Serious Medical Condition Definition

A serious medical condition is defined as an illness, in the opinion of MyCare’s medical director, that:

  • requires inpatient care in a hospital or other medical facility; or
  • if left untreated is likely to result in significant deterioration of health, permanent disability or death; or
  • requires a major orthopedic procedure.


Disability: A severe and prolonged impairment in physical or mental functions.

Hospital: A healthcare facility providing patient treatment with specialized medical and nursing staff and equipment.

Illness: Any unexpected and unforeseen condition or disease manifesting itself while the MyCare program is in force.

Inpatient: A person who is admitted to a hospital upon the recommendation of MyCare’s medical director as a patient for more than 15 consecutive hours and who receives medical treatment.

Major orthopedic: Procedures concerning bone and joint replacement and serious spine procedures.

Sickness: Any unexpected and unforeseen illness or disease manifesting itself while this plan is in force as to the member and which causes the plan member to incur medical expenses.

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