Any sudden and unforeseen event occurring during the policy year period, resulting in bodily injury, the cause or one of the causes of which is external to the victim’s own body and occurs beyond the victim’s control

  

An employee will be considered in active service on any day if he/she is then performing in the customary manner all the regular duties of his/her employment as performed or were capable of being performed on the last regularly scheduled work day

  

Activities of daily living are those activities normally associated with the day-to-day fundamentals of personal self-care, including but not limited to: walking, personal hygiene, sleeping, toilet/continence, dressing, cooking/feeding, medication and transferring (getting in and out of bed)

  

Treatment of a medical condition, which is covered under the terms of this policy, by needles or laser provided by or ordered by a licensed physician as defined in this policy

  

Medically necessary, short-term care for an illness or injury characterized by rapid onset, severe symptoms, and brief duration, including any intense symptoms, such as severe pain

  

The agreement between the Company, and the policyholder; who is providing coverage under this policy

  

Attention Deficit Disorder is a biologically based condition causing a persistent pattern of difficulties resulting in one or more of the following behaviors: inattention; hyperactivity; impulsivity

  

ADHD is a problem with inattentiveness, over-activity, impulsivity, or some combination of these. For these problems to be diagnosed as ADHD, they must be out of the normal range for the child's age and development

Counseling of a terminally ill or deceased member’s family by a licensed counselor, psychiatrist, psychologist, or pastor. Benefits for Bereavement Counseling are eligible for coverage only under the Outpatient Treatment, Mental Health benefit of this Policy

For the purposes of this policy, catastrophic illness is defined as the following conditions:

1	Cancer	The presence of uncontrolled growth, and the spread of malignant cells and invasion of tissue. Incontrovertible evidence of such invasion of tissue or definite histology of a malignant growth must be produced. The term “Cancer” also includes leukemia, lymphomas and Hodgkin’s disease. Non-invasive carcinomas in situ, localized non-invasive tumors showing only early malignant changes, tumors in the presence of any human immune-deficiency virus and all skin Cancers except malignant melanomas are excluded from the definition of Catastrophic Illness
2	Major Organ Failure and/or Transplant	The process, as a recipient, of a transplant of any major organ and the medical treatment preceding and following the approved transplant
3	Heart Attack	Death of a portion of heart muscle as a result of abrupt interruption of adequate blood supplies to the area. The diagnosis will be based upon all of the following criteria: a history of typical chest pain. new electrocardiograph changes. an elevation in cardiac enzyme levels
4	Stroke	Any cerebrovascular incident producing neurological sequelae lasting more than 24 hours and including infarction of brain tissue, hemorrhage or immobilization from an extra cranial source. Evidence of permanent neurological deficit must be produced. The catastrophic illness must be diagnosed by a registered medical practitioner and must be supported by clinical, radiological, histological, and laboratory evidence acceptable to the insurer
5	Coronary Artery Disease and Peripheral Vascular Disease	Coronary Artery Disease is defined as a disease of the arteries that supply blood to the heart muscle, causing damage to or malfunction of the heart. Peripheral Vascular Disease is defined as narrowing of blood vessels in the legs, and sometimes in the arms, restricting blood flow and causing pain and other medical complications in the affected area

  

The document (among others) that describes the outline of the policy type, the name of the policyholder, and endorsements (if any).

  

An injury, illness or condition, which does not require hospitalization, which may be expected to be of long duration without any reasonably predictable date of termination, and which may be marked by recurrences requiring continuous or periodic care as necessary

  

The Claims Administrator is the company appointed by the underwriter for the processing and evaluation of claims. All claims must be submitted to the Claims Administrator

  

A plan when all eligible persons must be included

  

Congenital Defect/ Birth Defect is a term that means an abnormality that has been present since birth. It may have been inherited genetically from the parents, may have occurred as a result of damage or infection in the uterus, or may have occurred at the time of birth. Note that “congenital” does not mean the same as “hereditary.” Not all congenital abnormalities are inherited, and many hereditary diseases are not apparent at birth. Diseases and disorders that are not congenital are called “acquired.”

