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DEFINITIONS
Accident
Medical
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Accident
or Accidental means a sudden, unexpected, specific and
abrupt event that occurs by chance at an identifiable time and
place during the Policy term. |
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Aggregate
Limit of Liability means the total benefits We will
pay for a Covered Accident or Covered Accidents
set forth in the Policy. For purposes of the Aggregate
Limit of Liability provision, Covered Accident or Covered
Accidents will include a Covered Loss or Covered
Losses arising out of a single event or related events or
originating cause and includes a resulting Covered Loss
or Covered Losses. If the total benefits under the
Aggregate Limit of Liability is not enough to pay full benefits
to each Insured Person, We will pay each one a reduced benefit
based upon the proportion that the Aggregate Limit of Liability
bears to the total benefits which would otherwise be paid. |
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Deductible
Amount means the portion of the Usual and Customary
Charges for Medically Necessary Covered Accident Medical
Services, incurred due to Covered Injuries sustained
by an Insured Person in a Covered Accident, which
must be met before the Accident Medical Expense Benefit
will be paid. The Deductible Amount is shown on the
Schedule. |
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Maximum
Benefit Period means, with respect to the Accident
Medical Expense Benefit, the maximum period for which
benefits will be payable for Covered Accident Medical
Services for or in connection with a single Accident
Medical Expense Covered Loss. The Maximum Benefit Period
for the Accident Medical Expense Benefit commences on the
first date of treatment or services and continues for the period
of time shown on the Schedule. |
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Policy means the Blanket Accident Insurance Policy. |
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Usual and Customary Charge(s) means a charge that is made
for a Covered Accident Medical Expense Benefit that: (1)
does not include charges that would not have been made if no
insurance existed; (2) is the lesser of the : (a) usual charges
for similar services, treatment, supplies, or Hospital
room and board in the locality where the expense is incurred.
(For a Hospital stay, the Usual and Customary Charge
is based upon the expense for a semi-private room and board
charge, unless the stay is a Medically Necessary stay in
an intensive care unit.) or (b) the allowable charge as
calculated by any Other Valid and Collectible Insurance
provider; and (3) with respect to drugs, 125% of the Average
Wholesale Price (AWP) will be considered Usual and Customary. |
General
Liability
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Additional
Insured: A person, company or entity protected by an
insurance policy in addition to the insured. |
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Benefits:
The amount payable by the insurance company to a claimant,
assignee or beneficiary under each coverage. |
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Certificate
of Insurance: A statement of coverage issued to an
individual insured under a group insurance contract, outlining
the insurance benefits and principal provisions applicable to
the member. |
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Exclusions: Specific
conditions or circumstances listed in the policy for which the
policy will not provide benefit payments. |
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In-Home: Any activity
occurring in or on a property intended for residential use. |
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Liability Insurance:
Insurance covering the policyholder's legal liability resulting
from injuries to other persons or damage to their property. |
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Loss: The happening of
the event for which insurance pays. |
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Master Policy (or Master
Contract): The policy issued to a group policyholder setting
forth the provisions of the group insurance plan. The
individuals insure under the policy are then issued certificates
of insurance. |
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Negligence: Failure to
use the care that a reasonable and prudent person would have
used under the same or similar circumstances. |
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Policy: The legal
document issued by the company to the policyholder, which
outlines the conditions and terms of the insurance; also called
the policy contract or the contract. |
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Reasonable and Customary
Charge: A charge for health care, which is consistent with
the going rate or charge in a certain geographical area for
identical or similar services. |
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