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  • Dependent upon the enrollee for 50% or more support and,

  • Otherwise eligible for coverage as a dependent except for age.

The disabling condition must have occurred prior to the dependent’s 19th birthday (unless already covered by the Plan as a student, in which case the condition must have occurred prior to the dependent’s 25th birthday).

Durable Medical Equipment: equipment prescribed by the attending physician and determined by Blue Cross & Blue Shield to be medically necessary for treatment of an illness or injury, or to prevent the participant’s further deterioration. The equipment must be (1) made to withstand repeated use; (2) primarily used to serve a medical purpose rather than for comfort or convenience; (3) generally not useful to a person in the absence of illness, injury, or disease; and (4) appropriate for use in the participant’s home.

Emergency Care: care as the result of the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical care could reasonably result in:

  • Permanently placing the participant’s health in jeopardy,

  • Serious impairment of bodily functions, or

  • Serious and permanent dysfunction of any bodily organ or part, or other serious medical

consequences. Determination of emergency care is based on presenting symptoms rather than final diagnosis.

This means the treatment given in a hospital’s or urgent care’s emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

Placing the person’s health in serious jeopardy; or Serious impairment to bodily function; or Serious dysfunction to a body part or organ; or In the case of a pregnant woman, serious jeopardy to the health of the mother or fetus.

Employee: an active full-time employee who has satisfied the specifications in the Health Insurance Eligibility and Enrollment section of this Plan Document and has enrolled for coverage under the Plan.

Employer Unit: any of the following whose employees are eligible to participate in the Plan:

  • State Agency,

  • Institution of Higher Learning,

  • Public School District,

  • Community/Junior College, or

  • Public Library.

Enrollee: an Employee, a Retired Employee, a COBRA Participant, or a Surviving Spouse who is enrolled in the Plan.


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