This Glossary defines the italicized terms appearing in your booklet.
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Active Appliance means an appliance like braces. used in orthodontic treatment to move
teeth.
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Ambulatory Surgical means a facility which is mainly engaged in performing outpatient surgery. It
Center must: (a) be staffed by doctors and nurses, under the supervision of a doctor; (b) have permanent operating and recovery rooms; (c) be staffed and equipped to give emergency care; and (d) have written back-up arrangements with a local hospital for emergency care. We'll recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either: (a) accredited for its stated purpose by either the Joint Commission or the Accreditation Association for Ambulatory Care; or lb) approved for its stated purpose by Medicare. We don't recognize a facility as an ambulatory surgical center if it is part of a hospital.
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Appliance means any dental device other than a prosthetic device.
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Benefit Year with respect to this plan's dental expense insurance, means a 12 month period which starts on January ist and ends on December 31st of each year.
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Benefit Year means each successive 12 month period which starts on January 1 st and ends on December 31st.
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Birthing Center means a facility which mainly provides care and treatment for people during
uncomplicated pregnancy, routine full-term delivery, and the immediate postpartum period. It must: (a) provide full-time skilled nursing care by or under the supervision of nurses; lb) be staffed and equipped to give emergency care; and (c) have written back-up arrangements with a local hospital for emergency care. We'll recognize it if: (a) it carries out its stated purpose under all relevant state and local laws; or lb) it is approved for its stated purpose by the Accreditation Association for Ambulatory Care; or (c) it is approved for its stated purpose by Medicare. We don't recognize a facility as a birthing center if it's part of a hospital.
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Close Relative means: (a) a covered person's spouse, children, parents, brothers and
sisters; and (b) any other person who is part of a covered person's household. We don't pay for services and supplies furnished by close relatives.
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Co-payment means the percentage of a covered charge that must be paid by a covered
person to a provider. Co-payments do not include deductibles or non-covered expenses.
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Covered Charges are reasonable charges for the types of services and supplies described in
the " Covered Charges" and "Charges Covered with Special Limitations" section of this plan's Major Medical Expense Insurance provisions, and the "Covered Drugs" section of this plan's Prescription Drug Expense Insurance provisions. The services and supplies must be: (a) furnished or ordered by a recognized health care provider; lb) medically necessary to diagnose or treat a sickness or injury, (c) accepted by a professional medical society in the United States as beneficial for the control or cure of the sickness or injury being treated; and (d) furnished within the framework of generally accepted methods of medical management currently used in the United States.
By "reasonable" we mean the charge isn't more than the usual local charge for that service or supply. When we decide what's reasonable, we look at the covered person's condition and how severe it is. And we also look at special circumstances.
A covered charge is incurred on the date the service or supply is furnished.
Subject to all of the terms of this plan, we pay benefits for covered charges
incurred by a covered person while he's insured by this plan. Read the
entire plan to find out what we limit or exclude.
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Covered Person with respect to this plan's dental expense insurance, means an employee or
any of his covered dependents.
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Covered Dependent means an eligible dependent who is covered by the Major AAedical Expense
portion of this plan.
Covered Family means you and those of your eligible dependents who are covered by the
Major Medical Expense portion of this plan.
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Covered Person with respect to the Major Medical Expense portion of this plan, means you or a covered dependent.
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Covered Person with respect to the Prescription Drug Expense portion of this plan, means you or a covered dependent.
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Custodial Care means any service or supply, including room and board, which: (a) is
furnished mainly to help a person meet his routine daily needs; and lb) can be furnished by someone who has no professional health care training or skills. Even if you or a covered dependent are in a hospital or other recognized facility, we don't pay for care if it's mainly custodial.
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Dentist means any dental or medical practitioner we are required by law to recognize who: (a) is properly licensed or certified under the laws of the state where he practices; and (b) provides services which are within the scope of his license or certificate and covered by this plan.
