2 - Complaint/Statements Of Claim Complaint-unofficial August 23, 2024 (2024)

 
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 Filing # 205398203 E-Filed 08/23/2024 07:14:00 AM IN THE CIRCUIT COURT OF THE 11th JUDICIAL CIRCUIT IN AND FOR MIAMI-DADE COUNTY, FLORIDA AMMAR ALI, Plaintiff, Case No.: v. AVMED, INC., Defendant. ____________________________________/ COMPLAINT Plaintiff, Ammar Ali, by and through undersigned counsel hereby files his Complaint against Defendant, AvMed, Inc., and says: JURISDICTION AND VENUE 1. This is an action for damages in excess of fifty thousand dollars ($50,000.00), exclusive of interest, costs and attorneys’ fees. 2. Plaintiff, Ammar Ali (“Ammar”), is a citizen of Florida and a resident of Miami- Dade County, Florida. 3. Defendant, AvMed, Inc. (“Defendant”), is a Florida not for profit corporation doing business in Florida. 4. Defendant is in the business of selling health benefits plans, and maintained, administered, insured, issued, and delivered the health benefits plan at issue in the State of Florida. 5. This action is governed by Florida law as the Plan was issued and delivered in Florida, and Defendant breached the contract in Florida. 6. At all times material hereto, Defendant was subject to the provisions of Chapter 641 of the Florida Statutes. 7. Defendant had a duty to ensure that its standards were met, and policies andprocedures were implemented and followed by its agents and employees and that health insuranceclaims were timely paid and administered. GENERAL FACTS 8. At all times material to this action, there was in full force and effect a health benefitsplan titled “AvMed Empower Plan for Individuals and Families Medical and Hospital ServiceContract with Point of Service Rider” (the “Plan”), constituting a binding contract of insurancebetween the parties. [The Plan is attached hereto as Exhibit “A”]. The Plan is a HMO plan. 9. The Plan provides health insurance coverage for Ammar as he is a member andbeneficiary of the Plan. 10. The Plan provides coverage for mental health services in a residential treatmentfacility and/or residential treatment center. 11. Ammar received inpatient medical care and treatment at Catalyst RTC (“Catalyst”)from September 2022 to March 2023. 12. Catalyst is a licensed residential treatment facility in Utah, which provides inpatienttreatment to adolescents with mental health, behavioral, and/or substance abuse problems. 13. At the time of his treatment at Catalyst, Ammar was a minor child. 14. Defendant denied claims for payment of Ammar’s medical expenses in connectionwith his inpatient treatment at Catalyst from September 2022 to March 2023. 15. Prior to his treatment at Catalyst, Ammar’s diagnoses included numerous severemental health conditions. 16. Ammar’s condition was so severe that he was at times at risk of harming himself. 2 17. From July – September 2022, Ammar received residential behavioral healthtreatment in Palm Beach Gardens, Florida. That treatment proved to be insufficient for the severityof Ammar’s illnesses. 18. Ammar’s condition was so severe that an escalated level of care was necessary. 19. Ammar’s treatment team recommended that he receive inpatient care, and he wastaken to Catalyst. 20. Pursuant to the Plan’s provisions, and prior to services being rendered to Ammar,Catalyst submitted a pre-authorization request to Defendant for coverage of Ammar’s residentialtreatment. 21. By letter dated September 19, 2022, Defendant denied Catalyst’s request forcoverage as not being a covered benefit under the Plan. 22. Specifically, Defendant’s September 19, 2022 adverse benefit determinationcontained the following rationale for the denial: Catalyst Residential Treatment does not provide services for Mental Health Residential Treatment Center (MH RTC) consistent with the Mental Health clinical guidelines: The Child and Adolescent Level of Care Utilization System/Child and Adolescent Service Intensity Instrument (CALOCUSCASII). Services were not clinically reviewed because this provider is not available for authorization for this level of care as noted above. 23. On February 28, 2023, Ammar’s father submitted an appeal on his behalf of thedenial of payment for Ammar’s treatment at Catalyst. 24. The appeal reminded Defendant that Ammar was entitled to certain rights andsafeguards under the Plan during the review process, including a full and fair review of the denialin compliance with Section 13.5 of the Plan. 3 25. The appeal also reminded Defendant that an appeal notification must comply withSection 13.6 of the Plan. 26. The appeal requested that Defendant take into account all information providedwith the appeal as is required by the terms of the Plan. 27. As is further required by the terms of the Plan, the appeal requested that Defendantassign a medical or vocational expert who is knowledgeable about generally accepted standardsand clinical best practices for residential treatment programs in the state of Utah, as well asappropriately qualified and experienced. 