Anniversary Date - the annual reoccurrence of the effective date.

Application - all questionnaires and forms required by Medical Mutual to determine your eligibility and insurability.

Benefit Period - the period of time specified in the Schedule of Benefits during which covered services are rendered, and benefit maximums, deductibles, coinsurance limits and non-PPO network coinsurance limits are accumulated. The first and/or last benefit periods may be less than 12 months depending on the effective date and the date your coverage terminates.

Billed Charges - Charges for all services and supplies that the covered person has received from the doctor, hospital or other healthcare professional, whether the services are covered or not.

Charges - the healthcare professional's list of charges for services and supplies before any adjustments for discounts, allowances, incentives or settlements. For a hospital, charges are the master charge list uniformly applicable to all payers before any discounts, allowances, incentives or settlements.

Coinsurance - a percentage for which you are responsible after you have met your deductible or paid your copayment.

Coinsurance Limit - a specified dollar amount of coinsurance expense incurred in a benefit period by a covered person for covered services received from a network doctor or hospital.

Condition - an injury, ailment, disease, illness or disorder.

Contract - the agreement between Medical Mutual and you. The contract includes the application, this policy, Schedules of Benefits and any riders or addenda.

Copayment - a dollar amount, if specified in the Schedule of Benefits, that you may or may not be required to pay at the time covered services are rendered.

Covered Charges - the billed charges for covered services. Medical Mutual reserves the right to limit the amount of covered charges for covered services provided by a non-network facility.

Covered Person - the policyholder and, if dependent coverage is in force, the policyholder's eligible dependent(s).

Covered Service - a healthcare professional's service or supply as described in the healthcare benefits section of this policy for which Medical Mutual will provide benefits, as listed in the Schedule of Benefits.

Creditable Coverage - coverage of an individual under any of the following:

• a group health plan, including church and governmental plans;
• health insurance coverage;
• Part A or Part B of Title XVIII of the Social Security Act (Medicare);
• the health plan for active military personnel, including CHAMPUS;
• the Indian Health Service or other tribal organization program;
• a state health benefits risk pool;
• the Federal Employees Health Benefits Program;
• a public health plan as defined in federal regulations;
• a health benefit plan under section 5 (c) of the Peace Corps Act; or
• any other plan which provides comprehensive hospital, medical and surgical services.

Custodian - a person who, by court order, has custody of a child.

Deductible - an amount, usually stated in dollars, for which you are responsible each benefit period before Medical Mutual will start to provide benefits.

Dependent Coverage - coverage for all eligible dependents.

Effective Date - 12:01 a.m. on the date when your coverage begins, as determined by Medical Mutual.

Experimental or Investigational Drug, Device, Medical Treatment or Procedure - a drug, device, medical treatment or procedure is experimental or investigational:

• 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;
• if reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I, II or III clinical trials or is under study to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy as compared with the standard means of treatment or diagnosis; or
• if reliable evidence shows that the consensus of 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, toxicity, safety, efficacy or efficacy as compared with the standard means of treatment or diagnosis. Reliable evidence means 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. Determination will be made by Medical Mutual at its sole discretion and will be final and conclusive.

Full-time Student - an eligible dependent who is enrolled at an accredited institution of higher learning. It must be certified annually that the student meets the institution's requirements for full-time status.

Immediate Family - the policyholder and the policyholder's spouse, parents, stepparents, grandparents, nieces, nephews, aunts, uncles, cousins, brothers, sisters, children and stepchildren by blood, marriage or adoption.

Incurred - rendered to you by a healthcare professional. All services rendered by a facility during an inpatient admission prior to termination of coverage are considered to be incurred on the date of admission.

Individual Coverage - coverage for the policyholder only.

Inpatient - a covered person who receives care as a registered bed patient in a hospital or other facility where a room and board charge is made.

Institution (Institutional) - a hospital or other facility that provides healthcare services.

Legal Guardian - an individual who is either the natural guardian of a child or who was appointed a guardian of a child in a legal proceeding by a court having the appropriate jurisdiction.

Lesser Amount - for PPO network healthcare professionals, the lesser of the negotiated amount or the covered charges. For non-PPO network healthcare professionals, the lesser amount means the traditional amount.

