Actual Charges means the amount(s) actually paid by or on behalf of the Covered Person and accepted by the provider as full payment for the covered services provided.Adult Companion means anyone 18 years of age or older.
Ambulance means a ground or air vehicle which is licensed as required by law, as an Ambulance, and is equipped to transport sick or injured persons.
Ambulatory Surgical Center means a licensed facility whose primary purpose is to provide surgical procedures and in which the patient is admitted to and discharged within the same day. It has one or more Physicians on duty whenever a patient is in the facility. It is not a facility existing for the primary purpose of terminated pregnancies or an office maintained by a Physician for the practice of medicine nor does it provide services or accommodations for patients to stay overnight.
Bone Marrow Transplant means the harvesting, storage and subsequent reinfusion of bone marrow, from the recipient or a matched donor (either autologous or allogenic). It includes administration of chemotherapy and/or total body radiotherapy to ablate the patient's residual bone marrow. It does not include the harvesting of peripheral stem cells and subsequent reinfusion.
Calendar Month means the applicable month of the Gregorian calendar, starting with the first day of the month and ending with the last day of the month.
Calendar Year means the period of time starting January 1 at 12:00 a.m. and ending December 31 at 12:00 p.m., under the Gregorian calendar.
Cancer means a disease which is manifested by the presence of a malignancy characterized by the uncontrolled and abnormal growth and spread of malignant cells in any part of the body. This includes Hodgkin's Disease, leukemia, lymphoma, carcinoma, sarcoma, malignant tumor or melanoma. It does not include other conditions which may be considered pre-cancerous, such as leukoplakia, hyperplasia, polycythemia, nonmalignant melanoma, moles or similar diseases or lesions.
Chemotherapy means a cancericidal chemical substance that is used for the purpose of modification or destruction of tissue invaded by Cancer.
Chemotherapy Enhancer Drug means a medication given contemporaneously with Chemotherapy to strengthen the ability of Chemotherapy to kill tissue invaded by Cancer.
Common Carrier means a commercial airline, passenger train or inter-city bus.
Confined/Confinement means a Covered Person’s admission to a Hospital for 14 hours or more as an overnight bed patient for which a charge is made for room and board. It does not include admission to a swing-bed program or a similar arrangement.
Covered Family Members means an Insured Spouse and/or Insured Children or an Insured Child.
Covered Person means any of the following:
1. the Named Insured; or
2. any eligible family member named in the application (Covered Family Member) and not excluded from coverage by a signed waiver; or
3. any eligible family member added to this Policy by endorsement after the Effective Date; or
4. a newborn child.Under an “Individual” Policy, newborn children are automatically covered from birth for a period of 90 days of the birth or before the next premium due date, whichever is later. In order to have coverage continue beyond such 90-day period, notification of the birth of a child and payment of a “Family” premium must be paid to Us within 90 days. If this is a “One Parent Family” or a “Two Parent Family” Policy, newborn children are automatically covered from birth. It is not necessary for You to notify Us of the child's birth, and there is no change in premium.
Dread Disease means any of the following:
Addison's Disease Muscular Dystrophy Tay-Sachs Disease
Amyotrophic Lateral Sclerosis Myasthenia Gravis Tetanus
Diphtheria Niemann-Pick Disease Toxic Epidermal Necrolysis
Encephalitis Osteomyelitis Toxic Shock Syndrome
Epilepsy Poliomyelitis Tuberculosis
Legionnaire’s Disease Reye’s Syndrome Tularemia
Lupus Erythematosus Rheumatic Fever Typhoid Fever
Meningitis Rocky Mountain Spotted Fever Whipple’s Disease
Multiple Sclerosis Sickle Cell Anemia Whooping Cough
Effective Date is defined in the Term of Policy provision of Part X.Emergency Situation means an unforeseeable and unplanned event involving a substantial likelihood of death unless if treatment is provided immediately.
Experimental Treatment means:
1. drugs or chemical substances as approved by the U.S. Food and Drug Administration for experimental use in the treatment of human Cancer; and
2. surgery or therapy endorsed by either the National Cancer Institute or the American Cancer Society for experimental studies. Included in such definitions are: (a) Chemotherapy or Immunotherapy using experimental drugs or chemicals; (b) Hyperthemia; and (c) Atomic Particle Therapy.
It does not include Bone Marrow Transplants.Extended Care Facility means a licensed nursing facility which:
1. operates under the direction of a Physician;
2. provides continuous skilled or intermediate care under the supervision of a graduate registered Nurse;
3. maintains daily medical records of each patient; and
4. is licensed by the state in which it is located.Home Health Care Agency means an agency that specializes in giving nursing and other medical services in the home. It must be approved by the state in which it is located to provide such services.
Hospice means an organization which is staffed and equipped to:
1. provide care for persons who are terminally ill and do not require the full services of a Hospital or Extended Care Facility;
2. offer medical services under the direction of a Physician and a 24-hour professional nursing staff;
3. provide, directly or by arrangement, social, psychological or spiritual services; and
4. is licensed, certified or registered if such is required by the state in which the facility is located.Hospital means a legally operated institution which: maintains and uses on its premises or in facilities available to it on a prearranged basis, a laboratory, x-ray equipment, and an operating room; maintains permanent and full-time facilities for the care of overnight resident bed patients under the supervision of one or more licensed Physicians; provides 24-hour-a-day nursing service by or under the supervision of a registered professional Nurse, and maintains on the premises the patient's written history and medical records.
