Laserfiche WebLink
<br />) <br /> <br />3.11 Conversion Contract means an individual Member or Subscriber contract which shall be available to <br />continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon <br />termination of the Subscribing Group Contract as provided in Part vrn of this Contract, and shall at <br />times be referred to as the 'Individual Conversion Contract.' <br /> <br />') <br /> <br />3.12 Co-payment means the charge, in addition to the prepaid premium amounts, which the Subscriber is <br />required to pay at the time certain health services are provided under this Contract. The Co-payment <br />may be a specific dollar amount or a percentage of the cost. The Member is responsible for the payment <br />of any Co-payment charges directly to the provider oftbe health services at the time of service. <br /> <br />3.13 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities <br />of daily living, such as bathing, feeding, dressing, walking, and taking oral medications. 'Custodial <br />Care' also rneans services and supplies that can be safely and adequately provided by persons other than <br />licensed health professionals, such as dressing changes and catheter care, or that ambulatory patients <br />customarily provide for themselves, such as ostomy care, administering insulin, and measuring and <br />recording urine and blood sugar levels. <br /> <br />3.14 Dental Care means dental x-rays, examinations and treatment of the teeth or any services, supplies or <br />charges directly related to: <br /> <br />,J <br /> <br />The care, filling, rernoval or replacement of teeth, or <br /> <br />The treatment of injuries to or disease of the teeth, gums or structures directly supporting or <br />attached to the teeth, that are custornarily provided by dentists (including orthodontics <br />reconstructive jaw surgery, casts, splints, and services for dental malocclusion). <br /> <br />3.15 Dependent means any member of a Subscriber's family who meets all applicable requirements of Part <br />IV and is enrolled hereunder and for whom the prepayrnent required by Part VII has actually been <br />received by AvMed. <br /> <br />3.14.01 <br />3.14.02 <br /> <br />3.16 <br /> <br />3.16.01 <br /> <br />Emergency Medical Condition means: <br /> <br />) <br /> <br />A medical condition manifesting itself by acute symptorns of sufficient severity such that the <br />absence of inunediate medical attention could reasonably be expected to result in any of the <br />following: <br /> <br />a) Serious jeopardy to the health of a patient, including a pregnant woman or fetus. <br /> <br />b) Serious impairment to bodily functions. <br /> <br />c) Serious dysfunction of any bodily organ or part. <br /> <br />With respect to a pregnant woman: <br /> <br />a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery; <br /> <br />b) That a transfer may pose a threat to the health and safety of the patient or fetus; or <br /> <br />c) That there is evidence of the onset and persistence of uterine contractions or rupture of <br />the membranes. <br /> <br />Examples of Emergency Medical Conditions include, but are not limited to: heart attack, <br />stroke, massive internal or external bleeding, fractured limbs, or severe trauma. <br /> <br />3.17 Emergency Medical Services and Care means medical screening, examination, and evaluation hy a <br />physician, or, to the extent permitted by applicable law, by other appropriate personnel under the <br />supervision of a physician, to determine if an Emergency Medical Condition exists and, if it does, the <br />care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the <br />Emergency Medical Condition within the service capability ofthe Hospital. <br /> <br />3.16.02 <br /> <br />3.16.03 <br /> <br />A V -GI 00-2009 <br />MP-5319 (10/09) <br /> <br />) <br /> <br />3 <br />