Accident or Accidental shall mean an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
Administrator shall mean Seven Corners, Inc.
Airworthiness Certificate or Airworthy Certificate shall mean the “Standard” Airworthiness Certificate issued by the Federal
Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil
aviation in the country of its registry.
Benefit Period shall mean the one hundred and eighty (180) days following the onset of an Eligible Accident, Injury in which to
receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to
receive Treatment so long as the Treatment is within Your Benefit Period and outside Your Home Country.
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Your responsibility to pay.
Common Carrier shall mean any land, sea, and/or air conveyance operating under a valid license for the transportation of
passengers for hire.
Congenital shall mean a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.
Covered Expense shall mean “Eligible Benefit”.
Deductible shall mean the amount of Covered Expenses which is Your responsibility to pay before benefits under the plan are payable.
Disablement (as used with respect to medical expenses) shall mean an Accidental bodily Injury necessitating medical
Treatment by a Physician.
Eligible Benefit(s) shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary
services, supplies, care, or Treatment; due to Injury; prescribed, performed or ordered by a Physician; Reasonable and
Customary charges; incurred while insured under this program and which do not exceed the maximum benefit.
Experimental/Investigational means all services or supplies associated with: 1)Treatment or diagnostic evaluation which is not
generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of
effectiveness documented in peer reviewed articles in medical journals published in the United States. For the Treatment or
diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available; or if
less effective than other available Treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have
FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR
807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical
journals published in the United States. For the device to be considered effective, such articles should indicate that it is more
effective than other available devices for the proposed use; or if less effective than other available devises, or is safer or less
costly. The Underwriter will make the final determination as to whether a service or supply is Experimental/Investigational.
Home Country shall mean the country where You have Your true, fixed and permanent home and principal establishment.
Hospital shall mean a place that 1) Is legally operated for the purpose of providing medical care and Treatment(s) to Sick or
Injured persons for which a charge is made that the Insured Person(s) is legally obligated to pay in the absence of insurance 2)
Provides such care and Treatment(s) in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its
use; 3) Provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4) Operates under the supervision of a staff of one or more Physician(s). Hospital also means a place that is accredited as a Hospital by the Joint
Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of
Health Care Organizations (JCAHO). Hospital does not mean:
- A Convalescent, nursing, or rest home or facility, or a home for the aged;
- A place mainly providing Custodial, Educational, or Rehabilitative Care; or
- A facility mainly used for the Treatment(s) of drug addicts or alcoholics.
Host Country shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent
home and principal establishment.
Illness shall mean a sickness, disorder, illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap,
deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind,
or any other medical, physical or health condition. Provided, however, that Illness does not include learning disabilities, or
attitudinal or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which
directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another
are considered to be one Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the
same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation
of the prior Illness and not a separate Illness.
Injury shall mean Accidental bodily Injury or injuries caused by an Accident which occurs after the Effective Date of this policy.
The Injury must be the direct cause of the loss, independent of disease or bodily infirmity.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
Insured or Insured Person shall mean a person eligible for benefits under the Policy who has applied for coverage and is
named on the application and for whom the Company has accepted premium.
Intensive Care shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint
Commission on Accreditation of Hospitals for Special Care Units.
Medically Necessary shall mean services and supplies received while insured that are determined by the Company to be: 1)
appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment of the Insured Person’s medical
conditions; 2) within the standards the organized medical community deems good medical practice for the Insured Person’s
condition; 3) not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider
or person; 4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are
used for any type of research program or protocol; and 5) not excessive in scope, duration, or intensity to provide safe and
adequate, and appropriate Treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the
kinds of services the Insured Person is receiving or the severity of the Insured Person’s condition, in that safe and adequate care
cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe,
order, recommend, or approve a service, supply, or level of care does not, of itself, make such Treatment Medically Necessary or
make the charge of a Covered Expense under this Policy.
Mental Illness and Mental and Nervous Disorder shall mean any mental, nervous, or emotional Illness which generally denotes
an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal
behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without
limitation: psychosis; depression; schizophrenia; bipolar affective disorder; any disease or condition, regardless of whether the cause
is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by
the U.S. Department of Health and Human Services; and those psychiatric and other Mental Illnesses listed in the current edition of
the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. Mental Illness and
Mental and Nervous Disorder does not mean or include learning disabilities, attitudinal disorders or disciplinary problems. For
purposes of this insurance, Mental Illness and Mental and Nervous Disorder do not include Substance Abuse.
Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either: 1) utilizing
harnesses, ropes, crampons or ice axes; or 2) ascending 4,500 meters or above.
Outpatient shall mean if You receive care in a Hospital or another institution, including; ambulatory surgical center;
convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is confined and is not charged for room
Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
Period of Coverage or Policy Period shall mean the Period of Coverage issued by the Underwriter to the Insured Person, typically
beginning with the Effective Date and ending with the Expiration Date or the date coverage is renewed by the Underwriter.
Physician(s) or Surgeon shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or
perform Surgery(ies) in accordance with the laws of the jurisdiction where such professional services are performed.
Pre-existing Conditions shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous
Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences
related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or any time during the 36 months prior to the effective date of coverage under this policy, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the 36 month period immediately preceding the effective date of coverage under this policy.
Reasonable and Customary shall mean the maximum amount that the plan determines is Reasonable and Customary for
Covered Expenses You receive, up to but not to exceed charges actually billed. The determination considers:
- Amounts charged by other Service Providers for the same or similar service in the locality where received, considering
the nature and severity of the bodily Injury in connection with which such services and supplies are received;
- Any usual medical circumstances requiring additional time, skill or experience; and
- Other factors included but not limited to, a resource based relative value scale.
Relative shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent,
son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
Service Provider shall mean a Hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital,
community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency
treatment center, birthing center, Physician, dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory,
assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
Sound Natural Tooth is a tooth that is whole or properly restored; is without impairment, periodontal or other conditions; is not more
susceptible to Injury than a virgin tooth, and is not in need of the Treatment provided for any reason other than Accidental Injury. A
tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or Treated by endodontics is not a Sound Natural Tooth.
Substance Abuse shall mean a condition brought about when an individual uses alcohol, chemicals or any other drug(s) in such
a manner that his/her health and/or judgment is impaired and/or ability to control actions is lost.
Surgery shall mean an invasive diagnostic procedure; or the treatment of Illness or Injury by manual or instrumental operations
performed by a Physician while the patient is under general or local anesthesia.
Terrorism shall mean an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or
similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear.
Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the
perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).
Traveling Companion shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling,
in-laws (parent son, daughter, brother, or sister), aunt, uncle, niece, nephew, legal guardian, ward, or business partner of the
Treatment means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic
procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.
Underwriter shall mean Certain Underwriters at Lloyds, London.
You or Your shall mean the Primary Insured Person