Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances. 1. Durable Medical Equipment a. Your Plan covers Durable Medical Equipment when a Physician prescribes the equipment before You get it. The equipment must not be mainly for the comfort or convenience of the Member or others. In addition, the equipment must meet all of the following criteria. It must be: (1) Able to withstand repeated use; (2) Primarily and customarily used for a medical purpose; (3) Generally not useful to someone who does not have the disease or injury; and (4) Appropriate for use in the patient’s home. b. Your Plan pays to rent or buy Durable Medical Equipment (1) We will base Benefits for renting the equipment on Our rental Allowable Charge (but Benefits will not be more than the purchase Allowable Charge). (2) If We choose, Your Plan will pay for buying Durable Medical Equipment, appropriate supplies, and oxygen required for therapeutic use. (3) If You select deluxe equipment only for comfort or convenience, We will base Your Benefits on the Allowable Charge for standard equipment. (4) We consider accessories and medical supplies that are necessary for covered Durable Medical Equipment to effectively function to be an integral part of the rental or purchase allowance. Your Plan will not cover them separately. (5) Your Plan pays to repair or adjust purchased Durable Medical Equipment or to replace components. Your Plan will not pay to replace equipment that is lost or damaged due to neglect or misuse. You Plan will also not pay for replacing equipment that was bought or rented less than 5 years ago. c. Limitations in connection with Durable Medical Equipment (1) When You rent Durable Medical Equipment, Your Plan does not pay to repair, adjust, or replace components and accessories because the company that supplied the equipment must pay for that. (2) Your Plan does not pay for equipment if a commonly available supply or appliance effectively serves the same purpose. (3) Your Plan does not pay to repair or replace equipment that is lost or damaged due to neglect or misuse. (4) We will determine reasonable quantity limits on Durable Medical Equipment items and supplies.
Appears in 4 contracts
Samples: Cancer and Serious Disease Limited Benefit Contract, Cancer and Serious Disease Limited Benefit Contract, Limited Benefit Contract
Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances. 1. Durable Medical Equipment
a. Your Plan covers Durable Medical Equipment when a Physician prescribes the equipment before You get it. The equipment must not be mainly for the comfort or convenience of the Member or others. In addition, the equipment must meet all of the following criteria. It must be:
(1) Able to withstand repeated use;
(2) Primarily and customarily used for a medical purpose;
(3) Generally not useful to someone who does not have the disease or injury; and
(4) Appropriate for use in the patient’s home.
b. Your Plan pays to rent or buy Durable Medical Equipment
(1) We will base Benefits for renting the equipment on Our rental Allowable Charge (but Benefits will not be more than the purchase Allowable Charge).
(2) If We choose, Your Plan will pay for buying Durable Medical Equipment, appropriate supplies, and oxygen required for therapeutic use.
(3) If You select When Durable Medical Equipment is approved by Us, Benefits for standard equipment will be provided toward any deluxe equipment. Deluxe equipment only or deluxe features and functionalities of equipment are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience, We will base Your Benefits on the Allowable Charge for standard equipment; or
(d) that are not determined by Us to be Medically Necessary.
(4) We consider accessories and medical supplies that are necessary for covered Durable Medical Equipment to effectively function to be an integral part of the rental or purchase allowance. Your Plan will not cover them separately.separately.
(5) Your Plan pays to repair or adjust purchased Durable Medical Equipment or to replace components. Your Plan will not pay to replace equipment that is lost or damaged due to neglect or misuse. You Plan will also not pay for replacing equipment that was bought or rented less than 5 five (5) years agoago that is not Medically Necessary as determined by Us. Regardless of Medical Necessity, repair, adjustment, or replacement of equipment subject to a recall within five (5) years after purchase or rental will not be covered. Regardless of Medical Necessity, repair, adjustment, or replacement of equipment will not be covered when provided under warranty.
c. Limitations in connection with Durable Medical Equipment
(1) When You rent Durable Medical Equipment, Your Plan does not pay to repair, adjust, or replace components and accessories necessary for the effective function and maintenance of covered equipment because this is the company that supplied responsibility of the equipment must pay for thatDurable Medical Equipment supplier.
(2) Your Plan does not pay for equipment if a commonly available supply or appliance effectively serves the same purpose.
(3) Your Plan does not pay to repair or replace equipment that is lost or damaged due to neglect or misuse.
(4) We will determine reasonable quantity limits on Durable Medical Equipment items and supplies.
(5) Regardless of Claims of Medical Necessity, deluxe equipment or deluxe features and functionalities of equipment that are not approved by Us are not covered.