28. By letter dated April 4, 2023, Defendant denied the appeal for payment of Ammar’streatment. The letter gave an entirely new reason for denying benefits. For the first time, Defendantclaimed that “services that require prior authorization without receiving approval are not a coveredbenefit.” 29. Defendant’s April 4, 2023 letter failed to address any of the arguments raised in theappeal letter regarding the merits of Defendant’s initial denial and failure to provide authorizationfor Ammar’s treatment. Instead, Defendant simply made a final denial decision on Ammar’salleged failure to obtain prior authorization. 30. By failing to pay a legitimate mental health claim, Defendant breached its dutiesunder the Plan. 31. Defendant’s denial is without justifiable reason, arbitrary and capricious, and aresult of its failure to act in good faith and to fairly administer benefits under the Plan. 32. The denial was in contravention of the Plan, in that Ammar’s treatment at Catalystshould be covered pursuant to the terms of the Plan. 4 33. Defendant’s refusal to pay Ammar’s treatment at Catalyst constitutes a breach ofthe Plan and caused Ammar to incur medical expenses that should have been paid by the Plan inan amount totaling over $120,000.00. 34. Ammar has been required to retain an attorney to enforce the Plan’s benefits and isentitled to reasonable attorney’s fees. 35. Ammar exhausted his pre-litigation appeal obligations under the terms of the Plan. COUNT I: BREACH OF CONTRACT Ammar incorporates the allegations contained in Paragraphs 1 through 35 as if fully statedherein and says further that: 36. Defendant and Ammar have a binding insurance policy that provides for paymentof the losses sustained in this case. 37. Ammar complied with all provisions and conditions of the Plan prior to filing suit. 38. Defendant, its agents and employees, materially breached the Plan by failing toprovide proper payment for the Ammar’s claims. 39. Defendant has breached the Plan by failing to indemnify Ammar for payment ofmedical services and benefits. 40. Defendant has breached the Plan by failing to comply with Plan requirements forreview procedures on appeal, the manner and content of appeal notifications, and medical necessitydeterminations. 41. Defendant has refused to honor its obligations under the Plan and, as a result,Ammar has suffered damages and incurred medical expenses. 42. Defendant has refused to pay benefits sought by Ammar, ignoring the medicalrecords and clear opinions of his treating physicians. 5 RELIEF REQUESTED Ammar incorporates the allegations contained in Paragraphs 1 through 42 as if fully statedherein and says further that: 43. As a result of the acts and/or omissions of Defendant as alleged herein, Defendantowes Ammar unpaid health benefits, plus interest. 44. Defendant is also liable for Ammar’s attorney’s fees and the costs of litigation. 45. Defendant is also liable to place Ammar in the position he would have enjoyedunder the Plan had he not been wrongfully denied benefits by Defendant. PRAYER FOR RELIEF WHEREFORE, Plaintiff, Ammar Ali, demands judgment against Defendant, AvMed, Inc.,for all Plan benefits due for his medical care, pre-judgment interest, costs and attorney’s fees, andsuch further relief this Court deems just under the circ*mstances. Plaintiff demands trial by juryon all issues so triable. Respectfully submitted this 23rd day of August 2024. /s/ Edward P. Dabdoub Edward Philip Dabdoub (FBN. 45685) eddie@longtermdisability.net Latanae L. Parker (FBN. 76591) latanae@longtermdisability.net DABDOUB LAW FIRM, P.A. 1600 Ponce de Leon Blvd., Suite 1202 Coral Gables, Florida 33134 Tel: (305) 754-2000 Fax: (305) 754-2007 Counsel for Plaintiff 6EXHIBIT A AvMed Empower Plan for Individuals and Families Medical and Hospital Service Contract with Point of Service Rider This Contract Contains Deductible Provisions For Member Engagement Call: 1-800-477-8768 James M. Repp President & COOAV-IN-COC-22 Empower-IN-1536 (01/22) TABLE OF CONTENTSService Area ............................................................................................................................................................. iiI. INTRODUCTION ............................................................................................................................................. 1II. DEFINITIONS................................................................................................................................................... 2III. ELIGIBILITY FOR COVERAGE ....................................................................................................................... 12IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE ................................................................................. 13V. TERMINATION .............................................................................................................................................. 16VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES.................................. 18VII. PHYSICIANS, HOSPITALS AND OTHER PROVIDERS ..................................................................................... 