Please Note: This information is a general reference tool. All terms, conditions and amounts may not be applicable to your benefit plan. Please refer to your Plan Document for a complete listing of terms, conditions, coverage and exclusions of your benefit plan.
Terms Beginning with the Letter "E"
Effective Date is the first day of coverage.
Employee means a person who is classified by the Employer as a regular common law employee such as by reporting of wages on Form W-2. An individual who is retroactively reclassified a common law employee will not be entitled to retroactive treatment as an Employee under this Plan.
Enrollment Date for purposes of complying with HIPAA regulations only, means the first day of the Waiting Period, if any.
ERISA is the Employee Retirement Income Security Act of 1974, as amended.
Exclusion is a service the health insurance company will not cover or pay for.
Experimental and/or Investigational means services, supplies, care and treatment which does not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical or dental community or government oversight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental or non-experimental standings of specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions. The decisions shall be rendered following a detailed factual background investigation of the claim and the proposed treatment. The decision of the Plan Administrator will be final and binding on the Plan and all Covered Persons. The Plan Administrator will be guided by the following principles:
- if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or
- if the drug, device, medical treatment or procedure, or the patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review or approval; or
- if Reliable Evidence shows that the drug, device, medical treatment or procedure is the subject of on‑going phase I or phase II clinical trials, is the research, experimental, study or investigational arm of on‑going phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or
- if Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis.
Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature: the written protocol or protocols used by the treating facility or the protocols(s) of another facility studying substantially the same drug, service e, medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.
Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use.
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