Definitions

“Accident” or “Accidental” shall mean an event, independent of Illness or self inflicted means, which is the direct cause of bodily Injury to an Insured Person.

“Company” shall be The Insurance Company of The State of Pennsylvania.

“Covered Expenses” shall mean 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; and which do not exceed the maximum limits shown is the Schedule of Benefits, under each stated benefit.

“Deductible” shall mean the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Policy are payable by the Company. The Deductible amount is stated in the Schedule of Benefits, under each stated benefit.

“Disablement” as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Policy.

“Elective Surgery or Elective Treatment” means surgery or medical treatment which is not necessitated by a pathological or traumatic change in the function or structure in any part of the body first occurring after the Insured’s effective date of coverage. Elective Surgery includes, but is not limited to, circumcision, tubal ligation, vasectomy, breast reduction, sexual reassignment surgery, and submucous resection and/or other surgical correction for deviated nasal septum, other than for necessary treatment of covered purulent sinusitis. Elective Surgery does not apply to cosmetic surgery required to correct a covered Accident. Elective Treatment includes, but is not limited to, treatment for acne, nonmalignant warts and moles, weight reduction, infertility, learning disabilities.

“Eligible Benefits” shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under this Policy; and which do not exceed the maximum limits shown in the Schedule of Benefits under each stated benefit.

“Emergency” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within 24 hours.

“Family Member” shall mean a spouse, parent, sibling or Child of the Insured Person.

“Home Country” shall mean the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.

“Hospital” as used in this Policy shall mean except as may otherwise be provided, 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.

“Illness” wherever used in this Policy shall mean sickness or disease of any kind contracted and commencing after the Effective Date of this Policy and Disablement covered by this Policy.

“Injury” wherever used in this Policy shall mean bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Policy is in force and resulting directly and independently of all other causes in Disablement covered by this Policy.

“Insured Person(s)” shall mean a person eligible for coverage under the Policy as defined in “Eligible Persons” 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).

“Medically Necessary” or “Medical Necessity” shall mean services and supplies received while insured that are determined by the Company to be:

1. appropriate and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person’s medical conditions;
2. within the standards the organized medical community deems good medical practice for the Insured Person’s condition;
3. not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider or person;
4. not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and
5. not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate treatment.

“Mental and Nervous Disorder” shall mean a Sickness that is a mental, emotional or behavioral disorder.

“Permanent Residence” shall mean the country where an Insured Person has his or her true, fixed and permanent home and principal establishment, and to which he or she has the intention of returning.

“Physician” as used in this Policy shall mean 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.

“Reasonable and Customary” shall mean 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.

“Relative” shall mean spouse, parent, sibling, Child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.

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