Eligible Expense Clause Samples

Eligible Expense. Charges incurred by the Participant for health care services and supplies, defined as benefits in this Policy, and are considered Eligible Expenses to the extent that they are: a) Usual, Customary and Reasonable in the opinion of Medavie Blue Cross, as defined in this Policy; b) recommended, approved or prescribed by a Health Care Professional as approved by Medavie Blue Cross; c) in excess of the charges reimbursed, or entitled to be reimbursed, from Providers of health and/or dental coverage; d) rendered by a Person who does not normally reside in the Participant's home and is not a member of the Participant's immediate family either by blood or marriage; e) rendered by a Medavie Blue Cross Approved Provider; and f) rendered after the effective date of this Policy and while this Policy is in effect, unless otherwise specified. Eligible Expense is considered to be incurred on the date the service or supply was received. The Benefit Maximums specified identify the maximum Eligible Expense prior to the application of the Co-insurance and after the application of any applicable Usual, Customary and Reasonable limits. Where more than one form or alternative form of treatment exists, Medavie Blue Cross, in Consultation with its Health Care Consultants, reserves the right to make payment for eligible services and supplies based on an alternate procedure or supply with a lower cost, when deemed appropriate and consistent with good health management. GEN (5537) 06/99 S-3.04 Amendment – 11 01 September 2011 Date of Issue: 27 September 2011