2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 81
Hospital Emergency Room is the department of a Hospital responsible for the provision of medical and surgical
care to patients arriving at the Hospital in need of Medical Emergency services.
Hour(s) of Service mean each hour for which an Employee is paid, or entitled to payment, for the performance of
duties for the Employer (or a related Employer) and each hour for which an Employee is paid, or entitled to payment
by the Employer (or a related Employer) for a period of time during which no duties are performed due to vacation,
holiday, Illness, incapacity (including disability), layoff, jury duty, military duty, or leave of absence, but excluding
Hours of Service to the extent that the compensation for those services constitutes income from sources outside
the United States or performed as (1) a bona fide volunteer (as defined in Treas. Reg. Section 54.4980H-1(a)(7))
or (2) part of a Federal or State work study program. For purposes of this definition, a related Employer is any entity
that must be treated as part of the same “applicable large employer” as the Employer for purposes of Code Section
4980H, as determined at the time that the applicable Hour of Service is performed or credited.
Illness means a disease, sickness, pregnancy or a condition involving bodily or mental disorder of any kind. All
disorders which exist simultaneously and are due to the same or related causes shall be considered one Illness.
Incurred means the date the service is rendered or the supply is obtained. With respect to a course of treatment
or procedure which includes several steps or phases of treatment, expenses are Incurred for the various steps or
phases as the services related to each step are rendered and not when services relating to the initial step or phase
are rendered. More specifically, Covered Expenses for the entire procedure or course of treatment are not Incurred
upon commencement of the first stage of the procedure or course of treatment.
Independent Freestanding Emergency Department means a health care facility that is geographically separate
and distinct and licensed separately from a Hospital under applicable State law and provides any services for
Medical Emergencies.
Injury means a bodily Injury which results independently of Illness and is caused by accidental means. All bodily
Injuries sustained in any one accident and all related conditions and recurrent symptoms will be considered one
Injury.
Late Enrollee is an eligible Employee or eligible Dependent that does not elect coverage under this Medical Plan
during their original 31-day eligibility period. A Special Enrollee is not considered a Late Enrollee.
Legal Guardian is defined in the "Eligibility for Participation" section of the Medical Plan.
Lifetime Maximum means the maximum benefit payable during an individual's lifetime while covered under this
Medical Plan. Benefits are available only when an individual is eligible for coverage under this Medical Plan. The
Medical Plan may provide for a Lifetime Maximum benefit for specific types of medical treatment. Any Lifetime
Maximum will be shown in the applicable Medical Schedule of Benefits or the applicable Covered Expenses
section of the Medical Plan.
Medical Emergency means medical services and supplies provided after the sudden onset of a medical condition
(Injury or Illness) manifesting itself by acute symptoms, including intense pain, which are severe enough that the
lack of immediate medical attention could reasonably be expected to result in any of the following: (1) the patient's
health would be placed in serious jeopardy; (2) bodily function would be seriously impaired; or (3) there would be
serious dysfunction of a bodily organ or part.
Medically Necessary/Medical Necessity means treatment is generally accepted by Physicians in the United
States as proven, effective and appropriate for the condition based on recognized standards of the health care
specialty involved.
(1)
"Proven" means the care is not considered Experimental and/or Investigational, meets a particular standard
of care accepted by the medical community and is approved by the Food and Drug Administration (FDA) for
general use.
77