 24-hour-a-day nursing service by a Nurse;
  3. It is under the supervision of a staff of duly-licensed Doctors;
  4. It provides organized facilities for diagnosis and for major operative surgery either on its premises or in facilities available on a prearranged basis; and

“Hospital” does not mean primarily a clinic, nursing home, rest or convalescent home, extended care facility, Hospice or similar establishment nor, other than incidentally, a place providing care for persons with mental illness or nervous disorders; the aged; or those suffering from alcoholism or drug addiction.

Confinement in a special unit of a Hospital used primarily as a nursing, rest, or convalescent home shall be deemed to be Confinement in an institution other than a Hospital.

Immediate Family means:  (1) the parent, spouse, brother, sister or children of a Covered Person; or (2) a resident in a Covered Person’s household.

Injury means bodily harm caused by an accident, directly and independently of Sickness or bodily infirmity, resulting in unforeseen trauma requiring immediate medical attention. The Injury must occur after the Covered Person’s Effective Date of coverage and while such person’s coverage is in force.  All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries, will be considered one injury.  Bodily damage caused by chewing is not considered an Injury.

Intensive Care Unit means a section, ward or wing within a Hospital which is separated from other Hospital facilities and: (1) is operated exclusively for the purpose of providing professional care and treatment for critically ill patients; (2) has special supplies and equipment necessary for such care and treatment which are available on a standby basis for immediate use; (3) provides room and board, and constant observation by a Nurse or other specially-trained Hospital personnel; and (4) is not maintained for the purpose of providing normal postoperative recovery treatment or service.

Initial Coverage Period means the initial length of time the Covered Person elected which begins on the Effective Date shown in the Schedule of Benefits.

Maximum Allowable Expense means the maximum charge that will be considered as a Covered Expense. It will be the lesser of billed charges, the Usual and Customary Fee, the negotiated or contracted discount, the Coverage Period Maximum Benefit Amount under this coverage, or 150% of the Medicare allowable charge.  The Company has discretionary authority to determine the Maximum Allowable Expense.

Medically Necessary means a Confinement, service, supply, or treatment that meets each of these requirements:

  1.  It is ordered by a Doctor for the diagnosis or the treatment of a Sickness or Injury; 
  2. For services, supplies, or treatment, the prevailing opinion within the appropriate specialty of the United States medical profession is that such service, supply, or treatment is safe and effective for its intended use, and that omission would adversely affect the Covered Person's medical condition. For Confinement in a Hospital, the prevailing opinion within the appropriate specialty of the United States medical profession is that inpatient acute care Confinement is necessary and any lesser level of care would adversely affect the Covered Person's medical condition; and
  3. It is furnished by a provider with appropriate licensing, training, experience, staff and facilities to offer that particular service or supply.

The fact that a Doctor may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Group Policy.

Mental Illness means any condition classified as neurosis, psychoneurosis, psychopathy, psychosis, or functional disorders of any type or cause appearing in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (the "DSM").

Nurse means a licensed registered graduate professional Nurse (R.N.) or a licensed practical Nurse (L.P.N.) who is under the direction of a Doctor. Nurse does not include the Immediate Family of a Covered Person.

Policyholder means the entity that has elected to offer You coverage under the Group Policy.

Prescription Or Legend Drugs means (1) a Legend Drug; (2) injectable insulin prescribed by a Doctor; (3) a compounded drug of which at least one part is a Legend Drug; or (4) any other drug that, under state law, may only be dispensed upon the written prescription of a Doctor. 

Registered Bed-Patient means an individual who, while Confined to a Hospital, is assigned to a bed in any department of the Hospital, and for whom a charge for room and board is made by the Hospital.

Rehabilitative means treatment for purposes of restring bodily function which has been lost due to a covered Sickness or Injury. Care ceases to be rehabilitative when the patient can perform the activities which are normal for someone of the same age and gender or the patient has reached maximum therapeutic benefit and further treatment cannot restore bodily function beyond the level the patient currently possess.

Routine Physical Exam means examination of the physical body by a Doctor for preventive or informative purposes only, and not for the diagnosis or treatment of any condition.

Sickness means an illness, disease, or infection which begins while coverage is in force under the Group Policy for the Covered Person.  All related conditions and recurring symptoms of Sickness to the same person will be considered one Sickness.  Sickness includes Complications of Pregnancy, provided conception occurred after the Covered Person’s Effective Date of coverage.

Substance Abuse means alcohol, drug (whether prescribed by a Doctor or not) or chemical abuse, overuse or dependency and the resultant physiological and/or psychological effects requiring medical treatment, procedures, services or supplies, including detoxification.

Usual, Reasonable and Customary means:

  1.  With respect to fees or charges, fees for medical services or supplies which are: (a) usually charged by the provider for the service or supply given; and (b) the average charged for the service or supply in the locality in which the service or supply is received; whichever is less, or
  2.  With respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition.

In reaching a determination as to what amount should be considered as Usual, Reasonable and Customary for services and supplies, We may use and subscribe to a standard industry reference source that collects data and makes it available to its member companies.  The data base used reflects the amounts charged by providers for health care services based on geographic zip code areas generating a statistically credible charge distribution.  The data is reflective of reported provider charges from the lowest to the highest for each service or supply.  The data is also adjusted periodically to reflect negotiated fee schedules with providers not included in the data base.

We, Us, Our, Company means Pan-American Life Insurance Company.

You or Your (alsoCertificateholder) means an Eligible Person who is properly enrolled for coverage under the Group Policy. You are the person (who is not a Dependent) on whose behalf the Group Policy is issued to the Policyholder.

 

*Definitions vary by state.  Please refer to your Certificate or Policy for details 

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