Definitions
| Complications of Pregnancy |
means conditions
which require medical treatment before pregnancy ends, and whose diagnosis is distinct from, but are caused or affected by pregnancy. Such conditions are: acute nephritis or nephrosis, cardiac decompensation; missed abortion; hyperemesis gravidarum; pre-eclampsia; non- elective cesarean section; termination of ectopic pregnancy; and spontaneous termination when a live birth is not possible. Complications of Pregnancy do not include: false labor; occasional spotting; voluntary abortion; Doctor prescribed rest during pregnancy; morning sickness; and similar conditions not medically distinct from a difficult pregnancy. |
| Covered
Expenses |
means expenses
actually incurred by or on behalf of a Covered Person for treatment, services and supplies not excluded or limited by the Policy. Coverage under the Policy must remain continuously in force from the date of the Accident or Sickness occurs until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained. |
| Covered Person |
means any eligible
person or an eligible Dependent who applies for coverage, and for whom the required premium is paid to Us. |
| Doctor | means a licensed
health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. The term, Doctor includes, but is not limited to: (1) Doctor of Osteopathy; (2) Doctor of Dental Surgery; (3) Doctor of Podiatry; (4) Doctor of Chiropody; (5) Optometrist; (6) Optician; (7) Psychologist; (8) Clinical Social Worker; (9) Professional Counselor; (10) Physical Therapist; (11) Chiropractor; (12) Audiologist; (13) Speech Pathologist; (14) Clinical Nurse Specialist in Psychiatric Mental Health; (15) Certified Licensed Nurse Practitioner; and (16) Physician's Assistant, Nurse Practitioner, or Advance Practice Nurse when working in a group medical practice. |
| Hospital | means an institution licensed in the state in which it is located, which meets the following: * Provides for a fee from its patients, diagnostic, medical and surgical facilities for the care and treatment of people who are injured or sick. * Has a staff of one or more doctors available at all times. * Has 24 hour-a-day services or R.N.s or other nursing services reporting to the doctor in charge. * Has inpatient facilities. |
| Injury | means bodily injury caused
by an accident. The accident must occur while the insured person's insurance is in force under this policy in order for it to be considered a covered injury. All injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these injuries, are considered a single covered injury. The injury must be the direct cause of loss and must be independent of all other causes. The injury must not be caused by or contributed to by sickness. |
| Medically
Necessary |
means a treatment,
service or supply
that is: 1) required to treat an Injury or Sickness; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the Covered Person's condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment for the condition at the time rendered. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may, at Our discretion, consider the cost of the alternative to be the Covered Expense. |
| Sickness | means an illness, disease,
or condition of the Covered Person that causes a loss for which a Covered Person incurs medical expenses while covered under the policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness. |
| Usual and Customary Charge |
means the average
amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. |
| We, Our, Us | means UniCare Life & Health Insurance Company. |
Mental Health/Substance Abuse Care
Pregnancy and Newborn Benefits
