As used in this Plan, the following words and phrases shall have the meanings indicated:

ACTIVE WORK or ACTIVELY AT WORK means an Employee's full-time performance of all customary duties of such Employee's occupation for at least the number of hours per week as outlined on your Schedule of Benefits and at the Company's usual place of business, or their business locations to which the Company requires the Employee to travel.

An Employee will be deemed to be Actively at Work on each day of a regular paid vacation and on each regular non-work day on which the Employee is not disabled, if such Employee was Actively at Work on the last preceding regular work day.

ADOPTED CHILD means the legally adopted child of the Employee or a child who is Placed For Adoption with the Employee. (Legal proof of Adoption date or Placement date must be provided.)

AMBULATORY SURGICAL CENTER: See definition for Outpatient Surgical Center.

BIRTHING CENTER means a part of a Hospital or a free-standing institution which provides care by a Certified Nurse Midwife with Physician backup or by a Physician and Nurse(s) with specialized training to monitor labor, delivery and post-partum care. A Hospital Birthing Center must have discounted rates as compared with the regular Hospital delivery room charges. This Plan will provide follow-up care to the specifications of the Birthing Center if the requirements of the center are met.

CERTIFICATE OF CREDITABLE COVERAGE means a written certificate provided to a Covered Person at the time a Covered Person ceases to be covered under the Plan or becomes covered under COBRA; at the time a person on COBRA coverage ceases that coverage; and upon request, if the request is made within twenty-four (24) months of termination of coverage. The certificate shows a Covered Person's period of Creditable Coverage.

COMPANY means your employer, and each participating subsidiary Company.

CO-PAY means any percentage of a bill that is your responsibility to pay after the Plan has paid, not including ineligible charges or Deductible.

COSMETIC SURGERY means surgery performed for the purpose of improving appearance rather than for restoring bodily function.

COVERED EMPLOYEE means an Employee for whom the coverage, provided by this Plan, is in effect.

COVERED PERSON means a Covered Employee or a Dependent for whom the coverage, provided by this Plan, is in effect. A Covered Person may be covered under this Plan as an Employee or as a Dependent, but not both at the same time. Dependents may not be dually covered by this Plan. (See your Schedule of Benefits for any exceptions.)

In situations where both spouses work for the same Company, they may opt for one Employee to be carried as a Dependent (based on Employer policy). In such cases, the Dependent Spouse Employee would be eligible for any and all other non-medical benefits.

CREDITABLE COVERAGE means coverage under employer health plans, other health insurance, public health plans, Social Security, and certain other sources (including COBRA coverage). Creditable Coverage does not include coverage which is not general health insurance such as accident or disability income insurance, liability insurance, workers' compensation insurance or automobile medical insurance. Also, Creditable Coverage does not include health coverage for limited benefits, such as limited scope dental or vision benefits or long-term care plans, and plans under which health benefits are secondary or incidental.

The number of days in a Waiting Period during which you have no other coverage are not considered Creditable Coverage under the plan, nor are these days taken into account when determining a significant break in coverage. A significant break is a break of sixty-three (63) days or more.

CUSTODY means legal guardianship required by court order for a Dependent child who is related to a covered Employee by blood or marriage, or required by a court order (a copy of the court order must be provided).

DEDUCTIBLE means the amount of Eligible Charges that a Covered Person must incur in a calendar year before benefits can be paid. When Eligible Charges equal to the Deductible amount have been incurred and submitted to the Third Party Administrator, the Deductible will be satisfied. Benefits will not be paid for the Eligible Charges applied toward the Deductible. (See your Schedule of Benefits to determine your Plan's Deductible.)

DEPENDENT means a person who is a Covered Employee's:
(See your Schedule of Benefits for a more complete definition of your Plan.)

At any time, the Third Party Administrator may require proof that a child continues to qualify as a Dependent. In addition to natural children, legally Adopted Children, and children Placed For Adoption; the word "child" includes a Covered Employee's stepchild if the child:

A child born outside of a legally recognized marriage must provide proof of legally established paternity. The term Dependent child does not include any person serving in the armed forces of any country.