20VIII. ACCESSING COVERED BENEFITS AND SERVICES ....................................................................................... 22IX. COVERED MEDICAL SERVICES.................................................................................................................... 24X. LIMITATIONS OF COVERED MEDICAL SERVICES ........................................................................................ 37XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES................................................................................... 39XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS.................................................. 46XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL ............................................... 49XIV. COORDINATION OF BENEFITS..................................................................................................................... 54XV. SUBROGATION AND RIGHT OF RECOVERY ................................................................................................ 56XVI. DISCLAIMER OF LIABILITY AND RELATIONSHIPS BETWEEN THE PARTIES .................................................... 57XVII. GENERAL PROVISIONS ................................................................................................................................ 58XVIII. PEDIATRIC DENTAL BENEFITS, LIMITATIONS AND EXCLUSIONS ................................................................. 60AV-IN-COC-22 i Empower-IN-1536 (01/22) AVMED CORPORATE OFFICE 9400 S. DADELAND BOULEVARD MIAMI, FL 33156-9004 AVMED MEMBER ENGAGEMENT CENTER - ALL AREAS 1-800-477-8768 SALES AREA Broward Miami-Dade SERVICE AREA Alachua Hamilton Osceola Baker Hernando Palm Beach Bradford Hillsborough Pasco Broward Lake Pinellas Citrus Lee Polk Clay Levy Sarasota Columbia Manatee Seminole Dixie Marion St. Johns Duval Miami-Dade Suwanee Gilchrist Nassau Union Orange SERVICE AREA OFFICE GAINESVILLE MIAMI 4300 NW 89th Boulevard 9400 South Dadeland Boulevard Post Office Box 749 Miami, Florida 33156-9004 Gainesville, Florida 3262-0749 (305) 671-5437 (352) 372-8400 (800) 432-6676 (800) 346-0231AV-IN-COC-22 ii Empower-IN-1536 (01/22) AVMED EMPOWER PLAN FOR INDIVIDUALS AND FAMILIES MEDICAL AND HOSPITAL SERVICE CONTRACT WITH POINT OF SERVICE RIDERIN CONSIDERATION of the payment of pre-paid monthly Premiums as provided herein, AvMed, Inc., aprivate Florida not-for-profit corporation, state licensed as a health maintenance organization underChapter 641, Florida Statutes (hereinafter, “AvMed”), and the Contractholder as named on the Applicationfor Coverage, agree as follows: I. INTRODUCTION1.1 Reliance on Applicant Information. In issuing this Contract to you, we relied on the truthfulness and accuracy of the information provided on your Application for Coverage with AvMed. Please carefully read the information provided in your Application, and notify us within ten days if any of the information on it is incorrect or incomplete. Failure to provide AvMed with truthful and accurate information on your Application could result in the cancellation or rescission of this Contract.1.2 Ten Day Review Period. If, after examining this Contract and your Application, you are not fully satisfied for any reason, your Premium payment will be refunded provided you return the Contract and AvMed Identification Card to us within ten days of the delivery date.1.3 Contract Enforcement. This Contract is not enforceable until the Contractholder's Application for coverage has been received by us, is acceptable to us, and we have received the Contractholder's first Premium payment. All subsequent Premium payments are payable in advance or within the grace period. The amount of the Contractholder's initial monthly Premium is indicated on the front cover of this Contract.1.4 Provision of Health Care Services and Benefits. During the term of this Contract, we agree to arrange for the provision of Covered Benefits or Covered Services which are Medically Necessary for the diagnosis and treatment of Members, subject to all applicable terms, conditions, Limitations and Exclusions described in this Contract. AvMed arranges for the delivery of Covered Services in accordance with the covenants and conditions contained in this Contract, and does not directly provide these Covered Services.1.5 Interpretation. In order to provide the advantages of Hospital and medical facilities and of In- Network Providers, AvMed operates on a direct service rather than indemnity basis. The interpretation of this Contract will be guided by the direct service nature of AvMed's program and the definitions and other provisions contained in this Contract.1.6 Important Considerations. When reading your Contract, please remember: a. You should read this Contract in its entirety in order to determine if a particular Health Care Service is covered. b. Many of the provisions of this Contract are interrelated. Therefore, reading just one or