Definitions

Hospital means a licensed or properly accredited general Hospital which; 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured person as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating Mental and Nervous Disorders.

Injury means bodily Injury: 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder or Injury; 2) treated by a Physician within 30 days after the date of accident; and 3) which causes loss during the term of the policy.

Medical Necessity means those services or supplies provided or prescribed by a Hospital or Physician which are: a. Essential for the symptoms and diagnosis or treatment of the Sickness or Injury; b. Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury; c. In accordance with the standards of good medical practice; d. Not primarily for the convenience of the Insured, or the Insured’s Physician; and e. The most appropriate supply or level of service which can safely be provided to the Insured

Pre-Existing Condition means any injury or illness which was contracted or which manifested itself, or for which treatment or medication was prescribed, prior to the effective date of this insurance as to the Insured.

Sickness means Sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under the policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.

Usual and Customary means charges for medical services or supplies essential to the care of the Insured if they are the amount normally charged by the provider for similar services and supplies and do not exceed the amount ordinarily charged by most providers of comparable services and supplies in the locality where the services or supplies are received.

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