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A
Accident means a sudden, unexpected and unforeseen,
identifiable event producing at the time objective symptoms of an Injury. The
Accident must occur while the Insured is covered under the Policy.
B
Benefits: The amount payable by the insurance company to a claimant,
assignee or beneficiary under each coverage.
C
Catastrophic Disability or Catastrophically
Disabled (in CA, FL, OR, SC, SD, TX & VT) means for the first 12 months: the
inability of the Insured Person, due to a Covered Accident, to engage in
substantially the same activities as the Insured Person had engaged in
immediately prior to the Covered Accident; and the irrecoverable loss suffered
by the Insured Person, due to a Covered Accident, of: speech; hearing of both
ears; sight in both eyes; use of both arms; use of both legs; use of one arm and
one leg; or severely diminished mental capacity due to brain stem or other
neurological Injury such that the Insured Person is unable to perform normal
daily functions.
For any period thereafter, Catastrophic Disability or
Catastrophically Disabled means: (in CA, FL & OR) the inability of the Insured
Person, due to a Covered Accident, to perform the material and substantial
duties of any gainful occupation or employment for compensation or profit for
which he or she is or may become reasonably fitted by education, training, or
experience; (in SC, SD, TX & VT) the inability of the Insured Person, due to a
Covered Accident, to engage in substantially the same activities as the Insured
Person had engaged in immediately prior to the Covered Accident; and the
irrecoverable loss suffered by the Insured Person, due to a Covered Accident,
of: speech; hearing of both ears; sight in both eyes; use of both arms; use of
both legs; use of one arm and one leg; or severely diminished mental capacity
due to brain stem or other neurological Injury such that the Insured Person is
unable to perform normal daily functions.
Claim: A request for payment of a loss which may come under the terms of an
insurance contract.
D
Dismemberment: Loss of body members (limbs), or use thereof, or loss of
sight due to an Injury.
E
Effective Date: The date on which the insurance under a
Policy begins.
Exclusions:
Specific conditions or circumstances listed in the Policy for which the Policy
will not provide Benefit payments.
F
Full Excess Coverage: Benefits are payable as
excess over other valid and collectible insurance or similar Benefit programs
available to the Insured Person for a Covered Loss. In Pennsylvania
Benefits are payable for the first $100 of covered expenses, without regard
to other insurance. Thereafter, Benefits are payable for covered expenses over
$100 that are not recoverable from any other group insurance Policies or
service contracts.
H
Heart or Circulatory Malfunction Death Benefit
means disease or illness of the heart or circulatory system which:
- is first diagnosed and treated while the Insured’s coverage under the
Policy is in force and occurs in a scheduled game or supervised practice,
within 24 hours after participation; and
- the Insured has not before such participation been medically advised
of/or received any medical treatment for such Heart or Circulatory
Malfunction.
Hospital (Student Accident) means a
place that meets all of the following requirements: (1) Has an organized medical
staff; (2) Has permanent facilities that are equipped and operated mainly for
the purpose of performing surgical procedures; (3) Provides continuous services
of Physicians and registered nurses, whenever a patient is in the facility.
Hospital also means a psychiatric Hospital as defined by
Medicare. It must be eligible to receive payments under Medicare.
A Hospital is mainly not a place for rest, a place for the
aged, a place for the treatment of drug addicts or alcoholics, or a nursing
home.
Hospital (Catastrophic Accident) means an institution
which meets all of the following requirements: (a) It is licensed (if required)
as a Hospital by applicable licensing authorities; (b) It is open at all times;
(c) It is operated mainly to diagnose and treat illnesses and Injuries on an
inpatient basis; (d) It has a staff of one (1) or more Doctors on call at all
times; (e) It has twenty-four (24) hour nursing services by registered nurses;
(f) It is not mainly a skilled nursing facility, clinic, nursing home, rest
home, convalescence home, or like place; and (g) It has organized facilities for
major surgery or provides for such facilities for its patients through formal
written agreement with other Hospitals.
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I
Injury (Student Accident) means bodily Injury caused
by an Accident. The Injury must occur while the Policy is in force and while
the Insured is covered under the Policy. The Injury must be sustained as stated
on the face page of the Policy, except where specifically stated otherwise in
the Policy.
Injury or Injuries (Catastrophic Accident) means bodily
Injury which results directly from an Accident and which is independent from
disease, sickness or other bodily functions.
Insured: A person
or organization covered by an insurance Policy, including the "named insured"
and any other parties for whom protection is provided under the Policy terms.
L
Loss: The happening of the event for which insurance pays.
O
Occurrence: An Accident, including continuous or repeated exposure to
substantially the same general, harmful conditions, that results in bodily
Injury or property damage during the period of an insurance Policy.
P
Partial Disability or Partially Disabled means
the inability as the direct result of Total Disability of an Insured Person who,
following a period of Total Disability for which Total Disability Benefits were
paid under the Policy, is engaged in an occupation, to perform all of the
important duties of such occupation, and to earn a Partial Disability Gross
Earnings Amount per month, or more, as shown in the Plan of Insurance.
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.
Policyholder: A school that pays a
Premium to an
insurance company in exchange for the insurance protection provided by a Policy
of insurance.
Premium: The sum paid by a
Policyholder to keep an
insurance Policy in force.
R
Reasonable Expense (Student Accident) means the usual,
reasonable and customary fee or charge for the services rendered and the
supplies furnished in the area where and at the time such services are rendered
or supplies furnished, as determined by Us. Such services and supplies must be
recommended and approved by a physician.
Reasonable and Customary (Catastrophic Accident) means an
expense that is determined by Us not to exceed the amount usually charged by
most providers in the same geographic area for similar treatment, service or
purchase, taking into account the nature and severity of the illness or Injury.
The same geographic area means the same city or town in which the treatment,
service or purchase occurs, if the city or town is large enough to obtain a
representative charge. In large cities, it may be a section or sections of the
city. In smaller urban or rural areas, the geographic area will be expanded as
necessary to obtain a representative charge.
T
Total Disability or Totally Disabled (in all
other states where coverage is available) means for the first 12 months: the
inability of the Insured Person, due to a Covered Accident, to engage in
substantially the same activities as the Insured Person had engaged in
immediately prior to the Covered Accident; and the irrecoverable loss suffered
by the Insured Person, due to a Covered Accident, of: speech; hearing of both
ears; sight in both eyes; use of both arms; use of both legs; use of one arm and
one leg; or severely diminished mental capacity due to brain stem or other
neurological Injury such that the Insured Person is unable to perform normal
daily functions.
For any period thereafter, Total Disability or Totally
Disabled means the inability of the Insured Person, due to a Covered Accident,
to engage in any gainful occupation or employment for compensation or profit for
which he or she is or may become reasonably fitted by education, training, or
experience; and the irrecoverable loss suffered by the Insured Person, due to a
Covered Accident, of: speech; hearing of both ears; sight in both eyes; use of
both arms; use of both legs; use of one arm and one leg; or severely diminished
mental capacity due to brain stem or other neurological Injury such that the
Insured Person is unable to perform normal daily functions.
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