two provisions may give you a misleading impression. Many words used in this Contract have special meanings (see Part II. DEFINITIONS). c. The headings of Parts and Sections contained in this Contract are for reference purposes only and will not affect in any way the meaning or interpretation of particular provisions.1.7 References in this Contract a. References to “you” or “your” throughout refer to you as the Contractholder and to your Covered Dependents, unless expressly stated otherwise or unless, in the context in which the term is used, it is clearly intended otherwise. Any references which refer solely to you as the Contractholder or solely to your Covered Dependents will be noted as such. b. References to “we”, “us” and “our” throughout refer to AvMed. c. Whenever used, the singular will include the plural and the plural the singular, and the use of any gender will include all genders.AV-IN-COC-22 1 Empower-IN-1536 (01/22) d. References to the “Plan” refer to this AvMed Empower Plan for Individuals and Families. e. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. If a word or phrase has a defined meaning, it will either be in Part II. DEFINITIONS or defined within the particular section where it is used.1.8 Shared Savings Incentive Program. This Contract is eligible for the Shared Savings Incentive Program per Section 641.31076, F.S. This voluntary program allows Members to participate in the savings generated from Shoppable Health Care Services located at providers on the AvMed’s shared savings list. a. AvMed’s shared savings list is available at www.avmed.org/smartshopper. This list includes all available Shoppable Health Care Services and their Shared Savings Incentive amount. Be aware, this list may change. Please check frequently to ensure you have accurate information. b. When you qualify for a reward, your Shared Saving Incentive will be sent to you by check approximately 30 days after we confirm that you received care at an incentive eligible location. c. AvMed must notify you, and the Office of Insurance Regulation, at least 30 days before termination of this program.1.9 Contract Renewal. This Contract is guaranteed renewable, subject to AvMed’s right to discontinue or terminate coverage as described herein. Renewals occur on the first day of January each year. Upon renewal, the term of coverage will be no less than 12-months, unless otherwise requested by the Contractholder in writing. Coverage will stay in effect as long as you and your Covered Dependents continue to meet the eligibility requirements, live in the AvMed Empower Plan Service Area, and pay your Premiums on time. Members are subject to all terms, conditions, Limitations, and Exclusions in this Contract and to all of the rules and regulations of the Plan. By paying Premiums or having Premiums paid on your behalf, you accept the provisions of this Contract.1.10 You must notify us immediately of any address change (or email us if you have opted for electronic communications). II. DEFINITIONSAs used in this Contract, each of the following terms will have the meaning indicated. For further definitions,go to www.healthcare.gov/glossary to review the Uniform Glossary provided as a result of the AffordableCare Act.2.1 Accidental Dental Injury means an injury to Sound Natural Teeth (not previously compromised by decay) caused by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or injuries to Sound Natural Teeth caused by biting or chewing, surgery or treatment for a disease or illness.2.2 Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in the Plan; and including: a. a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any Utilization Management Program, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational, or not Medically Necessary; and b. a cancellation or discontinuance of coverage that has retroactive effect, unless attributable to a failure to timely pay required Premiums or contributions toward the cost of coverage.2.3 Allowed Amount means the maximum amount established by AvMed upon which payment will be based for Covered Services rendered by In-Network Providers. The Allowed Amount may be changed at any time without notice to you or your consent.2.4 Ambulatory Surgery Center means a facility licensed pursuant to Chapter 395, Florida Statutes (or if outside Florida, applicable state law), the primary purpose of which is to provide surgical care to a patient admitted to, and discharged from, such facility within 24 hours.AV-IN-COC-22 2 Empower-IN-1536 (01/22)2.5 Attending Physician means the Physician primarily responsible for the care of a Member with respect to any particular Condition.2.6 AvMed Network Provider or AvMed Provider Network means the Health Care Providers with whom AvMed has contracted or made arrangements to provide Covered Benefits and Covered Services to AvMed Empower Plan Members. These are also referred to as “In-Network Providers.”2.7 Benefit Level means: a. For In-Network Providers the Copayment or Coinsurance percentage, of the Allowed Amount for Covered