2. Orthotic Devices As specified in this section, Your Plan will pay to buy Orthotic Devices. These Benefits will be subject to the following:
a. Your Plan does not pay for fitting or adjustments because this is included in the Allowable Charge for the Orthotic Device.
b. Your Plan pays to repair or replace Orthotic Devices only within a reasonable time-period after You bought them, subject to the expected lifetime of the devices. We will determine that time-period. Regardless of Medical Necessity, repair or replacement of the device will not be covered when provided under warranty or when the device is subject to a recall.
c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. Deluxe devices or deluxe features and functionalities of devices are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe devices or deluxe features and functionalities of devices that are not approved by Us are not covered.
e. No Benefits are available for supportive devices for the foot.
3. Prosthetic Appliances You Plan will pay to buy Prosthetic Appliances. These Benefits will be subject to the following:
a. Your Plan does not pay to fit or adjust appliances because as this is included in the Allowable Charge for the Prosthetic Appliance.
b. Your Plan pays to repair or replace Prosthetic Appliances only within a reasonable time- period after You bought them, subject to the expected lifetime of the appliance. We will determine this time-period. Regardless of Medical Necessity, repair or replacement of appliances will not be covered when provided under warranty or when the appliance is subject to a recall.
c. When Prosthetic Appliances are covered by Us, Benefits for standard appliances will be provided toward any deluxe appliance. Deluxe appliances or deluxe features and functionalities of appliances are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe appliances or devices or deluxe features and functionalities of appliances or devices that are not approved by Us are not covered.
Appears in 3 contracts
Samples: Limited Benefit Contract, Limited Benefit Contract, Limited Benefit Contract
Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances. 1. Durable Medical Equipment
a. Your Plan covers Durable Medical Equipment when a Physician prescribes the equipment before You get it. The equipment must not be mainly for the comfort or convenience of the Member or others. In addition, the equipment must meet all of the following criteria. It must be:
(1) Able to withstand repeated use;
(2) Primarily and customarily used for a medical purpose;
(3) Generally not useful to someone who does not have the disease or injury; and
(4) Appropriate for use in the patient’s home.
b. Your Plan pays to rent or buy Durable Medical Equipment
(1) We will base Benefits for renting the equipment on Our rental Allowable Charge (but Benefits will not be more than the purchase Allowable Charge).
(2) If We choose, Your Plan will pay for buying Durable Medical Equipment, appropriate supplies, and oxygen required for therapeutic use.
(3) If You select When Durable Medical Equipment is approved by Us, Benefits for standard equipment will be provided toward any deluxe equipment. Deluxe equipment only or deluxe features and functionalities of equipment are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience, We will base Your Benefits on the Allowable Charge for standard equipment; or
(d) that are not determined by Us to be Medically Necessary.
(4) We consider accessories and medical supplies that are necessary for covered Durable Medical Equipment to effectively function to be an integral part of the rental or purchase allowance. Your Plan will not cover them separately.separately.
(5) Your Plan pays to repair or adjust purchased Durable Medical Equipment or to replace components. Your Plan will not pay to replace equipment that is lost or damaged due to neglect or misuse. You Plan will also not pay for replacing equipment that was bought or rented less than 5 five (5) years agoago that is not Medically Necessary as determined by Us. Regardless of Medical Necessity, repair, adjustment, or replacement of equipment subject to a recall within five (5) years after purchase or rental will not be covered. Regardless of Medical Necessity, repair, adjustment, or replacement of equipment will not be covered when provided under warranty.
c. Limitations in connection with Durable Medical Equipment
(1) When You rent Durable Medical Equipment, Your Plan does not pay to repair, adjust, or replace components and accessories necessary for the effective function and maintenance of covered equipment because this is the company that supplied responsibility of the equipment must pay for thatDurable Medical Equipment supplier.
(2) Your Plan does not pay for equipment if a commonly available supply or appliance effectively serves the same purpose.
(3) Your Plan does not pay to repair or replace equipment that is lost or damaged due to neglect or misuse.
(4) We will determine reasonable quantity limits on Durable Medical Equipment items and supplies.
(5) Regardless of Claims of Medical Necessity, deluxe equipment or deluxe features and functionalities of equipment that are not approved by Us are not covered.
