Section 18: Definitions

Ambulatory Surgical Facility means a facility (other than a Hospital), that:

1. Has the primary function of providing surgical procedures on an ambulatory basis, and
   
   
2. Is duly licensed by the appropriate state and local authority to provide such services and is approved by Blue Cross Blue Shield of Illinois.
   

Behavioral Health Practitioner means a psychiatrist, mental health counselor, substance abuse counselor or social worker with a masters degree or higher. The provider must be legally licensed or authorized to practice or provide service, care or treatment for such conditions under state law, and act within the scope of that license.

Covered Employment means work for which a contributing employer is required to make contributions to the Welfare Fund on behalf of employees pursuant to the terms of a collective bargaining agreement with Sheet Metal Workers’ Local Union No. 73.

Dental Treatment Plan is a dentist’s report, on a form satisfactory to the Fund that:

1. Itemizes the dental services recommended by the dentist for the necessary and customary dental care of an eligible person,
   
   
2. Shows the charge for each dental service, and
   
   
3. Is accompanied by appropriate diagnostic materials as required by the Fund.
   

Dentist is a duly licensed dentist currently practicing within the scope of his or her license.

Diagnostic Services means tests rendered for the diagnosis of symptoms to evaluate or determine the progress of a condition, disease or injury. Such tests include, but are not limited to, x-rays, pathology services, clinical laboratory tests, pulmonary function studies, electrocardiograms, electroencephalograms, radioisotope tests and electromyogram.

Durable Medical Equipment means equipment which meets all of the following:

1. can withstand repeated use (i.e., could normally be rented, and used by successive patients);
   
   
2. is primarily and customarily used to serve a medical purpose;
   
   
3. generally is not useful to a person in the absence of illness or injury;
   
   
4. is appropriate for use in the home;
   
   
5. is used solely for the care and treatment of the patient
   

Experimental or Investigative means drugs, services, supplies and procedures that require approval by an agency of the U.S. Government that has not yet been received. Experimental treatments, services and supplies are also those that have been principally confined to laboratory or research settings or have progressed to limited human application, but lack wide recognition as proven and effective in clinical medicine. The Trustees have the authority to determine whether a treatment, service or supply is Experimental or Investigative. The fact that a Physician has prescribed, ordered, recommended or approved the treatment, service or supply does not in itself make it eligible for payment.

Hospital means a duly licensed institution that is engaged primarily in providing medical care and treatment of sick and injured persons under the care of a Physician on an inpatient basis at the patient’s expense and that fully meets all of the tests set forth in (1), (2) or (3) below:

1. 1. It is a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
   
   
2. It is a hospital, a psychiatric hospital, or a tuberculosis hospital, as those terms are defined in Medicare, that is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare.
   
   
3. It is an institution that fully meets all of the following tests:
   
   
   1. 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,
      
      
   2. it continuously provides on the premises 24 hour a day nursing service by or under the supervision of registered nurses (R.N.), and
      
      
   3. it is operated continuously with organized facilities for operative surgery on the premises.
      

Hospital does not mean health resorts, rest homes, nursing homes, Skilled Nursing Facilities, convalescent homes for the aged or similar institution.

Inpatient means that you are a registered bed patient and are treated as such in a Hospital or Skilled Nursing Facility.

Medically Necessary means that there is a proven need for treatment intervention to improve or preserve the health of the patient. To be considered Medically Necessary, the service, supply or treatment must:

1. Be ordered by a physician for diagnosis or treatment.
   
   
2. Be consistent with the diagnosis or treatment.
   
   
3. Be essential for the diagnosis or treatment of the injury or sickness for which it is prescribed or performed.
   
   
4. Meet generally accepted standards of medical practice.
   
   
5. Not be of research nature, experimental or educational in nature.
   
   
6. Not involve repeated tests.
   

THE FACT THAT A PHYSICIAN MAY PRESCRIBE, ORDER RECOMMEND OR APPROVE A SERVICE OR SUPPLY DOES NOT, OF ITSELF, MAKE IT MEDICALLY NECESSARY OR MAKE THE EXPENSE A COVERED CHARGE.

Mental or Nervous Disorder means neurosis, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder of any kind.

