Charges and Payment

1.    Accident  means an occurrence which: (a) is unforeseen; (b) is not due to or contributed to by sickness or disease of any kind; and, (c) causes injury.
2.    Covered Person  means a covered student while coverage under the Policy is in effect.
3.    Elective Treatment  means medical treatment, which is not necessitated by a pathological change in the function or structure in any part of the body, occurring after the Covered Person’s effective date of coverage.
4.    Eligible Expense  means a charge for any treatment, service or supply which is performed or given under the direction of a doctor for the Medically Necessary treatment of a Sickness or Injury that is: (a) not in excess of the Reasonable and Customary charges; (b) not in excess of the charges that would have been made in the absence of this coverage; (c) is the negotiated rate, if any, and (d) incurred while the Policy is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits Provision.
5.    “Emergency Medical Condition” means a medical condition that manifests itself by acute symptoms of sufficient severity, including, but not limited to, severe pain or by acute symptoms developing from a chronic medical condition that would lead a prudent lay person, possessing an average knowledge of medicine and health, to reasonably expect the absence of immediate medical attention of the Injury or after onset of sickness to result in any of the following: (a) placing the health of an individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part; and, (d) serious disfigurement.
6.    Injury means bodily injury due to an accident which: (a) results solely, directly and independently of disease, bodily infirmity or any other causes; (b) necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, Injury, or disease, or its symptoms; (c) the negotiated rate, if any; and, (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.
7.    Medical Necessity/ Medically Necessary means the covered services or supplies: (a) provided for the diagnosis, treatment, cure or relief of a health condition, illness, Injury, or disease; and except as allowed for Clinical Trials, not for experimental/investigational or cosmetic purposes; (b) necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, Injury, or disease, or its symptoms; (c) within generally accepted standards of medical care in the community; and, (d) not solely for the convenience of the Covered person, his or her immediate family, or the provider.
8.    Pre-Existing Condition*  means a Sickness, Injury, or pregnancy for which medical care, treatment, diagnosis, or advice was received or recommended within the 6 months prior to the Covered Person’s effective date of coverage under the Policy.
9.    Reasonable and Customary (R&C)  means the charge, fee, or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and, (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.
10.    Sickness means disease, illness, or complications of pregnancy including related conditions and recurrent symptoms of the Sickness which begins after the effective date of a Covered person’s coverage. All Sicknesses due to the same or a related cause are considered one Sickness.
11.    *Pre-Existing Conditions Limitation  Expenses incurred by a Covered Person as a result of a Pre-Existing Condition will not be considered Eligible Expenses for a period of 12 months of continuous coverage while covered under the Policy. This limitation will not apply if, during the period immediately preceding the Covered Person’s effective date of coverage under the policy, the Covered Person was covered under prior creditable coverage for 12 consecutive months. Prior Creditable Coverage of less than 12 months will be credited toward satisfying the Pre-existing Condition limitation. This waiver of Pre-existing Condition limitation will apply only if the Covered Person becomes eligible and enrolls for coverage within 63 days of termination of his or her prior coverage. Pre-existing Conditions limitations does not apply to: (a) a newborn Dependent child; (b) a child adopted by the covered Student or placed with the Covered Student for adoption, if adoption or placement for adoption occurs while covered under the Policy; or, (c) a foster child placed with the Covered Student while covered under the Policy.