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Doctor means any practitioner we are required by law to recognize who: (a) is properly licensed or certified to provide medical care under the laws of the state where he practices; and lb) provides medical services which are within the scope of his or her license or certificate and are covered by this plan.
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Drug Abuse Centers, Alcohol Abuse Centers, Mental Health Centers mainly provide treatment for people with drug abuse, alcohol abuse or mental
health problems. We'll recognize such a place if it carries out its stated
purpose under all relevant state and local laws, and it is either: (a) accredited
for its stated purpose by the Joint Commission; or (b) approved for its stated
purpose by Medicare.
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Eligibility Date for dependent coverage is the earliest date on which: (a) you@ have initial
dependents; and (b) are eligible for dependent coverage.
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Eligible Dependent is defined in the provision entitled "Dependent Coverage."
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Employer means CYRIX CORPORATION.
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Encounter Fee is a $15.00 charge paid to a PPO doctor each time a covered person visits his office. This fee is distinct from the cash deductible and is a non-covered expense.
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Enrollment Period with respect to dependent coverage, means the 31 day period which starts on the date that you first become eligible for dependent coverage.
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Experimental means treatment: (a) that has not been scientifically proven or fully Treatment developed; (b) cannot be supported in medical literature published by a professional medical society in the United States; (c) is not accepted by a professional medical society in the United States as beneficial for the control or cure of sickness or injury being treated; or (d) is not furnished within the framework of generally accepted methods of medical management currently being used in the United States.
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Extended Care means a facility which mainly provides full-time inpatient skilled nursing care
Center for sick or injured people who don't need to be in a hospital. We'll recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either: (a) accredited for its stated purpose by the Joint Commission; or (b) approved for its stated purpose by Medicare. In some places, an "Extended Care Center" may be called a "Skilled Nursing Center."
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Home Health means a provider which mainly provides home health care to sick or injured
Agency people under a home health care pr ' ogram designed to reduce or eliminate hospital stays. We will recognize it if: (a) it carries out its stated purpose under all relevant state and local laws, and lb) it is approved for its stated purpose by Medicare.
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Hospice means a facility which mainly provides palliative and supportive care for
terminally ill people under a hospice care program. We will recognize a hospice if it carries out its stated purpose under all relevant state and local laws, and it is either: (a) approved for its stated purpose by Medicare; or (b) accredited for its stated purpose by either the Joint Commission or the National Hospice Organization.
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Hospital means a facility which mainly provides inpatient care and treatment for sick or injured people. It may also provide outpatient services. We'll recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either: (a) accredited as a hospital by the Joint Commission; or (b) approved as a hospital by Medicare.
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Initial Dependents means those eligible dependents you have at the time you first become eligible for employee coverage. If at this time you do not have any eligible dependents, but you later acquire them, the first eligible dependents you acquire are your initial dependents.
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Injury with respect to this plan's dental expense insurance, means all damage to a covered person's mouth due to an accident, and all complications rising from that damage. But the term injury does not include damage to teeth, appliances or prosthetic devices which results from chewing or biting food or other substances.
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Injury means all damage to a covered person's body due to an accident, and all complications arising from that damage.
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Inpatient means a covered person who is physically confined as a registered bed
patient in a hospital or other recognized health care facility.
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Joint Commission means the Joint Commission on the Accreditation of Health Care Facilities.
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Legend Drug means any drug or vitamin which must be labelled "Caution - Federal Law
prohibits dispensing without a prescription".
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Medicaid means the health care program for the needy provided by Title XIX of the Social Security Act, as amended from time to time.
Medicare means Parts A and B of the health care program for the aged and disabled provided by the Title XVIII of the Social Security Act, as amended from time to time.
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Mental and Nervous Condition means a sickness which manifests symptoms which are.primarily mental or
nervous, regardless of any underlying physical cause.
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Newly Acquired means an eligible dependent you acquire after you already have coverage in
Dependent force for initial dependents.