  

The portion of the eligible medical treatment expenses that the Insured Person must pay in addition to the annual deductible as stated on the Certificate of Insurance and the member’s Identification Card.
Co-payments are applied to each Insured Person per policy year.
There are two types of co-payments: general policy co-payments and benefit specific co-payments. General policy co-payments apply to the first US$10,000 of each individual’s medical costs. Benefit Co-pays may apply to specific treatment as described in the Benefits section of this policy

Credible coverage refers to the time an insurance applicant has spent covered under a health insurance plan directly prior to the inception of this Policy

In order to be considered credible coverage for the purposes of this Policy, the previous health insurance plan must have provided coverage commensurate, in terms of benefit type and scope, with the health benefits in force under this Policy. For example, a Dental benefits only plan will not be judged commensurate with a Medical benefits plan. Prior coverage must be substantially the same as coverage under this Policy.

The prior coverage must be of at least 12 months consecutive duration, without lapse either within the 12 prior month period, or between the prior coverage and the commencement of this Policy. The previous insurer must provide documentation adequate to establish the requirements described herein

The amount paid on an annual or per office visit basis by each of the Insured Persons for eligible medical treatment expenses. Deductibles are indicated on the Identification Card and Certificate of Insurance and can range from $0 to $5,000 on an annual basis, or from $0, $25, $50, $75, $100, $125 to $150 on a per office visit basis.

Note: Deductibles on a per office visit basis will be applied per visit for each time medical services, including consultations and follow-ups, are received. The office visit deductible does not apply to bills received for Ancillary services such as Laboratory and Radiology services (i.e. blood tests and x-rays)

The date shown on the Health Coverage List attached to the Certificate of Insurance on which an Insured Person was included under this policy

  

In order to be covered under this policy, each individual is subject to certain conditions. For eligibility criteria, please see Page 9 of this policy.

• Employees not in active service at the effective date must be approved for coverage by the enrollment department.
• Coverage will automatically cease at the first renewal date following an Insured Person’s 75th birthday.
• Coverage will automatically cease at the Insured Person’s permanent return to his/her home country unless pre- arranged with the Company.
• Termination of the insurance of the employee shall also cancel all coverage for dependents

  

A group member’s spouse and/or children, who are legally dependent under 21 years of age (under 24 years of age if a full-time student) who are included in the group pursuant to the agreement. Coverage for dependent children will cease at the end of the policy year in which the dependent’s 21st birthday occurs or their 24th birthday if they are a full-time student

  

Emergency dental treatment is emergency treatment necessary to restore or replace sound natural teeth damaged in an accident. Sound teeth do not include teeth with previous crowns, fillings, or cracks. Damage to teeth caused by chewing foods does not qualify for emergency dental coverage

  

In the event of a Life Threatening emergency, when appropriate treatment is not available locally, this policy provides Emergency Medical Transportation to the closest medical facility capable of providing the required care. Should treatment be available locally but the Insured Person chooses to be treated elsewhere, transportation expenses shall be the responsibility of the Insured Person

In the event of such emergency, the Care Coordination Dept. must be contacted in advance in order to approve and arrange such Emergency Medical Air Transportation. The Care Coordination Company, on behalf of the insurer, retains the right to decide the medical facility to which the Insured Person shall be transported. If the person chooses not to be treated at the facility and location arranged by the Care Coordination Company, then transportation expenses shall be the responsibility of the Insured Person.
All emergency medical transportation must be arranged, in advance, with the Care Coordination Dept. located on the back of the membership card. Failure to arrange transportation as indicated will result in non-payment of transportation costs

  

An Insured Person is in active service on a full time basis at least 20 or more hours per week with the employer. It does not mean a person in casual employment.