2. Orthotic Devices As specified in this section, Your Plan will pay to buy Orthotic Devices. These Benefits will be subject to the following:
a. Your Plan does not pay for fitting or adjustments because this is included in the Allowable Charge for the Orthotic Device.
b. Your Plan pays to repair or replace Orthotic Devices only within a reasonable time-period after You bought them, subject to the expected lifetime of the devices. We will determine that time-period. Regardless of Medicall Necessity, repair or replacement of the device will not be covered when provided under warranty or when the device is subject to a recall.
c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. Deluxe devices or deluxe features and functionalities of devices are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe devices or deluxe features and functionalities of devices that are not approved by Us are not covered.
e. No Benefits are available for supportive devices for the foot.
a. Your Plan does not pay to fit or adjust appliances because as this is included in the Allowable Charge for the Prosthetic Appliance.
b. Your Plan pays to repair or replace Prosthetic Appliances only within a reasonable time- period after You bought them, subject to the expected lifetime of the appliance. We will determine this time-period. Regardless of Medical Necessity, repair or replacement of appliances will not be covered when provided under warranty or when the appliance is subject to a recall.
c. When Prosthetic Appliances are approved by Us, Benefits for standard appliances will be provided toward any deluxe appliance. Deluxe appliances or deluxe features and functionalities of appliances are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe appliances or devices or deluxe features and functionalities of appliances or devices that are not approved by Us are not covered.
Appears in 1 contract
Samples: Cancer and Serious Disease Limited Benefit Contract
Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances. 1. Durable Medical Equipment
a. Your Plan covers Durable Medical Equipment when a Physician prescribes the equipment before You get it. The equipment must not be mainly for the comfort or convenience of the Member or others. In addition, the equipment must meet all of the following criteria. It must be:
(1) Able to withstand repeated use;
(2) Primarily and customarily used for a medical purpose;
(3) Generally not useful to someone who does not have the disease or injury; and
(4) Appropriate for use in the patient’s home.
b. Your Plan pays to rent or buy Durable Medical Equipment
(1) We will base Benefits for renting the equipment on Our rental Allowable Charge (but Benefits will not be more than the purchase Allowable Charge).
(2) If We choose, Your Plan will pay for buying Durable Medical Equipment, appropriate supplies, and oxygen required for therapeutic use.
(3) If You select When Durable Medical Equipment is approved by Us, Benefits for standard equipment will be provided toward any deluxe equipment. Deluxe equipment only or deluxe features and functionalities of equipment are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience, We will base Your Benefits on the Allowable Charge for standard equipment; or
(d) that are not determined by Us to be Medically Necessary.
(4) We consider accessories and medical supplies that are necessary for covered Durable Medical Equipment to effectively function to be an integral part of the rental or purchase allowance. Your Plan will not cover them separately.separately.
(5) Your Plan pays to repair or adjust purchased Durable Medical Equipment or to replace components. Your Plan will not pay to replace equipment that is lost or damaged due to neglect or misuse. You Plan will also not pay for replacing equipment that was bought or rented less than 5 years agoago that is not Medically Necessary as determined by Us. Repair, adjustment, or replacement of equipment will not be covered when provided under warranty.
c. Limitations in connection with Durable Medical Equipment
(1) When You rent Durable Medical Equipment, Your Plan does not pay to repair, adjust, or replace components and accessories necessary for the effective function and maintenance of covered equipment because this is the company that supplied responsibility of the equipment must pay for thatDurable Medical Equipment supplier.
(2) Your Plan does not pay for equipment if a commonly available supply or appliance effectively serves the same purpose.
(3) Your Plan does not pay to repair or replace equipment that is lost or damaged due to neglect or misuse.
(4) We will determine reasonable quantity limits on Durable Medical Equipment items and supplies.
(5) Regardless of Claims of Medical Necessity, deluxe equipment or deluxe features and functionalities of equipment that are not approved by Us are not covered.
2. Orthotic Devices As specified in this section, Your Plan will pay to buy Orthotic Devices. These Benefits will be subject to the following:
a. Your Plan does not pay for fitting or adjustments because this is included in the Allowable Charge for the Orthotic Device.
b. Your Plan pays to repair or replace Orthotic Devices only within a reasonable time period after You bought them, subject to the expected lifetime of the devices. We will determine that time period. Repair or replacement of the device will not be covered when provided under warranty.
c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. Deluxe devices or deluxe features and functionalities of devices are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe devices or deluxe features and functionalities of devices that are not approved by Us are not covered.
e. No Benefits are available for supportive devices for the foot.
a. Your Plan does not pay to fit or adjust appliances because as this is included in the Allowable Charge for the Prosthetic Appliance.
b. Your Plan pays to repair or replace Prosthetic Appliances only within a reasonable time period after You bought them, subject to the expected lifetime of the appliance. We will determine this time period. Repair or replacement of appliances will not be covered when provided under warranty.
c. When Prosthetic Appliances are approved by Us, Benefits for standard appliances will be provided toward any deluxe appliance. Deluxe appliances or deluxe features and functionalities of appliances are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe appliances or devices or deluxe features and functionalities of appliances or devices that are not approved by Us are not covered.