Services, after any applicable Calendar Year Deductible is met. Benefits for Covered Services received from In-Network Tier A Providers are payable at the high Benefit Level. Benefits for Covered Services from In-Network Tier B Providers are payable at the middle Benefit Level. b. For Out-of-Network Providers, the Copayment or Coinsurance percentage, of the Maximum Allowable Payment for Covered Services, after the applicable Calendar Year Deductible is met. Benefits for Covered Services received from Out-of-Network Providers are payable at the low Benefit Level.2.8 Birthing Center means a facility licensed pursuant to Chapter 383, Florida Statutes (or if outside Florida, applicable state law), which is freestanding, and is not a Hospital or in a Hospital, in which births are planned to occur away from the mother’s usual residence following a normal, uncomplicated, low-risk pregnancy. Birthing Centers must provide facilities for obstetrical delivery and short-term recovery after delivery, care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse midwife, and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post- delivery confinement.2.9 Breast Reconstructive Surgery means surgery to reestablish symmetry between the two breasts following breast cancer treatment.2.10 Calendar Year Deductible means the first payments up to a specified dollar amount that a Member must make in the applicable calendar year for Covered Benefits. It is the amount you owe for certain Covered Services before AvMed begins to pay, and must be satisfied once each calendar year. The Calendar Year Deductible may not apply to all services. The Deductible applies to each Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the Deductible, “family” means the Contractholder and Covered Dependents. Third-party Copayment assistance by a drug manufacturer or any other entity toward your cost-sharing for Covered Services including Specialty Medications, does not apply toward satisfaction of the Deductible.2.11 Calendar Year Out-of-Pocket Maximum means the maximum amount you will pay during a calendar year before AvMed begins to pay 100% of the Allowed Amount or Maximum Allowable Payment for Covered Services during the same calendar year. This limit never includes your Premiums, Prescription Drug Brand Additional Charges, third-party Copayment assistance by a drug manufacturer or any other entity toward your cost-sharing for Covered Services including Specialty Medications, charges in excess of the Maximum Allowable Payment for Covered Services rendered by Out-of-Network Providers, or charges for health care that AvMed does not cover.2.12 Claim means a request for benefits under this Contract, made by or on behalf of a Member in accordance with AvMed’s procedures for filing benefit Claims. a. Pre-Service Claim means any Claim for benefits under this Contract for which, in whole or in part, a Claimant must obtain authorization from AvMed in advance of such services being provided to or received by the Member. b. Urgent Care Claim means any Claim for medical care or treatment for a Condition that could seriously jeopardize the Member’s life or health, or the Member’s ability to regain maximum function or, in the opinion of a Physician with knowledge of the Member’s Condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested.AV-IN-COC-22 3 Empower-IN-1536 (01/22) c. Concurrent Care Claim means any request by a Claimant that relates to an Urgent Care Claim to extend a course of treatment beyond the initial period of time or number of treatments previously approved. d. Post-Service Claim means any Claim for benefits under this Contract that is not a Pre-Service Claim.2.13 Claimant means a Member or a Member’s authorized representative acting on behalf of a Member. AvMed may establish procedures for determining whether an individual is authorized to act on behalf of a Member with respect to a Claim for benefits.2.14 Coinsurance means the portion of the cost for a Covered Service that a Member must pay once any applicable Deductible has been met, and is expressed as a percentage, established solely by AvMed, of the Allowed Amount or Maximum Allowable Payment for the Covered Service, or the percentage of an amount based on the Maximum Medicare Allowable or Average Wholesale Price for the Covered Service. Members are responsible for the payment of any applicable Coinsurance directly to a Health Care Provider at the time Covered Services are received.2.15 Condition means a disease, illness, ailment, injury, or pregnancy.2.16 Contract means this AvMed Empower Plan for Individuals and Families Medical and Hospital Service Contract with Point of Service Rider, which may at times be referred to as “Individual Contract” or “Point of Service Plan” and all Applications, schedules, amendments, and any other document approved by the Florida Office of Insurance Regulation for incorporation into this Contract.2.17 Contractholder means an individual who meets and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered under this Contract