Selected Healthcare Terminology
An unexpected, unusual and unforeseen event that happens without intention or design, excluding known complications or side effects of medical or dental treatment.
Activities of Daily Living
Activities that most people can perform for themselves during the normal course of a day, such as eating, getting dressed, bathing, personal hygiene, transferring from bed and chair, and moving inside the home.
Bermuda Fee Schedule
A fee schedule for any benefit listing the amounts payable for any surgical, anaesthetic, medical, diagnostic or dental procedures provided in-hospital and approved by the Minister of Health.
An insured person normally resident in Bermuda for at least six months in any calendar year or for whom a subsidy is payable under the Health Insurance Act.
The following classifications are used to describe the level of coverage provided:
2 Hospital accommodation
3 Hospital accommodation
4 Hospital accommodation (Employer Groups only)
A Employee or individual policyholder insured for self only
B Employee or individual policyholder insured for self and non-working dependent spouse only
C Employee or individual policyholder insured for self, non-working dependent spouse and dependent child(ren)
D Employee or individual policyholder insured for self and dependent child(ren)
Terminology for Employer Group Health Insurance customers
E Employee insured for self and working dependent spouse only, subject to the proviso that the employee’s dependent spouse is insured elsewhere as an employee for Act Benefits
F Employee insured for self, working dependent spouse and dependent child(ren), subject to the proviso that the employee’s dependent spouse is insured elsewhere as an employee for Act Benefits
G Employee insured for Act Benefits only
H Employee and dependent spouse insured for Act Benefits only
An evaluation provided at the request of another physician with the goal of recommending a course of care or determining if the patient’s condition warrants transfer to specialty services.
The care and assistance, including room and board, that is given principally for personal hygiene or for assistance in activities of daily living and can, according to generally accepted medical standards, be performed by persons who have no medical training.
Examples of custodial care include help in walking, getting in and out of bed, bathing, dressing, feeding and use of toilet facilities, food preparation and supervision of medication that does not entail or require the continued presence of trained medical personnel.
A dependent child is an unmarried natural child, step-child, child of a dependent spouse, or legally adopted child who is under age 19, or under age 26, if enrolled in and in full-time attendance at, a recognised school, college or university, or over the age of 19, but is incapable of self support due to a mental or physical handicap.
Such child must be dependent on the insured parent for support.
A legally married spouse or a person who is living with the insured person in a recognised conjugal relationship, and has so lived for at least 12 months.
Procedures or laboratory measurements that can help reveal a diagnosis.
A negotiated reduction in the fees that a service provider would normally charge for services rendered.
The actual expenses incurred by an insured person that are reasonable for medically necessary care and services, are administered, prescribed or ordered by a physician or other recognised provider of service, and at least a portion of which is considered to be an eligible expense under the policy.
Initial treatment, ordered or provided by a physician or dentist, of a traumatic bodily injury resulting from an accident, or an acute, unexpected or unforeseen sickness requiring immediate non-discretionary medical care, and of such a nature that failure to render immediate care could reasonably result in placing the insured person’s life in jeopardy, or cause serious or permanent impairment to the bodily function of the insured person.
Emergency Overseas Treatment
Emergency care provided to an insured person while resident or travelling outside Bermuda.
Experimental and/or Investigational Treatment
Procedures, drugs, devices and supplies that have not yet gained acceptance by the medical community as standard care and treatment at the time the service is rendered.
Such care and treatment may include any treatment that is undergoing clinical investigation and is not generally recognised by the medical community in Bermuda, the United States and Canada as established and accepted practice, has not yet been approved by the Pharmacy and Poisons Act in Bermuda, the Food and Drug Administration (FDA) in the United States, Health and Welfare – Canada (Food and Drug), and any other governmental agency in these jurisdictions for the purpose for which it is being prescribed, or is of uncertain therapeutic benefit, restricted to use in clinical trials, or of questionable safety and effectiveness for the insured person’s condition.
Any physician who is not a specialist.
Health Insurance Act 1970
The Health Insurance Act 1970, its regulations, orders, rules and any amendments or additions thereto.
Health Insurance Act Benefits
Benefits detailed in the Health Insurance Act 1970.
Bodily injury caused by an accident occurring while the insurance policy is in force with respect to the insured person.
An eligible Employee or Dependent who applies for coverage under this policy following the 31-day period of first becoming eligible for insurance.
Licenced, Certified or Registered
A provider of service who is currently licenced, certified or registered to practise the profession or provide the service, by the appropriate licencing or registration authority in the jurisdiction in which the services of such practitioner are rendered, and who is practising within the scope of such profession.
LifetimeLifetime, as used in reference to benefit maximums and limitations, is understood to mean while insured under the health insurance policy and will not be interpreted to mean the lifetime of the insured person.
Local Treatment & Services
Services rendered, or provider of services or another organisation located, in Bermuda.
Medically Necessary Care & Services
Care, treatment, services and supplies, other than personal comfort items, which are widely accepted by the medical profession as effective, appropriate and essential in the prevention, diagnosis and treatment of the particular sickness or injury and the most appropriate level of treatment consistent with the diagnosis or symptoms of such sickness or injury, based on generally recognised and accepted standards of healthcare.
Such care and services are not intended primarily for the convenience of the insured person, his physician, hospital or any other healthcare provider and are not conducted for research purposes.
Care, services and supplies are not “medically necessary” solely on the grounds that they have been prescribed, ordered, recommended or approved by a physician.
Mental & Nervous Disorder
A clinically significant behavioural or psychological syndrome that is associated with distress, impairment in one or more important areas of functioning, or with sufficiently increased risk of suffering death, pain, disability, or an important loss of freedom.
Services rendered, or provider of services, located outside Bermuda.
A doctor of medicine who is duly licenced to prescribe and administer medical and/or surgical treatment within the scope of his licence.
The first policy year is the period of time commencing on the Policy Effective Date and ending on April 30th next following such date. Any subsequent policy year is the 12-month period commencing on each Policy Renewal Date.
Preferred Provider Network
A healthcare benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated healthcare providers who contract with the preferred provider network at a discount.
Steps that can be taken to help ensure wellness, including the use of appropriate vaccinations and encouraging healthy lifestyle habits.
Provider of Service
A licenced, certified or registered facility or practitioner of the healing arts who is acting within the scope of his licence and provides medical and/or dental care, treatment, services or supplies.
An insured person’s illness or disease.
A physician who is properly qualified in the speciality by virtue of training and/or experience in the speciality and appropriate certification by an internationally recognised speciality.
The Worker’s Compensation Act 1965
The Act that enables workers who are injured on the job to receive compensation from their employers.
A state of incapacity caused by bodily or mental injury, or sickness that requires the regular and personal attendance of a physician and prevents an insured person from performing or engaging in any gainful occupation or work for remuneration or profit, or performing at least three of the activities of daily living.
Usual & Customary Charge
A charge, which is not higher than the usual charge made by a service provider, and does not exceed the general level of charges made by providers of similar standing in the locality or geographical area where the charge is incurred.