Exceptions by joint review of Employer, Third Party Administrator, and the Stop-Loss Provider.

If a husband and wife are both Covered Employees through the same Company, their Dependents, if any, may be considered as Dependents of either the husband or the wife, but not of both. A Covered Person may either be a Covered Employee or a Dependent of a Covered Employee, but not both at the same time. (See your Schedule of Benefits for any exceptions.)

EMPLOYEE means a person:

1. whose employment with the Company is:
(a) on a regular full-time basis;
(b) the person's principle occupation;
(c) for regular wage or salary;
2. who is regularly scheduled to work at such occupation at least the required number of hours each week (see Schedule of Benefits);
3. who is a member of an Employee class which is eligible for Coverage under this Plan;
4. who is a permanent resident of the United States or Canada. (See your Schedule of Benefits for any exceptions.)
5. This Plan will comply with all federal mandates defining full-time Employee.

1. performs services of a recognized profession, including but not limited to, an attorney, accountant, and consultant; or
2. is paid on a basis other than regular wage or salary, (full-time) regular Employees who work on commission or salary and commission do qualify.

ENROLLMENT DATE means the earlier of your first day of coverage or the date the Covered Person's Waiting Period begins (usually date of hire). If an Employee or Dependent enrolls during a Special Enrollment Period or during an Open Enrollment, the Enrollment Date is the effective date of coverage. (See your Schedule of Benefits to determine if your Plan has Open Enrollment.)

EXPERIMENTAL/INVESTIGATIVE: A drug, device, medical treatment, or procedure is experimental or investigative:

1. if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or
2. if the drug, device, medical treatment, or procedure, or the patient informed consent document utilized with the drug, device, treatment, or procedure, was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review or approval; or
3. if Reliable Evidence shows that the drug, device, medical treatment, or procedure is the subject of on-going phase I or phase II clinical trials, is the research, experimental, study, or investigational arm of on-going phase III clinical trials, or is otherwise under study to determine its' maximum tolerated dose, its' toxicity, its' safety, its' efficiency, or its' efficacy as compared with a standard means of treatment or diagnosis; or
4. if Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its' maximum tolerated dose, its' toxicity, its' safety, its' efficiency, or its' efficacy as compared with a standard means of treatment or diagnosis.

Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment, or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment, or procedure.

EXTENSION OF BENEFITS means your prior insurance policy will continue paying eligible charges in the event a Covered Person is in the Hospital on the day the prior insurance ends until discharged from the Hospital or until benefits have been exhausted, whichever comes first.

FAMILY UNIT means a Covered Employee and persons covered under this Plan as such Covered Employee's Dependents.

FREE-STANDING CHEMICAL DEPENDENCY TREATMENT CENTER means a place which meets all of the following requirements:

1. it is accredited by the Joint Commission on Accreditation of Hospitals or is licensed by the appropriate state licensing authority as a Chemical Dependency Treatment Center;
2. it is operated chiefly for the treatment of Chemical Dependency; and
3. it provides only Treatment that is directly under the supervision of a Physician M.D.

FULL-TIME STUDENT means an unmarried child, within the age specified on your Schedule of Benefits, who is enrolled for a minimum of twelve (12) credit hours at an accredited secondary school, university, or college.

If your school considers less than twelve (12) credit hours to be full-time, we will need documentation from the school regarding full-time qualifications. At age specified on your Schedule of Benefits, verification of student status must be submitted each quarter/semester.

GENERIC DRUG means a drug that is generically equivalent to a brand name drug and meets all FDA bioavailability standards.

HOME HEALTH CARE PROVIDER means a home health agency or a visiting nurses' association which meets all of the following requirements:

1. is licensed by the state;
2. qualifies as a home health care agency under Medicare;
3. meets the standards of the applicable area-wide health care planning agency;
4. provides Skilled Nursing Services and other services on a visiting basis in the patient's home;
5. is responsible for administering a home health care program; and
6. supervises the delivery of a home health care program as prescribed and approved in writing by the patient's attending Physician.

