Page 116 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity (including
severe pain) so 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:
• Placing the health of the Covered 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.
Emergency Health Care Services - with respect to an Emergency:

• A medical screening exam (as required under section 1867 of the Social Security Act, 42 U.S.C.
1395dd) that is within the capability of the emergency department of a Hospital, including ancillary
services routinely available to the emergency department to evaluate such Emergency, and
• Such further medical exam and treatment, to the extent they are within the capabilities of the staff
and facilities available at the Hospital, as are required under section 1867 of the Social Security Act
(42 U.S.C. 1395dd(e)(3)).
Enrolled Dependent - a Dependent who is properly enrolled under the Plan.

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,
substance-related and addictive disorders or other health care services, technologies, supplies,
treatments, procedures, drug therapies, medications or devices that, at the time the Claims Administrator
makes a determination regarding coverage in a particular case, are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service or the United States
Pharmacopoeia Dispensing Information as appropriate for the proposed use.
• Subject to review and approval by any institutional review board for the proposed use. (Devices
which are FDA approved under the Humanitarian Use Device exemption are not Experimental or
Investigational.)
• The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III clinical trial set
forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.
Exceptions:

• Clinical trials for which Benefits are available as described under Clinical Trials in Section 1:
Covered Health Care Services.

• The Claims Administrator may, as the Claims Administrator determines, consider an otherwise
Experimental or Investigational Service to be a Covered Health Care Service for that Sickness or
condition if:
 You are not a participant in a qualifying clinical trial, as described under Clinical Trials in
Section 1: Covered Health Care Services: and
 You have a Sickness or condition that is likely to cause death within one year of the request
for treatment.
Prior to such a consideration, the Claims Administrator must first establish that there is sufficient evidence
to conclude that, even though unproven, the service has significant potential as an effective treatment for
that Sickness or condition.
Freestanding Facility - an outpatient, diagnostic or ambulatory center or independent laboratory which
performs services and submits claims separately from a Hospital.

113 Section 9: Defined Terms