2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 78
Covered Expenses means the medical expenses covered pursuant to the terms of this Health Care Plan.
Covered Person means, individually, an eligible Employee or eligible Dependent whose coverage has become
effective and has not been terminated.
Custodial Care means care or confinement provided primarily for the maintenance of the Covered Person,
essentially designed to assist the Covered Person, whether or not totally disabled, in the activities of daily living,
which could be rendered at home or by persons without professional skills or training. This care is not reasonably
expected to improve the underlying medical condition, even though it may relieve symptoms or pain. Such care
includes, but is not limited to, bathing, dressing, feeding, preparation of special diets, assistance in walking or
getting in and out of bed, supervision over medication which can normally be self-administered and all domestic
activities.
Dentist means an individual who is duly licensed to practice dentistry or to perform oral Surgery in the state where
the service is performed and is operating within the scope of such license. A Physician will be considered a Dentist
when performing any covered dental services allowed within such license.
Dependent is a Covered Person, other than the Employee, who is covered by the Medical Plan pursuant to the
terms and conditions set forth in the "Eligibility and Enrollment" section of the Medical Plan.
Durable Medical Equipment means equipment that:
(1)
Must be ordered by a Physician;
(2)
Must not be disposable;
(3)
Can withstand repeated use;
(4)
Is primarily and customarily used to serve a medical purpose;
(5)
Generally, is not useful to a person in the absence of an Illness or Injury; and
(6)
Is appropriate for use in the home; and
(7)
Would have been covered if provided in a Hospital.
Employee is defined in the "Eligibility for Participation" section of the Medical Plan.
Employer means RCAA Administrative Services, Inc., or any successor thereto, and its participating Affiliated
Companies.
Endodontic Treatment means procedures for the prevention and treatment of diseases of the dental pulp, pulp
chamber, root canal and surrounding periapical structures.
Experimental and/or Investigational means services, supplies, care and treatment which do not constitute
accepted and appropriate medical practice considering the facts and circumstances of the case and by the generally
accepted standards of a reasonably substantial, qualified, responsible, relevant segment of the appropriate medical
community or government oversight agencies at the time services were rendered, as determined by the Employer
as set forth below.
The Employer must make an independent evaluation of the Experimental or non-Experimental standings of specific
technologies. The Employer shall be guided by a reasonable interpretation of Medical Plan provisions. The
decisions shall be made in good faith and rendered following a detailed factual background investigation of the
claim and the proposed treatment. The decision of the Employer will be final and binding on the Medical Plan. In
addition to the above, the Employer will be guided by the following principles to determine whether a proposed
treatment is deemed to be Experimental and/or Investigational:
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