The following is a brief listing of important definitions:

“Fund” means the I.B.E.W. Local No. 25 Health and Benefit Fund.

“You” means a Plan Participant covered under the Plan.

“He” or “His” means either a male or a female unless a distinction is specified.

“Dependent” means any person eligible as described in the eligibility rules.

“Injury” means a bodily injury caused by an accident. The accident must occur while the coverage for You or Your Dependent is in force.

“Sickness” means a disease.

“Physician” means a legally qualified and licensed doctor of medicine (M.D.) or doctor of osteopathy (D.O.), provided that such doctor is neither the Participant, the Participant’s spouse, nor the child, brother, sister nor parent of the Participant. The term”Physician” shall include a duly licensed or certified practitioner, as required by state law for services which are:

1. within the scope of the license or certificate, and
2. a covered charge under this Plan.

The Trustees may require, in their sole discretion, that any physician have training as a specialist.

“Spouse” refers to a person to whom you are recognized as lawfully married under the laws of the state in which the marriage ceremony occurred.

“Medically Necessary Treatment” means medical or dental treatment which is consistent with currently accepted medical or dental practice, and which is given at the appropriate level of care. Any confinement, operation, treatment or service that is not a valid course of treatment recognized by an established medical or dental society in the United States is not considered “Necessary Treatment.” No treatment or service, or expense in connection therewith, which is experimental in nature, is considered “Necessary Treatment.”

The Plan may use Peer Review Organizations or other professional medical opinion to determine if health care services are:

1. Medically necessary;
2. Consistent with professionally recognized standard of care with respect to quality, frequency and duration; and
3. Provided in the most economical and medically appropriate site for Treatment.

In determining questions of medical necessity, consideration will be given to customary practices of physicians and the community where the service is provided.

A service will not be considered medically necessary if:

• the procedures are of unproven value or of questionable usefulness;
• the procedures could be deemed unnecessary when performed in combination with other procedures;
• the diagnostic procedures are unlikely to provide a physician with additional information when used repeatedly;
• the procedures are not ordered by a physician: are not documented in a timely fashion in the patient’s medical records; or can be performed with equal efficiency at another type of facility (e.g., on an outpatient basis).

Services, supplies or treatment will not be considered medically necessary and no benefits will be payable if:

• the services rendered were not medically necessary;
• services were not provided at the appropriate level of care.

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.

“Hospital” means an establishment which:

1. Holds a license as a Hospital (if required in the state) and is accredited by the Joint Commission on Accredited Hospitals (JCAH).
2. Operates primarily for the care and treatment of sick or injured persons as inpatients;
3. Provides around the clock nursing service;
4. Has a staff of one or more Physicians available at all times;
5. Provides organized facilities for diagnosis and surgery;
6. Is not primarily a clinic, nursing, rest or convalescent home or a Skilled Nursing Facility or a similar establishment; and
7. Is not, other than incidentally, a place for treatment of drug addiction.
8. The nursing service must be registered or graduate nurses on duty or call. The surgical facilities may be either at the Hospital or at a facility with which it has a formal arrangement.

Confinement in a special unit of a Hospital used primarily as a nursing, rest or convalescent home or Skilled Nursing Facility will not be deemed to be confinement in a Hospital.

“Hospital” also includes a licensed ambulatory surgical center. The center must have permanent facilities and be equipped and operated primarily for the purpose of performing surgical procedures. The types of procedures performed must permit discharge from the center in the same”working day.” The center will not qualify as a”Hospital” if:

1. Its primary purpose is performing abortions;
2. It is maintained as an office by a Physician for the practice of medicine; or
3. It is maintained as an office for the practice of dentistry.

“Custodial Care” means care which is designed to help a person in the activities of daily living where continuous attention by trained medical or paramedical personnel is not necessary. Such care may involve:

1. Preparation of special diets;
2. Supervision over medication that can be self-administered; and
3. Assisting the person getting in or out of bed; to walk; to bathe; to dress; to eat; and to use the toilet.

“Essential Health Benefits” means any covered expense under the Plan that falls under the following categories, as defined under the Patient Protection and Affordable Care Act:

• Ambulatory Services;
• Emergency Services;
• Hospitalization;
• Maternity and Newborn Care;
• Mental Health and Substance Use Disorder Services, including behavioral health treatment;
• Rehabilitative and Habilitative services and devices;
• Laboratory Services;
• Prescription Drugs;
• Preventive and Wellness Services and chronic disease management;
• Pediatric Services, including oral and vision care;

“Non Essential Health Benefits” means any covered expense that is not an essential benefit.

“Pediatric” means age newborn to age 19.

“Covered Expenses” means any claim that satisfies the following conditions:

1. Is Medically Necessary Treatment as defined on page 5;
2. To the extent that it does not exceed usual, customary and reasonable charges as defined by Plan Policy;
3. Is received while covered for Medical Benefits; and
4. Is covered under the Plan.