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Non-covered Expenses are expenses which do not meet our definition of "covered charges," or
which exceed any of the benefit limits shown in this plan, or which are specifically identified as non-covered expenses or are otherwise not covered by this plan.
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Nurse is a registered nurse or licensed practical nurse, including a nursing specialist such as a nurse mid-wife or a nurse anesthetist, who: (a) is properly licensed or certified to provide medical care under the laws of the state where he or she practices; and (b) provides medical services which are within the scope of his or her license or certificate and are covered by this plan,
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Orthodontic means the movement of one or more teeth by the use of active appliances. Treatment It includes: (a) diagnostic services; (b) the treatment plan; (c) the fining, making and placement of an active appliance; and (d) all related office visits,
including post-treatment stabilization.
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Out-of-pocket Expense means this plan's deductibles and co-payments, to the extent that they are
paid by a covered person out of his own pocket.
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Plan means the Guardian group plan purchased by your employer, except in the provision entitled "Coordination of Benefits" where "plan" has a special meaning. See that provision for details.
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PPO means Private Healthcare Systems, Inc. (PHCS) , a preferred provider organization.
Preferred Provider means a health care practitioner or facility that: (a) is a member of the PPO; and (b) has a participating agreement in force with us.
Preferred Provider Organization see PPO.
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Proof or Proof of Insurability means an application for insurance showing that a person is insurable.
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Prosthetic Device means a device which is used to replace missing or lost teeth or tooth structure. It includes all types of dentures, crowns, bridges, pontics and cast restorations.
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Rehabilitation means a facility which mainly provides therapeutic and restorative services to
Center sick or injured people. We'll recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either: (a) accredited for its stated purpose by either the Joint Commission or the Commission on Accreditation for Rehabilitation Facilities; or (b) approved for its stated purpose by Medicare. In some places a rehabilitation center is called a ..rehabilitation hospital."
Residential Treatment Facility means a facility which provides 24 hour treatment for people with drug abuse, alcohol abuse or mental health problems on an inpatient basis. It must provide at least the following: room and board; medical services; nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services. We'll recognize a residential treatment facility if it's accredited for its stated purpose by the Joint Commission, and carries out its stated purpose in compliance with all relevant state and local laws.
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Routine Foot Care means the cutting, debridement, trimming, reduction, removal or other care
of corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain,
dystrophic nails, excresences, helomas, hyperkeratosis, hypertrophic nails,
non-infected ingrown nails, deratomas, keratosis, onychauxis,
onychocryptosis, tylomas or symptomatic complaints of the feet.
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Routine Nursing means the nursing care customarily furnished by a recognized facility for the
Care benefit of its inpatients.
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Sickness means any illness or disease suffered by a covered person. We consider all complications or recurrences, and all related conditions as one sickness.
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Special Care Unit means a part of a hospital set up for very sick patients who must be observed constantly. The unit must have a specially trained staff. -And it must have special equipment and supplies on hand at all times. Some types of special care units are: (a) intensive care units; (b) cardiac care units; (c) neonatal care units; and (d) burn units.
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Spinal Manipulation includes manipulation or adjustment of the spine; hot or cold packs; electrical muscle stimulation; diathermy; skeletal adjustments; massage, adjunctive, ultra-sound, doppler, whirlpool or hydro therapy; or other treatment of a similar nature.
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Important Notice: The employer and The Guardian have made an arrangement -whereby the employer is responsible for directly funding a certain portion of the claims on a non-insured basis under this plan. The Guardian is liable only for benefits which are not the liability of the employer.
But this arrangement, between the employer and The Guardian, should not affect the way a covered person submits claims while the arrangement stays in force.
If this arrangement ends, the employer will remain responsible for funding benefits for three months. After that, we will be responsible for funding benefits payable under this plan, which were incurred while the plan was in effect. The employer will give his employees a notice in that event explaining how this works.
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