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Definitions
Covered Expenses means expenses which are for Medically Necessary
services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed
of ordered by a Physician; Reasonable and Customary charges; incurred while insured
under this Policy;
Dependent means the spouse who is legally married to the Primary
Insured Person; the Primary Insured Person’s unmarried Child from birth until his/her
19th birthday; or the Primary Insured Person’s unmarried Child who is over 18 years
old but not older than 25 years old and is enrolled as a full-time student at an
accredited school or college and is not employed on a full-time basis and is dependent
on the Primary Insured Person for his/her support and maintenance. The age limits
that apply to Dependent Child(ren) will not apply to any insured Child of the Primary
Insured Person who remains dependent on the Primary Insured Person for support and
maintenance because he a she becomes incapable of working due to a physical handicap
or retardation which occurs: before reaching the age limit; and while insured under
this Policy or any prior plan, provided such Child was insured on the date of termination
of the prior plan.
Hospital a Hospital (other than an institution for the aged, chronically
ill or convalescent, resting or nursing homes) operated pursuant to law for the
care and treatment of sick or Injured persons with organized facilities for diagnosis
and Surgery and having 24-hour nursing service and medical supervision. Means a
place that 1.) is legally operated for the purpose of providing medical care and
treatment to sick or injured persons for which a charge is made that the Insured
is legally obligated to pay in the absence of insurance 2.) provides such care and
treatment in medical, diagnostic, or surgical facilities on its premises, or those
prearranged for its use; 3.) provides 24-hour nursing service under the supervision
of a Registered Nurse at all times; and 4.) operates under the supervision of a
staff of one or more Doctors. Hospital also means a place that is accredited as
a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic
Association, or the Joint Commission on Accreditation of Heath Care Organizations
(JCAHO). Hospital does not mean:
-a convalescent, nursing, or rest home or facility, or a home for the aged;
-a place mainly providing custodial, educational, or rehabilitative care; or
-a facility mainly used for the treatment of drug addicts or alcoholics.
Injury means Accidental bodily Injury
or Injuries caused by an Accident. The Injury must be the direct cause of the Loss,
independent of disease or bodily infirmity. Any Loss due to Injury must begin after
the Effective Date of this Policy.
Insured Person(s) means a person eligible for coverage under the
Policy who has applied for coverage and is named on the application and for whom
the company has accepted premium. This may be the Primary Insured Person or Dependent(s).
Physician as used in this Policy means a doctor of medicine or
a doctor of osteopathy licensed to render medical services or perform Surgery in
accordance with the laws of the jurisdiction where such professional services are
performed, however, such definition will exclude chiropractors and physiotherapists.
Pre-existing Condition for the purposes of this Policy means a
condition for which manifestation, medical advice, diagnosis, care or treatment
was recommended, received or noticed during the 12 months prior to the Effective
Date of coverage under this Policy
Reasonable and Customary means the maximum amount that the Company
determines is Reasonable and Customary for Covered Expenses the Insured Person receives,
up to but not to exceed charges actually billed. The Company’s determination considers:
1) amounts charged by other Service Providers for the same or similar service in
the locality were received, considering the nature and severity of the bodily Injury
or Illness in connection with which such services and supplies are received; 2)
any usual medical circumstances requiring additional time, skill or experience;
and 3) other factors the Company determines are relevant, including but not limited
to, a resource based relative value scale.
For a Service Provider who has a reimbursement agreement, the Reasonable and Customary
charge is equal to the amount that constitutes payment in full under any reimbursement
agreement with the Company.
If a Service Provider accepts as full payment an amount less than the negotiated
rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable
and Customary charge.
The Reasonable and Customary charge is reduced by any penalties for which a Service
Provider is responsible as a result of its agreement with the Company.
Sickness means illness or disease contracted and causing loss commencing
while the policy is in force as to the Insured Person whose Sickness is the basis
of claim. Any complication or any condition arising out of a Sickness for which
the Covered Person is being treated or has received Treatment will be considered
as part of the original Sickness.
If you have any questions please contact us at:
1-800-244-1180
mailbox@isoa.org
www.isoabroad.com
ISO representatives are here to help you!
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