Appears in 1 contract
Samples: Limited Benefit Contract
Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances. 1. Durable Medical Equipment
a. Your Plan covers Durable Medical Equipment when a Physician prescribes the equipment before You get it. The equipment must not be mainly for the comfort or convenience of the Member or others. In addition, the equipment must meet all of the following criteria. It must be:
(1) Able to withstand repeated use;
(2) Primarily and customarily used for a medical purpose;
(3) Generally not useful to someone who does not have the disease or injury; and
(4) Appropriate for use in the patient’s home.
b. Your Plan pays to rent or buy Durable Medical Equipment
(1) We will base Benefits for renting the equipment on Our rental Allowable Charge (but Benefits will not be more than the purchase Allowable Charge).
(2) If We choose, Your Plan will pay for buying Durable Medical Equipment, appropriate supplies, and oxygen required for therapeutic use.
(3) If You select When Durable Medical Equipment is approved by Us, Benefits for standard equipment will be provided toward any deluxe equipment. Deluxe equipment only or deluxe features and functionalities of equipment are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience, We will base Your Benefits on the Allowable Charge for standard equipment; or
(d) that are not determined by Us to be Medically Necessary.
(4) We consider accessories and medical supplies that are necessary for covered Durable Medical Equipment to effectively function to be an integral part of the rental or purchase allowance. Your Plan will not cover them separately.separately.
(5) Your Plan pays to repair or adjust purchased Durable Medical Equipment or to replace components. Your Plan will not pay to replace equipment that is lost or damaged due to neglect or misuse. You Plan will also not pay for replacing equipment that was bought or rented less than 5 years agoago that is not Medically Necessary as determined by Us. Repair, adjustment, or replacement of equipment will not be covered when provided under warranty.
c. Limitations in connection with Durable Medical Equipment
(1) When You rent Durable Medical Equipment, Your Plan does not pay to repair, adjust, or replace components and accessories necessary for the effective function and maintenance of covered equipment because this is the company that supplied responsibility of the equipment must pay for thatDurable Medical Equipment supplier.
(2) Your Plan does not pay for equipment if a commonly available supply or appliance effectively serves the same purpose.
(3) Your Plan does not pay to repair or replace equipment that is lost or damaged due to neglect or misuse.
(4) We will determine reasonable quantity limits on Durable Medical Equipment items and supplies.
(5) Regardless of Claims of Medical Necessity, deluxe equipment or deluxe features and functionalities of equipment that are not approved by Us are not covered.
2. Orthotic Devices As specified in this section, Your Plan will pay to buy Orthotic Devices. These Benefits will be subject to the following:
a. Your Plan does not pay for fitting or adjustments because this is included in the Allowable Charge for the Orthotic Device.
b. Your Plan pays to repair or replace Orthotic Devices only within a reasonable time period after You bought them, subject to the expected lifetime of the devices. We will determine that time period. Repair or replacement of the device will not be covered when provided under warranty.
c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. Deluxe devices or deluxe features and functionalities of devices are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe devices or deluxe features and functionalities of devices that are not approved by Us are not covered.
e. No Benefits are available for supportive devices for the foot.
a. Your Plan does not pay to fit or adjust appliances because as this is included in the Allowable Charge for the Prosthetic Appliance.
b. Your Plan pays to repair or replace Prosthetic Appliances only within a reasonable time period after You bought them, subject to the expected lifetime of the appliance. We will determine this time period. Repair or replacement of appliances will not be covered when provided under warranty.
c. When Prosthetic Appliances are covered by Us, Benefits for standard appliances will be provided toward any deluxe appliance. Deluxe appliances or deluxe features and functionalities of appliances are those:
(a) that do not serve a medical purpose;
(b) that are not required to complete daily living activities;
(c) that are solely for Your comfort or convenience; or
(d) that are not determined by Us to be Medically Necessary.
d. Regardless of Claims of Medical Necessity, deluxe appliances or devices or deluxe features and functionalities of appliances or devices that are not approved by Us are not covered.
Appears in 1 contract
Samples: Limited Benefit Contract