HOSPICE means a public agency or private organization which meets all of the following requirements:

1. is primarily engaged in providing care to terminally ill patients;
2. provides twenty-four (24)-hour care to control the symptoms associated with terminal Illness;
3. has on its staff an interdisciplinary team which includes at least one Physician, one registered professional Nurse (R.N.), one social worker, and at least one pastoral or other counselor, and volunteers;
4. must be a licensed organization whose standards of care meet those of the National Hospice Organization;
5. maintains central clinical records on all patients;
6. provides appropriate methods of dispensing drugs and medicines; and
7. offers a coordinated program of Home Care and Inpatient Care for a terminally ill patient.

The term "Hospice" does not include an organization or part thereof which:

1. is primarily engaged in providing:
(a) custodial care;
(b) care for Chemical Dependency;
(c) domestic services;
2. is a place of rest;
3. is a place for the aged; or
4. is a hotel or similar institution.

HOSPITAL means a place which meets all of the following requirements:

1. it is accredited as a general Hospital by the Joint Commission on Accreditation of Hospitals:
2. it is open at all times;
3. it is operated chiefly for the Treatment of sick or injured persons as inpatients;
4. it has a staff of one or more Physicians available at all times;
5. it provides twenty-four (24)-hour nursing service by graduate Registered Nurses; and
6. it includes areas designed for diagnosis and major surgical procedures. Or, if it is chiefly a place for the Treatment of mentally handicapped persons, it has an agreement, by contract or otherwise, with an accredited Hospital to perform surgery which may be required.

The term "Hospital" does not include:

1. a convalescent, nursing, rest, or Skilled Nursing Facility; or
2. a facility chiefly operated for Treatment of the aged or Chemical Dependency.

ILLNESS means a disorder of the body or mind, a disease, or pregnancy. All Illnesses which are due to the same cause or to a related cause or causes will be deemed to be an Illness.

INJURY means bodily Injury caused by an accident which results directly from the accident and independently of all other causes.

INPATIENT means confined as a registered bed patient in a Hospital, Skilled Nursing Facility, Hospice, or Free-Standing Chemical Dependency Treatment Center.

LATE ENROLLEE means an individual who enrolls after the initial eligibility date. An individual who enrolls during a Special Enrollment Period shall not be considered a Late Enrollee.

MEDICALLY NECESSARY means a service must be consistent with the diagnosis and Treatment of your condition, in accordance with standards of good medical practice, not solely for your convenience or the convenience of your family or your provider, and it must be furnished in the least expensive type of medical care setting required by your medical condition. This also means that your condition must require the level of skilled services provided. Medically Necessary means:

1. there is an Illness or Injury which requires Treatment; and
2. the confinement, service, or supply used to treat the Illness or Injury is:
(a) required;
(b) generally professionally accepted as the usual, customary, and effective means of treating the Illness or Injury in the United States; and
(c) approved by regulatory authorities such as the Food & Drug Administration.

Diagnostic X-rays and lab tests are Medically Necessary when:

1. performed due to definite symptoms of Illness or Injury; or
2. they reveal the need for Treatment.

MEDICARE means the medical benefits provided by Title XVIII of the Social Security Act, as amended.

NURSE means a registered professional Nurse (R.N.) licensed in the state in which they are practicing. Nurse does not include a person who is the Covered Person receiving Treatment or a person who is a relative by blood, marriage, or legal adoption to the fourth degree of kinship of the Covered Person, or is an Employee of the participating Employer.

OPEN ENROLLMENT means a period of time, usually at the policy anniversary date, when an active Employee may come on the Plan, add or drop Dependents, or change Plans if your Plan offers different levels of benefits. (See your Schedule of Benefits to determine if your Plan has Open Enrollment.)

OUT-OF-POCKET means the annual amount that is your responsibility to pay after the Deductible for eligible expenses, only up to Reasonable and Customary allowance is considered. (Ineligible charges and charges paid at 100% do not accumulate toward your Out-of-Pocket.)

OUTPATIENT means the receiving of medical services, but not confined as a registered bed patient.

