When the following terms are used in this booklet, these
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
A calendar quarter means a period of three consecutive
months, commencing with any January 1, April 1, July 1, or
Stands for the Consolidated Omnibus Budget Reconciliation
Act of 1985, as amended.
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
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
A participant who maintains the eligibility requirements
and his or her qualifying dependents.
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.
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
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
- 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
- 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
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.
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.
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
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
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
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.
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
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
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.