Medical Emergency - the sudden and unexpected onset of a severe medical ailment, condition, disease, illness or disorder, including severe pain, requiring emergency services.

Medically Necessary (or Medical Necessity) - a service, supply and/or prescription drug that is required to diagnose or treat a condition and that Medical Mutual determines is

• appropriate with regard to the standards of good medical practice and not experimental or investigational;
• not primarily for your convenience or the convenience of a healthcare professional; and
• the most appropriate supply or level of service that can be safely provided to you. When applied to the care of an inpatient, this means that your medical symptoms or condition require that the services cannot be safely or adequately provided to you as an outpatient. When applied to prescription drugs, this means the prescription drug is cost effective compared to alternative prescription drugs that will produce comparable effective clinical results.

Medicare - the program of healthcare for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.

Non-Covered Charges - billed charges for services and supplies that are not covered services.

Non-PPO Network Coinsurance - a percentage of the lesser amount for non-PPO network healthcare professionals or the covered charges for non-PPO network facilities for which you are responsible after you have met your deductible or paid your copayment, if applicable.

Non-PPO Network Coinsurance Limit - a specified dollar amount of non-PPO network coinsurance expense for which you are responsible in each benefit period.

Non-PPO Network Deductible - an amount that applies for services received from a non-PPO network healthcare professional, usually stated in dollars, for which you are responsible each benefit period before Medical Mutual will start to provide benefits for services received from a non-PPO network healthcare provider.

Non-PPO Network Provider - a doctor, hospital or other healthcare professional or facility that is not designated by Medical Mutual as a PPO network provider.

Other Facility Provider - the following Institutions which are licensed, when required, and where Covered Services are rendered which require compensation from their patients. Other than incidentally, these facilities are not used as offices 39 or clinics for the private practice of a Physician or Other Professional Provider. Medical Mutual will only provide benefits for services or supplies for which a charge is made. Only the following Institutions which are defined below are considered to be Other Facility Providers:

Other Professional Provider - only the following persons or entities which are licensed as required:

• advanced nurse practitioner (A.N.P.);
• ambulance services;
• dentist;
• doctor of chiropractic medicine;
• durable medical equipment or prosthetic appliance vendor;
• laboratory (must be Medicare Approved);
• licensed independent social workers (L.I.S.W.);
• licensed practical nurse (L.P.N.);
• licensed professional clinical counselor;
• licensed vocational nurse (L.V.N.);
• mechanotherapist (licensed or certified prior to November 3, 1975);
• nurse-midwife;
• occupational therapist;
• physical therapist;
• physician assistant;
• podiatrist;
• Psychologist;
• registered nurse (R.N.); and
• registered nurse anesthetist;
• Urgent Care Provider.

Outpatient - the status of a covered person who receives services or supplies through a hospital, doctor, or other healthcare professional or facility while not confined as an inpatient.

Physician - a person who is licensed and legally authorized to practice medicine.

Policy - this document.

Policyholder - an eligible person who has enrolled for coverage under the terms and conditions this policy and whose name appears on the identification card.

PPO Network Deductible - an amount that applies for services received from a PPO network provider, usually stated in dollars, for which you are responsible each benefit period before Medical Mutual will start to provide benefits, for services received from a PPO network provider.

PPO Network Provider - a doctor, hospital or other healthcare professional that is included in a limited panel of healthcare providers as designated by Medical Mutual and for which the greatest benefit will be payable when one of these providers is used.

Prescription Drug (Federal Legend Drug) - any medication that by federal or state law may not be dispensed without a prescription order.

Prescription Order - the request for medication by a physician appropriately licensed to make such a request in the ordinary course of professional practice.

Provider - a hospital, doctor, or other healthcare facility or professional.

Rider - a document that amends or supplements your coverage.

Surgery -

• the performance of generally accepted operative and other invasive procedures;

• the correction of fractures and dislocations;

• usual and related preoperative and postoperative care; or

• other procedures as reasonably approved by Medical Mutual.

United States - all the states, the District of Columbia, the Virgin Islands, Puerto Rico, American Samoa, Guam and the Northern Mariana Islands.