Non-Plan Skilled Nursing Facility means a Skilled Nursing Facility that does not have an agreement with Blue Cross Blue Shield of Illinois but has been certified in accordance with guidelines established by Medicare. No benefits under the Fund are provided for services received in a Non-Plan Skilled Nursing Facility.

Call or write the Fund Office before admission to a Skilled Nursing Facility to verify that the facility is a Plan Skilled Nursing Facility.

Non-PPO Hospital means a Plan Hospital that is not included in the Blue Cross Blue Shield of Illinois PPO Network at the time services are rendered.

Orthodontic Procedures means movement of teeth by means of an active appliance or appliances to correct the position of malposed teeth.

Outpatient means that you or your dependent is receiving treatment while not an inpatient.

Physician (M.D.) means any individual licensed to practice medicine and perform general surgery in the State where the license is given.

Plan Approved Dialysis Facility means a facility (other than a Hospital) that:

1. Has the primary function of treatment and/or provision of maintenance and/or training dialysis on an ambulatory basis for renal-dialysis patients,
   
   
2. Is duly licensed by the appropriate governmental authority to provide such services, and
   
   
3. Is approved by Blue Cross Blue Shield MSA.

Plan Hospital means a Hospital located in Illinois that has a written agreement with Blue Cross Blue Shield of Illinois to provide services to the member at the time services are rendered, or a Hospital located in another state if the Hospital has a written agreement with the Blue Cross Blue Shield plan of that state.

Plan Skilled Nursing Facility means a Skilled Nursing Facility that has a written agreement with Blue Cross Blue Shield of Illinois to provide services to you or your dependents at the time services are rendered.

Call or write the Fund Office before admission to a Skilled Nursing Facility to verify that the facility is a Plan Skilled Nursing Facility.

PPO Ambulatory Surgical Facility means a Preferred Provider Organization ambulatory surgical facility that has been approved by Blue Cross Blue Shield of Illinois to provide services to the member at the time services are rendered.

PPO Hospital means a Preferred Provider Organization Hospital that is included in the Blue Cross Blue Shield of Illinois PPO Network at the time services are rendered to you.

Call the Fund Office at (312) 372-3653 or Blue Cross Blue Shield at 1-800-255-5192 or visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com to find out if a particular Hospital is a PPO Hospital.

Provider means any health care facility such as a Hospital or Skilled Nursing Care Facility, or any person such as a physician duly licensed to render covered services to you or your dependents.

Reasonable and Customary means charges made for medical services or supplies essential to your care or your dependents’ care that do not exceed the amount ordinarily charged in the geographic area where the services and supplies are received, with due consideration given to the nature and severity of the condition being treated and any medical complications or unusual circumstances that require additional time, skill or experience.

Sickness means illness or disease that causes loss covered by the Fund. Losses incurred because of pregnancy, childbirth and related medical conditions are covered under the Fund to the same extent as any other sickness.

Skilled Nursing Facility means an institution or a distinct part of an institution that:

1. Has a transfer agreement with one or more Hospitals, and
   
   
2. Is primarily engaged in providing comprehensive post-acute Hospital and rehabilitative inpatient care, and
   
   
3. Is duly licensed by the appropriate governmental authority to provide such services.
   

Skilled Nursing Facility does not mean institutions that provide only minimum care, custodial care services, ambulatory or part-time care services or institutions that primarily provide for the care and treatment of mental or nervous disorders, pulmonary tuberculosis or substance abuse.

Substance Abuse means the uncontrollable or excessive abuse of addictive substances including, but not limited to: alcohol, cocaine, morphine, heroin, opium, cannabis and other barbiturates, amphetamines, tranquilizers and/or hallucinogens and the resultant physiological and/or psychological dependency that develops with continued use of such addictive substances requiring medical care as determined by a physician.

Totally Disabled means, for the purpose of the Extension of Benefits provision in Section 10.9:

1. With respect to the employee, the inability to perform each and every duty pertaining to his or her occupation or employment,
   
   
2. With respect to the spouse, the inability to perform each and every duty pertaining to his or her occupation or employment where the term “occupation” means the normal duties of a spouse.
   
   
3. With respect to a child, confinement in the house of the member or spouse or in a Hospital.