OUTPATIENT SURGICAL CENTER means any public or private establishment which:

1. has an organized medical staff of Physicians;
2. has permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures;
3. provides continuous Physician services and registered professional nursing services while patients are in the facility; and
4. which does not provide services or other accommodations for patients to stay overnight.

PHYSICIAN means a medical practitioner who:

1. is a legally qualified Physician or Surgeon or a Certified Physician's Assistant working under the direct supervision of a Medical Doctor (or is a professional person deemed by state law to be the same as a legally qualified Physician); and
2. is acting within the lawful scope of his/her license. (If other than an M.D., D.C., D.O., PhD., or PsyD., we may require a copy of the provider's state license.)

Physician does not include a person who:

1. is the Covered Person receiving Treatment;
2. is a relative by blood, marriage, or legal adoption to the fourth degree of kinship of the Covered Person receiving Treatment; or
3. is an Employee of the participating Employer.

PLACED FOR ADOPTION in connection with any Placement for Adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. (Legal proof of placement date must be provided.)

For group health plan purposes, these provisions override state laws requiring the legal guardianship of a child Placed For Adoption to remain with the appropriate agency until the adoption is finalized.

PREADMISSION TESTING means x-ray and lab exams which:

1. are performed on an Outpatient basis;
2. are performed within seven (7) days of a scheduled surgery which is performed within forty-eight (48) hours following the Covered Person's admission to the Hospital; and
3. are related to the Illness or Injury that caused Hospital confinement or the need for surgery.

PREAUTHORIZATION means a written determination of benefit coverage and Medical Necessity is made by your Third Party Administrator prior to having a procedure performed or prior to incurring services or acquiring supplies.

PRECERTIFICATION means the Hospital admitting office, the Physician's office or the patient must call the telephone number shown on the covered individual's ID card prior to admission. Your Plan may also require advance notice on certain Outpatient procedures. Precertification is not a verification of coverage and does not guarantee coverage.

QUALIFICATION PERIOD: See Waiting Period.

QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) means a judgment, decree, or order issued by a court, domestic relations magistrate, or administrator that provides for child support related to health benefits or enforces a state Medical Child Support Order under the Social Security Act (for Medicaid purposes). It requires that the child(ren) named in the order have the right to receive benefits from their parent through any group medical plan under which the parent is enrolled, whether or not the parent has family coverage. The QMCSO must contain:

1. the name and last known mailing address of the participant;
2. the name and mailing address of each child (alternate recipient) covered by the order;
3. a reasonable description of the type of coverage to be provided by the group health plan to each alternate recipient or the manner in which coverage will be determined;
4. the period of time to which the order applies; and
5. the identification of each plan to which the order applies.

REASONABLE AND CUSTOMARY: See Usual and Customary.

REHABILITATIVE TREATMENT means services provided by a Licensed or registered therapist, Registered Nurse (R.N.), or Physician for physical, occupational, or speech therapy services necessary to restore or improve lost function caused by an Illness or Injury.

ROOM AND BOARD means charges covered up to semi-private room rate. Exceptions for Medical Necessity as determined by review of medical records.

SIGNIFICANT BREAK IN COVERAGE means a period of sixty-three (63) or more consecutive days without Creditable Coverage. A Waiting Period or HMO affiliation period (period of time that must expire before HMO insurance coverage becomes effective and during which an HMO is not required to provide benefits) is not considered for purposes of determining whether a significant break in coverage has occurred.

SKILLED NURSING FACILITY means a place, or a distinct part of a place, which meets all of the following criteria:

1. it is licensed according to state or local laws;
2. its chief purpose is to provide Skilled Nursing Services to a Covered Person who is recovering from an Illness or Injury;
3. it includes areas for medical Treatment;
4. it provides twenty-four (24)-hour nursing service under the full-time supervision of a Physician or a graduate Registered Nurse (R.N.);
5. it maintains daily health records for each patient;
6. it has an agreement which provides for the services of a Physician;
7. it has a suitable method for providing drugs and medicines to patients;
8. it has an arrangement with one or more Hospitals for the transfer of patients;
9. it has an effective utilization review plan;
10. its functions are developed with the advice and review of a skilled group which includes at least one Physician;
11. it is not solely a place for:
(a) rest or custodial care;
(b) the aged;
(c) treatment of Chemical Dependency; or
(d) those who are mentally handicapped or who have mental disorders.

