Page 28 - Aegion PPO SPDs
P. 28
Effective Date - The date Your coverage begins under the Plan. You must be Actively at Work on Your
Effective Date. If You are not Actively at Work on Your Effective Date, Your Effective Date will be the date
You become Actively at Work. A Dependent's coverage under the Plan begins on the Effective Date of the
sponsoring Subscriber. No benefits are payable for services and supplies received before Your Effective
Date or after Your termination date.
Eligible Person - A person who satisfies the Employer’s eligibility requirements and is entitled to apply to
be a Subscriber.
Emergency Medical Condition - (“Emergency services,” “emergency care,” or “Medical Emergency”)
Emergency Medical Condition means a medical or behavioral health condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in one of the following conditions:
Placing the health of the individual or the health of another person (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
Employer – The legal entity contracting with the Claims Administrator for administration of group health
care benefits.
Enrollment Date - The first day of coverage under the Plan or, if there is a waiting period, the first day of
the waiting period (typically the date employment begins).
Experimental/Investigative - Any Drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a
disease, injury, illness, or other health condition which the Claims Administrator determines to be unproven.
The Claims Administrator will deem any Drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service, or supply to be Experimental/Investigative if the Claims Administrator, determines that
one or more of the following criteria apply when the service is rendered with respect to the use for which
benefits are sought. The Drug, biologic, device, diagnostic, product, equipment, procedure, treatment,
service, or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA), or other licensing or regulatory agency, and such final approval has not been
granted;
Has been determined by the FDA to be contraindicated for the specific use; or
Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar
function; or
Is provided pursuant to informed consent documents that describe the Drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service, or supply as Experimental/Investigative,
or otherwise indicate that the safety, toxicity, or efficacy of the Drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service, or supply is under evaluation.
Any service not deemed Experimental/Investigative based on the criteria above may still be deemed
Experimental/Investigative by the Claims Administrator. In determining whether a Service is
Experimental/Investigative, the Claims Administrator will consider the information described below and
assess whether:
The scientific evidence is conclusory concerning the effect of the service on health outcomes;
The evidence demonstrates the service improves net health outcomes of the total population for whom
the service might be proposed by producing beneficial effects that outweigh any harmful effects;
28
Effective Date. If You are not Actively at Work on Your Effective Date, Your Effective Date will be the date
You become Actively at Work. A Dependent's coverage under the Plan begins on the Effective Date of the
sponsoring Subscriber. No benefits are payable for services and supplies received before Your Effective
Date or after Your termination date.
Eligible Person - A person who satisfies the Employer’s eligibility requirements and is entitled to apply to
be a Subscriber.
Emergency Medical Condition - (“Emergency services,” “emergency care,” or “Medical Emergency”)
Emergency Medical Condition means a medical or behavioral health condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in one of the following conditions:
Placing the health of the individual or the health of another person (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
Employer – The legal entity contracting with the Claims Administrator for administration of group health
care benefits.
Enrollment Date - The first day of coverage under the Plan or, if there is a waiting period, the first day of
the waiting period (typically the date employment begins).
Experimental/Investigative - Any Drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a
disease, injury, illness, or other health condition which the Claims Administrator determines to be unproven.
The Claims Administrator will deem any Drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service, or supply to be Experimental/Investigative if the Claims Administrator, determines that
one or more of the following criteria apply when the service is rendered with respect to the use for which
benefits are sought. The Drug, biologic, device, diagnostic, product, equipment, procedure, treatment,
service, or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA), or other licensing or regulatory agency, and such final approval has not been
granted;
Has been determined by the FDA to be contraindicated for the specific use; or
Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar
function; or
Is provided pursuant to informed consent documents that describe the Drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service, or supply as Experimental/Investigative,
or otherwise indicate that the safety, toxicity, or efficacy of the Drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service, or supply is under evaluation.
Any service not deemed Experimental/Investigative based on the criteria above may still be deemed
Experimental/Investigative by the Claims Administrator. In determining whether a Service is
Experimental/Investigative, the Claims Administrator will consider the information described below and
assess whether:
The scientific evidence is conclusory concerning the effect of the service on health outcomes;
The evidence demonstrates the service improves net health outcomes of the total population for whom
the service might be proposed by producing beneficial effects that outweigh any harmful effects;
28
