Definitions

When the following terms are used in this booklet, these definitions apply.

Accident

A non-occupational bodily injury that is caused by an event that is external, violent, sudden and not foreseen, exact as to time and place and independent of all other causes.

Calendar Quarter

A calendar quarter means a period of three consecutive months, commencing with any January 1, April 1, July 1, or October 1.

Cobra

Stands for the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Cosmetic Surgery

Refers to medically unnecessary surgical procedures, usually, but not limited to, plastic surgery directed toward preserving beauty or correcting scars, burns or disfigurements and not intended to restore a bodily function.

Covered Employment

Covered employment is work performed for any employer with respect to which the employer is obligated to make contributions to the Steamfitters’ Industry Welfare Fund (i) pursuant to the Collective Bargaining Agreement with Local Union 638 or (ii) pursuant to an existing reciprocal agreement between the Fund and another fund or (iii) pursuant to another agreement to make contributions to the Welfare Fund.

Covered Person

A participant who maintains the eligibility requirements and his or her qualifying dependents.

Custodial Care

The care, including room and board needed to provide such care, that is given principally for personal hygiene or for assistance in daily living activities which can be performed by persons who have no medical training.

Daily Living Activities

Includes those activities necessary to sustain daily living such as feeding, bathing, toileting, dressing, personal hygiene, transferring and ambulating.

Experimental Or Investigational

Those services, supplies, care and treatment which do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered.

Hospital

An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient’s expense and which fully meets all the tests set forth in (a) or (b) or (c) below:

a. It is a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations.

b. It is a hospital or psychiatric hospital as those terms are defined for Medicare insurance purposes, which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare.

c. It is an institution which fully meets all of the following tests:

• It maintains on the premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians; and
• It continuously provides on the premises 24 hour a day nursing service by or under the supervision or registered graduate nurses; and
• It continuously maintains organized facilities for operative surgery on the premises.

Hospital Services & Supplies

Services and supplies furnished to the individual and required for treatment, other than room and board, the services of any physician and any private duty, or special nursing services (including intensive nursing care by whatever name called), regardless of whether such services are rendered under the direction of the hospital or otherwise.

Maintenance Care

Those charges incurred after the patient has reached a maximum level of improvement; or for which no further medical improvement can be reasonably anticipated; or for the general conditioning of a body part.

Medically Necessary

Care and treatment that is recommended or approved by a physician; is consistent with the patient’s condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider; is not conducted for research purposes; and is the most appropriate level of services which can be safely provided to the patient.

Medicare

The program established by Title I of Public Law 89-88 (79 Statute 291), as amended, entitled Health Insurance for the Aged Act, and which includes both Parts A and B.

Mental Or Nervous Disorder

A neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. Personality disorders such as autism are included, as long as such condition has as its standard and accepted course of treatment the taking of prescription drugs. Presenile and arteriosclerotic dementias are not classified as mental or nervous disorders, but as any other illness. Learning disabilities, behavior problems or attention-deficient disorders are not classified as mental or nervous disorders, nor are they considered an illness. Psychiatric disorders resulting from specific external factors, such as grief, are classed as mental or nervous disorders. Senile dementia is, by itself, a non-covered illness. Alcoholism and substance abuse are not, by themselves, considered a mental or nervous disorder.

Morbid Obesity

A diagnosed condition in which the body weight exceeds the medically recommended weight by either 100 pounds or is twice the medically recommended weight in the most recent Metropolitan Life Insurance Co. tables for a person of the same height, age and mobility as the covered person.

No-Fault Auto Insurance

The basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Participant

A participant is (a) a member of the union or other employee on whose behalf contributions are required under an agreement between an employer and the union; (b) a steamfitter who is a salaried official of the union; (c) an employee of any of the related funds, provided that the union and the trustees of such related funds, respectively, have agreed to make contributions to the Fund on the employees’ behalf at the rate of contributions in effect for other employees or (d) retirees who meet the eligibility requirements.

Pharmacy

A licensed establishment where covered prescription drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices.

Physician

A legally licensed medical or dental doctor or surgeon, chiropractor, osteopath, podiatrist, chiropodist, optometrist, certified consulting psychologist, certified nurse anesthesiologist, or midwife, to the extent that same, under their license, are permitted to perform services provided for in this Plan. The term Physician shall not include the covered person or any person who is the spouse, parent, child, brother or sister, in blood or in-law, of the covered person.

Prescription Drug

Any of the following: a drug or medicine which, under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription"; and injectable insulin, but only when dispensed upon a written prescription.

Room & Board

Room, board, general duty nursing and any other services regularly furnished by the hospital as a condition of occupancy of the class of accommodations occupied, but not including professional service of physicians nor charges for intensive nursing care by whatever name called.

Total Disability With Respect To Health Insurance

You or your dependent’s complete inability to perform the normal activities of a person of like age and sex.

Well Baby/Child Care

Those charges made by the caring hospital, or similar institution, for the custodial and nursing care of a baby which is deemed to be free of any identifiable illness, disease or malfunction. It will also include any periodic check-ups in a clinic or physician’s office.