Page 114 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Congenital Anomaly - a physical developmental defect that is present at the time of birth, and that is
identified within the first twelve months of birth.

Copayment - the charge, stated as a set dollar amount, that you are required to pay for certain Covered
Health Care Services.

Please note that for Covered Health Care Services, you are responsible for paying the lesser of the
following:

• The Copayment.
• The Allowed Amount.

Cosmetic Procedures - procedures or services that change or improve appearance without significantly
improving physiological function.
Covered Health Care Service(s) - health care services, including supplies or Pharmaceutical Products,
which the Claims Administrator determines to be all of the following:
• Medically Necessary.

• Described as a Covered Health Care Service in this SPD under Section 1: Covered Health Care
Services and in the Schedule of Benefits.

• Not excluded in this SPD under Section 2: Exclusions and Limitations.
• Provided for the purpose of preventing, diagnosing or treating Sickness, Injury, Mental Illness and
Substance-Related and Addictive Disorders, or their symptoms.
• Consistent with nationally recognized scientific evidence as available and prevailing medical
standards and clinical guidelines. In applying the above definition, "scientific evidence" and
"prevailing medical standards" have the following meanings:

 "Scientific evidence" means the results of controlled clinical trials or other studies published
in peer-reviewed, medical literature generally recognized by the relevant medical specialty
community.

 "Prevailing medical standards and clinical guidelines" means nationally recognized
professional standards of care including, but not limited to, national consensus statements,
nationally recognized clinical guidelines, and national specialty society guidelines.
• Not provided for the convenience of the Covered Person, Physician, facility or any other person.

• Described as a Covered Health Care Service in this SPD under Section 1: Covered Health Care
Services and in the Schedule of Benefits.

• Provided to a Covered Person who meets the Plan's eligibility requirements.
• Not excluded in this SPD under Section 2: Exclusions and Limitations.

Covered Person - the Participant or a Dependent, but this term applies only while the person is enrolled
under the Plan. The Plan Sponsor uses "you" and "your" in this SPD to refer to a Covered Person.

Custodial Care - services that are any of the following non-Skilled Care services:
• Non health-related services such as help with daily living activities. Examples include eating,
dressing, bathing, transferring and ambulating.
• Health-related services that can safely and effectively be performed by trained non-medical
personnel and are provided for the primary purpose of meeting the personal needs of the patient or

111 Section 9: Defined Terms