The term “Hospital” shall not include any institution, or part thereof used as a place for rehabilitation, rest, the aged, drug addicts or alcoholics, a mental institution, sanitarium, nursing home, geriatrics ward, or an extended care facility for the care of convalescent or rehabilitative patients. Furthermore, the term “Hospital” shall not include any facility contracted for or operated by the United States Government for the treatment of members or ex-members of the armed forces, except where a legal liability exists.
Immunotherapy (as it pertains to Cancer) means therapy intended to stimulate the normal immune system to kill Cancer cells.
Immunotherapy (as it pertains to Dread Disease) means treatment to direct a normal immune system to reverse, arrest or modify the course of the Dread Disease.
Injury means physical trauma or harm caused by an accident and requiring immediate medical attention.
Insured Children or Insured Child means any dependent child or children for whom You have applied for insurance under this Policy and for whom premium payments are made. At the time of application, a dependent child must be: (a) dependent upon You for his or her support; (b) unmarried; (c) under the age of twenty-one or twenty-five if a full-time student; and (d) Your child or Your spouse’s child, Your grandchild, natural born, legally adopted, or pending legal adoption and is in placement in the residence of the Named Insured. A dependent child includes a stepchild or a child under a medical support order.
Insured Spouse means Your spouse for whom You have applied for insurance coverage under this Policy and for whom premium payments are made. At the time of application, Your spouse must be at least 18 years of age and no more than 69 years of age.
Local means a trip within 50 miles one way from Your residence to the facility in which any Covered Person is to be admitted or receive a covered treatment. In the event that a Covered Person does not reside with You, the distance shall be measured from the residence of the Covered Person.
Named Insured means the Named Insured who applies for this Policy. At the time of application, You, the Named Insured must be at least 18 years of age and no more than 69 years of age.
Non-Local means not Local.
Nurse means any of the following who is not a Relative:
1. licensed practical nurse (L.P.N.);
2. licensed vocational nurse (L.V.N.); or
3. graduate registered nurse (R.N.).Pathologist means a legally licensed Doctor of Medicine certified by the American Board of Pathology to practice Pathologic Anatomy. It does not include a Relative.
Period of Confinement means each Confinement in a Hospital which begins more than 30 days after the end of a previous Hospital Confinement, whether or not such Confinement is due to the same or related cause. If less than 30 days separates two periods of Hospital Confinement, then for the purpose of calculating Hospital Confinement benefits, such second period of Hospital Confinement shall be considered to be a continuation of the prior period of Hospital Confinement.
Physical, Occupational or Speech Therapy means therapy provided by a licensed therapist to address the effects of Cancer or Dread Disease to the Covered Person’s physical, occupational, or speech abilities.
Physician means (1) a doctor who is duly qualified and legally licensed to practice medicine, whose permanent practice is in the United States, who is legally authorized to and does use the designation M.D., and who is legally practicing within the scope of his or her license; or (2) a doctor who is duly qualified and legally licensed to practice osteopathy, whose permanent practice is in the United States, who is legally authorized to and does use the designation D.O., and who is legally practicing within the scope of his or her license. It does not include a Relative of a Covered Person.
Policy Date or Effective Date means the date We issued this Policy, and it becomes effective.
Positive Diagnosis (of Cancer) means a diagnosis by a legally licensed Physician certified by the American Board of Pathology to practice Pathological Anatomy, or an Osteopathic Pathologist. Pathologic interpretations of the histology of skin lesions will be accepted from dermatologists certified by the American Board of Dermatology. Diagnosis must be based on a microscopic examination of fixed tissue, or preparations from the hemic system either during life or post mortem. The Pathologist establishing the diagnosis shall base his judgment solely on the criteria of malignancy as accepted by the American Board of Pathology or the Osteopathic Board of Pathology after a study of the histocytologic architecture or pattern of the suspect tumor, tissue or specimen. Clinical diagnosis of Cancer will be accepted as evidence that Cancer exists in a Covered Person when a pathological diagnosis cannot be made provided such medical evidence substantially documents the diagnosis of Cancer and the Covered Person received definitive treatment of Cancer.
Positive Diagnosis (of Dread Disease) means a diagnosis by a qualified Physician based on generally accepted diagnostic procedures and criteria.
Private Duty Nursing Service means a care service provided by a Nurse to a Covered Person Confined in a Hospital. The Nurse must be retained by the Covered Person (or an authorized representative of the Covered Person) to provide services on an individual basis only to the Covered Person. When providing the service to the Covered Person, the Nurse must be independent of the Hospital and services that the Hospital may be providing to the Covered Person. The service must be authorized by the attending Physician.
Radio-Active Isotopes Therapy means the interstitial or intracavity application by a Radiologist of radium or radioisotopes in sealed or non-sealed sources for the purpose of modification or destruction of tissue invaded by Cancer.
Radiologist means one who is licensed to administer X-ray, radium, or radio-active isotopes therapy and is certified by the American Board of Radiology.
Relative means the spouse, father, mother, sons, daughters, brothers, sisters, grandfathers, grandmothers, aunts, uncles, and any first cousins of any Covered Person.
Teleradiotherapy means the directing by a Radiologist of either natural or artificially propagated radiation from a distance at tissue invaded by Cancer for the purpose of modification or destruction of the tissue invaded by Cancer.
Totally Disabled or Total Disability means the Named Insured is:
1. unable, due to Cancer or Dread Disease, to work at any job for which he or she is qualified by education, training or experience;
2. not working at any job for pay or benefits; and
3. under the care of a Physician for the treatment of Cancer or a Dread Disease.Tutor means one who is legally certified to teach or otherwise professionally qualified to teach. Such person must not be a Relative of the Covered Person.
Waiting Period means the first thirty days after the Effective Date of this Policy.