Decision-Making for Health Care Services. Any and all decisions pertaining to the medical need for, or desirability of, the provision or non-provision of Health Care Services, including without limitation the most appropriate level of such services, must be made solely by the Member and his Physician in accordance with the normal patient/Physician relationship for purposes of determining what is in the best interest of the Member.
a. AvMed does not have the right of control over the medical decisions made by a Member’s Physician. A Member and his Health Professionals are responsible for deciding what medical care should be rendered or received and when that care should be provided. AvMed is solely responsible for determining whether expenses incurred for Health Care Services are Covered Benefits or Covered Services under this Contract. In making coverage decisions, we will not be deemed to participate in or override your decisions concerning your health or the medical decisions of your Attending Physicians and other Health Professionals.
b. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service. Subscribing Group and Members acknowledge it is possible that a Member and his Physicians may determine that such services are appropriate even though such services are not covered and will not be arranged or paid for by AvMed.