Individuals who are on a leave of absence may be considered eligible under this policy, however, the Company must be informed immediately, and the Company reserves the right to determine whether or not such individuals may continue coverage under the Group Plan

  

The Company and the Claims Administrator shall have the right and opportunity, through their medical representatives, to examine any person whenever and as often as they may reasonably require within the duration of any claim. The Insured Person shall make available all medical reports and records, and where required, shall sign all authorization forms necessary to give the Company a full and complete medical history. The Company and the Claims Administrator shall have the right and the opportunity to require an autopsy in the case of death, unless forbidden by law or religious beliefs

The document attached to the Certificate of Insurance, which lists all Insured Persons who are designated by the policyholder to be insured for medical coverage

  

Acquired Immune Deficiency Syndrome (AIDS) and all diseases caused by and/or related to the HIV Virus

  

The home country of any insured individual under this policy is deemed to be the country from which the primary insured holds a passport. In the event that a citizen of the United States holds more than one passport, the United States shall be deemed the home country

  

A system of alternative medicine that seeks to treat patients by administering small doses of medicines that would bring on symptoms similar to those of the patient in a healthy person. For example, the homeopathic treatment for diarrhea would be a miniscule amount of a laxative

  

A hospice, part of a hospital or recognized in-home medical care unit devoted to the care of patients with progressive disease where curative treatment is no longer possible; as an inpatient or domicile basis

  

An institution that is legally licensed as a medical or surgical hospital, in the country in which it is located. Illnesses/diseases of acute nature, as well as emergencies, can be treated in this facility. It must be under the constant supervision of a resident physician. A hospital is not a spa, hydro-clinic, sanitarium, rehabilitation institution, nursing home, or homes for the aged

The document provided the individual member and his/her dependents, which outlines the policy benefits, name of the policyholder, Insured Persons, and endorsements, if any. On this card, members will find benefit information, as well as contact information for submitting claims and emergency medical treatment. Members may in certain circumstances have two (2) identification cards

  

An Insured Person who occupies a bed overnight in a hospital for the sole purpose of receiving treatment

  

A group member or an eligible dependent

The cost of prenatal care, Delivery, Medically Necessary C-Sections, and postnatal treatment subject to the specific limit. Any complications related to pregnancy including Cesarean section will be treated as maternity and will be subject to the specified limits. Maternity also includes Pre-natal vitamins and two (2) routine Ultrasounds. Elective C-Section excluded

  

This phrase is used under two different contexts in this policy

  

A general medical practitioner is registered or recognized by the law of the country in which he/she practices and is recognized by the Company

  

A treatment, service, supply, or drug, is medically necessary if it:
• is prescribed by a Physician and is appropriate and essential to diagnose or treat the patient’s Illness or Injury;
• does not exceed, in scope, duration, or intensity, the level of care which is needed to provide safe, adequate, and appropriate diagnosis or treatment;
• is consistent with widely accepted professional standards of medical practice in the jurisdiction where treatment is rendered;
• is not primarily for the personal comfort or convenience of the patient, the family, Physician, or other provider of care;
• is not a part of or associated with the scholastic education or vocational training of the patient;
• is not Experimental or Investigative;
• in the case of inpatient care, cannot be provided safely on an outpatient basis;
• the regulations and guidelines authorized by the U.S. Department of Health & Human Services, Food & Drug Administration and Center for Devices & Radiological Health may be used to determine appropriateness of service and treatment provided

An Insured Person who receives treatment at a hospital, specialist’s consulting room, or other facility recognized by the Company, where the Insured Person does not remain overnight

Is any person legally licensed to practice medicine in the country where treatment is provided and includes doctors of medicine, general practitioners, specialists and consultants and anyone who renders such treatment within the scope of their licensing and training

  

Our contract of insurance with the policyholder, under which the Company provides the coverage described in the policy document and the agreement for group members and their eligible dependents. The Application, Certificate of Insurance, List of Contract Medical Providers and Hospitals (current at the relevant date) form part of the contract and must be read together with this policy document (as amended from time to time). A complete list of providers may be found at www.claimssite.com

  

The employer or the Insured Person to whom the Certificate of Insurance is issued and who is responsible for the premium payment and for the reporting of additions and deletions

  

The date as shown in the Certificate of Insurance, when coverage under this policy commences.