other than as a Covered Dependent.2.18 Copayment means the fixed dollar amount, established solely by AvMed, that a Member must pay once any applicable Deductible has been met, for certain Covered Services rendered by a Health Care Provider at the time the Covered Services are received. The Copayment is a portion of the Allowed Amount or Maximum Allowable Payment for the Covered Service, or a portion of the Maximum Medicare Allowable or Average Wholesale Price, for the Covered Service.2.19 Coverage Criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies. AvMed reserves the right to make changes in Coverage Criteria for covered products and services.2.20 Covered Benefits or Covered Services means those Health Care Services to which a Member is entitled under the terms of this Contract. Member’s cost-sharing responsibilities for Covered Services, including any applicable Deductible, Copayments and Coinsurance amounts, are outlined in the Schedule of Benefits.2.21 Covered Dependent means any dependent of a Contractholder’s family, who meets and continues to meet all applicable eligibility requirements, and who is enrolled and actually covered under this Contract other than as a Contractholder.2.22 Custodial or Custodial Care means care that serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self- administered. Custodial Care essentially is personal care that does not require the continuing attention of trained medical personnel. In determining whether a person is receiving Custodial Care, consideration is given to the frequency, intensity and level of care, medical supervision required and furnished, patient's diagnosis, type of Condition, degree of functional limitation, or rehabilitation potential.2.23 Dental Care means: a. dental x-rays, examinations and treatment of the teeth or any services, supplies or charges directly related to: i. the care, filling, removal or replacement of teeth; orAV-IN-COC-22 4 Empower-IN-1536 (01/22) ii. the treatment of injuries to, or disease of, the teeth, gums or structures directly supporting or attached to the teeth, that are customarily provided by dentists (including orthodontics, reconstructive jaw surgery, casts, splints and services for dental malocclusion). b. Dental Care is covered only for children through the end of the month in which they turn 19, except as described in Part IX COVERED MEDICAL SERVICES. For more information about covered pediatric dental benefits please see Part XVIII. PEDIATRIC DENTAL BENEFITS.2.24 Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug dependent, individual is assisted through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors, or alcohol in combination with drugs, as determined by a licensed Health Professional, while keeping the physiological risk to the individual at a minimum.2.25 Durable Medical Equipment (DME) is any equipment that meets all of the following requirements: a. can withstand repeated use; and b. is primarily and customarily used to serve a medical purpose; and c. generally is not useful to a person in the absence of an illness or injury; and d. is appropriate for use in the Member’s home.2.26 Emergency Medical Condition means: a. A Condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following: i. serious jeopardy to the health of a patient, including a pregnant woman or fetus; ii. serious impairment to bodily functions; or iii. serious dysfunction of any bodily organ or part; and iv. with respect to a pregnant woman: 1) that there is inadequate time to effect safe transfer to another Hospital prior to delivery; 2) that a transfer may pose a threat to the health and safety of the patient or fetus; or 3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. b. Examples of Emergency Medical Conditions include heart attack, stroke, massive internal or external bleeding, fractured limbs, or severe trauma.2.27 Emergency Medical Services and Care means medical screening, examination and evaluation by a Physician or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a Physician, to determine if an Emergency Medical Condition exists and, if it does, the care, treatment, or surgery for a Covered Service by a Physician necessary to relieve or eliminate the Emergency Medical Condition within the service capability of the Hospital. a. In-area emergency does not include elective or routine care, care of minor illnesses or care that can reasonably be sought and obtained from the Member’s Physician. The determination as to whether or not an illness or injury constitutes an Emergency Medical Condition will be made by AvMed and may be made retrospectively based upon all information known at the time the Member was present for treatment. b. Out-of-area emergency does not include care for Conditions for which a Member could reasonably have foreseen the need of such care before leaving the Service Area or care that could safely be delayed until prompt return to the Service Area. The determination as to whether or not an illness or injury constitutes an Emergency Medical Condition will