SKILLED NURSING SERVICES means services which require the professional proficiency and scientific skills of a Registered Nurse or Licensed Practical Nurse. Services must be performed on a regular basis under the general direction of a Physician in order to ensure the safety of the patient and achieve the medically desired result. Skilled Nursing Services do not include Custodial Care or services such as the following which could be performed by the average non-medical person with proper training:

1. Administration of oral medication, eye drops, or ointments;
2. Non-infected wound care;
3. Monitoring vital signs;
4. Monitoring oxygen levels;
5. Treatment of minor skin problems;
6. Irrigation and other routine care of catheters;
7. Maintenance care of ostomies; or
8. Routine care regarding braces and similar devices.

SPECIAL ENROLLMENT PERIOD means a period of time when an individual, who did not enroll in a Company's group health plan when first eligible due to the existence of other coverage, may enroll, if the individual:

1. had other coverage when the Employee Plan was initially offered;
2. stated in writing that the other coverage was the reason for declining enrollment (but only if the Company required such a statement);
3. had COBRA coverage that was exhausted, or other health plan coverage that was terminated due to loss of eligibility or termination of employer contributions; and
4. requests enrollment within thirty-one (31) days of exhaustion or termination of coverage.

If your Plan offers Dependent coverage, Dependents also have a Special Enrollment Period of thirty-one (31) days if they become Dependents through marriage, birth, Adoption, Placement for Adoption, legal Custody, or a Qualified Medical Child Support Order. If the Employee or spouse is otherwise eligible for enrollment in the Plan, but he/she has not enrolled, the Employee or spouse is also allowed to enroll at the time of birth, Adoption, Placement for Adoption, legal Custody, or a Qualified Medical Child Support Order. Coverage through this Special Enrollment Period is effective on the date of marriage, birth, Adoption, Placement for Adoption, legal Custody, or the date a Qualified Medical Child Support Order is put in place and any required contribution is paid.

SUBROGATION means the Company may recover any and all benefit payments made from any settlement, recovery, or judgment a Covered Person receives from a third party or from any uninsured or underinsured motorist insurance, or proceeds resulting from any claim or litigation for the recovery of special, general, or punitive damages or any release, receipt, promise not to sue, acquittance, or agreement of any kind, written or oral. The Plan is entitled to recover from any and all settlements or judgements, even those designated as "pain and suffering" or "non-economic damages" only. The Plan has first priority to receive reimbursement from any recovery whether or not the injured party is made whole. This Plan is entitled to recover from any or all settlements or judgements prior to payment of additional expenses, such as attorney fees or court costs.

TOTAL DISABILITY means an Injury or Illness which:

1. with respect to a Covered Employee, prevents the Covered Employee from doing all of the main duties of such Covered Employee's occupation with the Company; and
2. with respect to Dependent, prevents the Dependent from performing the normal activities of a healthy person of the same age and sex.

TREATMENT means the consultations, tests, procedures, and interventions that are:

1. customarily applied in the care of persons with similar complaints and findings by similarly trained practitioners; and
2. generally accepted as the effective elements of care.

USUAL AND CUSTOMARY means the ordinary charge made by a person, group, or other entity which provides service, Treatments, or materials. It does not include any charge which the Third Party Administrator finds to be more than the general level of charges made:

1. by others who provide such services, Treatments, or materials;
2. for an Illness or Injury of comparable severity and nature to the Illness or Injury being treated; or
3. by persons providing similar services in the area where the Covered Person normally resides. The term "area" means a county or zip code area as is required to obtain a typical cross section of others who provide such services, Treatments, or materials.

WAITING PERIOD means the period of time that begins with an Employee's most recent date of Active Work employment with the Company and ends on the day prior to the day such Employee is eligible for Coverage under the Plan.