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IMPORTANT CONTRACT DEFINITIONS

The following are several important Policy definitions typically referenced by a TPA’s claim staff. These do not represent all Policy definitions. We remind our TPA’s to always carefully review the Policy if there are any questions regarding coverage or terms.

Covered Person:

This means an individual covered under the Plan
 

Covered Unit:

This means an employee, an employee with dependents or such other defined unit as agreed upon and as shown on the Application.
 

Benefit Period:

This means the period of time during which Eligible Expenses must be Incurred by a Covered Person and Paid by the Policyholder to be eligible for reimbursement under the Policy. This period does not alter the Policy Effective Date or Policy Period. It does not waive the Policy’s eligibility requirements.
 

Eligible Expenses:

The eligible charges payable under the Plan and for which the Covered Person is liable to pay. It does not include expenses specifically excluded or limited by the Policy, Application for Policy, Schedule of Insurance or any Endorsements.
 

Incurred:

This means:

1. With respect to medical services or supplies, the date on which the services are rendered or supplies are received by the Covered Person; and

2. With respect to disability income benefits, the date each periodic benefit payment becomes payable to the Covered Person (not the date the disability commences).

Paid (Payment):

This means that a claim has been adjudicated by the TPA and the funds are actually disbursed by the Plan prior to the end of the Benefit Period. Payment of a claim is the unconditional direct payment of a claim to the Covered Person or their health care provider(s). Payment will be deemed made on the date that both:

1. The payer directly tenders payment by mailing (or by other form of delivery) a draft or check; and
2. The account upon which the payment is drawn contains and continues to contain, sufficient funds to permit the check or draft to be honored by the institution upon which it is drawn.

Plan Benefits:

This means the health benefits covered by the Plan during the Policy Period which are:

1. 1. Incurred on or after the Effective Date of the Policy; and

2. Incurred while the Policy is in force; and

3. Incurred and Paid during the Policy Period.

Plan Benefits will also include those health benefits covered by the Plan during the Policy Period which are Paid during any Run-Out period or Incurred during any Run-In Period applicable to this Policy.

Plan Benefits do not include:

1. Deductibles of the Plan;

2. co-insurance or co-payment amounts of the Plan;

3. any expenses that are not covered by the Plan or this Policy;

4. any amount recoverable from any other source; or

5. any amount Paid under a previous Policy or arrangement or excess loss coverage, whether issued by SLG Benefits, on behalf of the insurance company or another entity.
    

Policy Period:

This means the time period beginning on the Effective Date and ending on the Expiration Date.
 

Run-in Limit:

This means the maximum benefit amount Paid by the Policyholder under the Plan for Eligible Expenses Incurred by a Covered Person during the Run-in Period which will be applied toward payment under the Policy.
 

Run-in-Period:

This means the period of time shown in the Schedule of Insurance immediately prior to the first day of a Policy Period during which Eligible Expenses Incurred by a Covered Person, which are Paid by the Policyholder during the Policy Period, will be considered when determining benefit payments under this Policy.
 

Run-out-Period:

This means the period of time shown in the Schedule of Insurance immediately following the Policy Expiration Date during which Plan Benefits Paid by the Policyholder for Eligible Expenses Incurred by a Covered Person during the Policy Period will be considered when determining benefit payments under this Policy.
 

Individual Claim Limit:

This means the maximum amount of Payments for Eligible Expenses that will be counted for any one Covered Person under the Aggregate Excess Loss. The Individual Claim limit is shown in the Schedule of Insurance. It is also commonly referred to in the industry as a Loss Limit.
 

Large Claim:

This means Paid or pending claims reaching or with the potential to reach 50% of the Specific Attachment Point or a Potentially Catastrophic Loss.
 

Potentially Catastrophic Loss:

This means a Paid or pending claim that has the potential to be catastrophic. Potentially Catastrophic Losses include, but are not limited to the list of conditions found in the forms section of this guide.
 

Usual and Customary Charges:

This means the common charge for the same or comparable service or supply in the geographic area in which the service or supply is furnished. Usual and Customary Charges are determined based upon:

1. 1. the amount of resources expended to deliver the treatment;

2. the complexity of the treatment rendered; and

3. charging protocols and billing practices generally accepted by the medical community

Experimental or Investigational:

Experimental or Investigational means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered Experimental/Investigational if the Covered Person is required to sign a consent form which indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, which is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental/Investigational. Treatment is also considered Experimental/Investigational if such treatment has not been granted, at the time services were rendered, any required approval by a federal or state governmental agency, including without limitation, the Federal Department of Health and Human Services, Food and Drug Administration (FDA) or any other comparable state governmental agency and the Federal Health Care Finance Administration as approved for reimbursement under Medicare Title XVIII. A drug, device or biological product is considered Experimental/Investigational if it does not have FDA approval or it has FDA approval only under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.