be made by AvMed and may be made retrospectively based upon all information known at the time the Member was present for treatment.2.28 Essential Health Benefits has the meaning set forth under the Affordable Care Act, Section 1302(b), and applicable regulations. The ten categories of Essential Health Benefits are: a. ambulatory patient services; b. emergency services;AV-IN-COC-22 5 Empower-IN-1536 (01/22) c. hospitalization; d. maternity and newborn care; e. mental health and substance use disorder services (including behavioral health treatment); f. prescription drugs; g. rehabilitative and habilitative services and devices; h. laboratory services; i. preventive and wellness services and chronic disease management; j. pediatric services (including oral and vision care).2.29 Exclusion means any provision of this Contract whereby coverage for a specific hazard, service or Condition is entirely eliminated.2.30 Experimental or Investigational means: a. Any evaluation, treatment, therapy, or device which involves the application, administration or use, of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds if, as determined by AvMed: i. such evaluation, treatment, therapy, or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) or the Florida Department of Health and approval for marketing has not, in fact, been given at the time such is furnished to the Member; ii. such evaluation, treatment, therapy, or device is provided pursuant to a written protocol which describes as among its objectives the following: determinations of safety, efficacy, or efficacy in comparison to the standard evaluation, treatment, therapy, or device; iii. such evaluation, treatment, therapy, or device is delivered or should be delivered subject to the approval and supervision of an institutional review board or other entity as required and defined by federal regulations; iv. credible scientific evidence shows that such evaluation, treatment, therapy, or device is the subject of an ongoing Phase I or II clinical investigation, or the experimental or research arm of a Phase III clinical investigation, or under study to determine maximum tolerated dosages, toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; v. credible scientific evidence shows that the consensus of opinion among experts is that further studies, research, or clinical investigations are necessary to determine maximum tolerated dosages, toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; vi. credible scientific evidence shows that such evaluation, treatment, therapy, or device has not been proven safe and effective for treatment of the Condition in question, as evidenced in the most recently published medical literature in the United States, Canada, or Great Britain, using generally accepted scientific, medical, or public health methodologies or statistical practices. b. Credible scientific evidence is defined by AvMed as one of the following: i. records maintained by Physicians or Hospitals rendering care or treatment to the Member or other patients with the same or similar Condition; ii. reports, articles, or written assessments in authoritative medical and scientific literature published in the United States, Canada, or Great Britain; iii. published reports, articles, or other literature of the United States Department of Health and Human Services or the United States Public Health Service, including any of the National Institutes of Health, or the United States Office of Technology Assessment; iv. the written protocol or protocols relied upon by the Attending Physician or institution or the protocols of another Physician or institution studying substantially the same evaluation, treatment, therapy, or device;AV-IN-COC-22 6 Empower-IN-1536 (01/22) v. the written informed consent used by the Attending Physician or institution or by another Physician or institution studying substantially the same evaluation, treatment, therapy, or device; or vi. the records (including any reports) of any institutional review board of any institution which has reviewed the evaluation, treatment, therapy, or device for the Condition in question.2.31 Full-Time Student or Part-Time Student means one who is attending a recognized and accredited college, university, vocational or secondary school and is carrying sufficient credits to qualify as a Full-Time or Part-Time Student in accordance with the requirements of the school.2.32 Habilitation Services are services that help a person keep, learn or improve skills and functioning for daily living. Such services may be provided in order for a person to attain and maintain a skill or function never learned or acquired due to a disabling Condition. They are services that are deemed necessary to meet the needs of individuals with developmental disabilities in programs designed to achieve objectives of improved health, welfare and the realization of individuals’ maximum physical, social, psychological and vocational potential for useful and productive activities.2.33 Health Care Providers means Health Professionals and includes institutional providers, such as Hospitals, Medical Offices or Other Health Care Facilities that are engaged in the delivery of Health Care Services and are licensed and practice under an institutional license or other authority consistent with state law.2.34 Health Care Services (except as limited or excluded by this Contract) means the services of Health Professionals, including medical, surgical, diagnostic, therapeutic and preventive services that are: a. generally and customarily provided in the Service Area; b. performed, prescribed or directed by Health Professionals acting within the scope of their licenses; and c. Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness.2.35 Health Professionals means allopathic and osteopathic Physicians, podiatrists, chiropractors, physician assistants, nurses, licensed clinical social workers, pharmacists, optometrists, nutritionists, occupational therapists, physical therapists, certified nurse midwives and midwives, and other professionals engaged in the delivery of Health Care Services, who are appropriately licensed under applicable state law.2.36 Home Health Care Services (Skilled Home Health Care) means Physician-directed professional, technical and related medical and personal care services provided on an intermittent or part-time basis directly by (or indirectly through) a home health agency in your home or residence. Such services include professional visiting nurses or other Health Professionals for services covered under this Contract. For purposes of this definition, a Hospital, Skilled Nursing Facility, nursing home or other facility will not be considered a home or residence.2.37 Hospice means a public agency or private organization licensed pursuant to Chapter 400, Florida Statutes (or if outside Florida, applicable state law), to provide Hospice services. Such licensed entity must be principally engaged in providing pain relief, symptom management, and supportive services to terminally ill Members and their families.2.38 Hospital means a facility licensed pursuant to Chapter 395, Florida Statutes (or if outside Florida, applicable state law), that offers services which are more intensive than those required for room, board, personal services and general nursing care; offers facilities and beds for use beyond 24 hours; and regularly makes available at least clinical laboratory services, diagnostic x-ray services and treatment facilities for surgery or obstetrical care or other definitive medical treatment of similar extent. a. The term Hospital does not include an Ambulatory Surgery Center; Skilled Nursing Facility; stand- alone Birthing Center; convalescent, rest or nursing home; or facility which primarily provides Custodial, educational or rehabilitative therapies.AV-IN-COC-22 7 Empower-IN-1536 (01/22) b. If services specifically for the treatment of a physical disability are provided in a licensed Hospital which is accredited by The Joint Commission, the American Osteopathic Association or the Commission on the Accreditation of Rehabilitative Facilities, payment for these services will not be denied solely because such Hospital lacks major surgical facilities and is primarily of a rehabilitative nature. Recognition of these facilities does not expand the scope of Covered Services. It only expands the setting where Covered Services can be performed for coverage purposes.2.39 Hospital-owned or affiliated means under common ownership, licensure or control of a Hospital. As may be noted in your Schedule of Benefits, the cost-sharing for some services can vary depending on whether or not they are obtained at a Hospital-owned or Hospital-affiliated facility. Also see Independent Facility below.2.40 Identification Card means the cards AvMed issues to Members. The card is our property and is not transferable to another person. Possession of such card in no way verifies that a particular individual is eligible for, or covered under, this Contract.2.41 Independent Facility means a facility not under common ownership, licensure or control of a Hospital. The cost-sharing for some services may vary depending on whether or not they are obtained at an Independent Facility.2.42 Injectable Medication means a medication that is approved by the U.S. Food and Drug Administration (FDA) for administration by one or more of the following routes: intra-articular, intracavernous, intramuscular, intraocular, intrathecal, intravenous or subcutaneous injection; or intravenous infusion. Medications intended to be injected or infused by a Health Professional are generally covered as a medical benefit. Prior Authorization may be required for Injectable Medications.2.43 In-Network Provider means any Health Care Provider with whom AvMed has contracted or made arrangements to render the Covered Benefits and Covered Services described in this Contract to AvMed Empower Plan Members. For a listing of In-Network Providers, please refer to your AvMed Empower Plan Provider Directory 

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