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SERIOUS MEDICAL CONDITION DEFINITION

A Serious Medical Condition is defined as an illness, in the opinion of MyCare’s Medical Director, that:

  • Requires inpatient care in a Hospital or other medical facility; or
  • If left untreated is likely to result in significant deterioration of health, permanent disability or death; or
  • Requires a Major Orthopedic procedure.

 

Disability: Means a severe and prolonged impairment in physical or mental functions.

Hospital: A healthcare facility providing patient treatment with specialized medical and nursing staff and equipment.

Illness: Any unexpected and unforeseen condition or disease manifesting itself while the MyCare program is in force.

Inpatient: A person who is admitted to a Hospital upon the recommendation of MyCare’s Medical Director as a patient for more than 15 consecutive hours and who receives medical treatment.

Major Orthopedic: Procedures concerning bone and joint replacement and serious spine procedures.

Sickness: Any unexpected and unforeseen illness or disease manifesting itself while this plan is in force as to the Member and which causes the Plan Member to incur Medical Expenses.

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