  

The period of insurance coverage as stated in the Certificate of Insurance and any subsequent period for which the policyholder pays a premium that the Company accepts

  

Relates to admission to a hospital as an inpatient for the purpose of receiving predetermined medical treatment

  

Pre-Authorization is a process by which an Insured Person obtains written approval for certain medical procedures or treatments, from the Care Coordination Company (see page 8 or the back of your I.D. Card) prior to the commencement of the proposed medical treatment. Certain medical procedures will require the Pre-Authorization process to be followed. Failure to comply with pre-authorization procedures will result in a 40% co-payment without any out-of- pocket limit. For full information on how to pre-authorize medical treatment and relevant contact information, refer to Pages 7-8 of this Policy

  

Any known medical condition(s) that is a consequence of any previous illness that has been diagnosed or required hospitalization, medical treatment and/or medication prior to the first day of this insurance

A chartered or state-registered physiotherapist, or someone, who on professional advice the Company accepts, is of the equivalent professional status in the relevant country.

therapeutic services designed to improve a patient’s medical condition within a predetermined time period through establishing a maintenance program designed to maintain the patient’s current condition, prevent it from deteriorating and assist in recovery. Inpatient rehabilitation is only covered during the acute and sub-acute recovery phase of treatment and only when authorized by the Care Coordination Department

  

The actual date when treatment was administered

  

End stage renal failure due to chronic irreversible failure of both kidneys to function. This must be evidenced by the insured undergoing regular renal dialysis or having had renal transplantation

  

The annual anniversary of the policy’s effective date

  

This is the expense of preparation and the air transportation of the mortal remains of the Insured Person from the place of death to their home country, or the preparation and local burial of the mortal remains of an Insured Person who dies outside his/her home country. This benefit is excluded where death occurs in their home country.

  

The following rules apply to the location and physical address of the insured member and dependents.

• The residence of primary insured and all dependents is assumed to be the location of the employer. If the residency of the spouse or dependents is otherwise, the Company must be notified in writing of their full-time residence immediately. Further, it is assumed that primary insured is residing in location of employer during the employment year. Any change must be immediately reported to the Company.
• If the spouse or dependent of an insured is living full-time in the specified restricted areas, the premiums will be adjusted according to the applicable surcharge.
• Residence of the primary insured, spouse and dependents under this policy is presumed to be at the location of employer during the employment year, any deviation must be reported immediately to the Company who reserves the right to change rates to reflect normal residency

  

Respite care is Inpatient care for a chronically or terminally ill patient, for the sole purpose of relieving the patient’s primary caregiver. Respite care is not covered under this Policy

  

Countries and/or facilities, where medical treatment may not be covered under certain policies, as defined by the Company. Consult www.claimssite.com for a complete list of restricted areas and facilities

Skilled care is medical care which requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and effectively. Skilled nursing and rehabilitative staff include registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists. When covered on an Inpatient basis, it is only during the acute and sub-acute care phases of treatment, and only for the duration to be determined and approved by the Care Coordination Department

  

A skilled nurse is one whose name is currently on any register or roll of nurses maintained by any statutory nursing registration body within the country in which they are resident

  

Medical care which is somewhat acute, falling between acute and chronic care, but with some acute features.

Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization (s) or government (s).

  

All use of “TieCare” is intended to be the same as TieCare International/Global Benefits Group, Inc

  

Surgical or medical procedures that have the sole purpose of curing or relieving acute illnesses or injury

Benefits payable under this policy are limited to medically necessary services and treatments, and shall be limited to the reasonable, usual, and customary charges for hospital and medical services.

  

The Company retains the right to determine the medical necessity of a planned treatment. The appropriateness of care and the treatment plan will be reviewed in consultation with the attending physician and alternative care options may be recommended