We publish for sharing expenses you incur for providing medical care to your membership household within the guidelines approved by the members or the board of directors (and the dollar and time limits of Sections VI and VII). The approved Guidelines place some limitations on the types of physical maladies and medical services for which we publish needs, and limit the publication of expenses incurred due to injuries from certain listed causes. This Section is designed to allow you to quickly check the physical condition (Part A), the medical services needed (Part B), and the cause thereof if an injury, to confirm whether or not a particular medical expense is publishable. There are a few services and charges that are not published (Parts C & D). Please call your Member Services Team if you have any questions regarding the application of these Guidelines. Also see Section XI regarding Advisory and Binding opinions.

A. Physical Conditions for Which Medical Expenses are Shared
Expenses for all types of physical conditions are generally publishable with special provisions for some conditions as explained below:

1. Back Problems—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

2. Broken Bones—We publish needs for:

a. broken bones, including emergency treatment, office visits, x-rays, setting, casts, operations, and other related medical expenses until two weeks after the last cast, splint or pin is removed

b. breaks not requiring casts or pins for 75 days after the patient is released from the hospital or after the doctor’s initial treatment. For the time limitations for physical therapy related to broken bones see Section VIII:B.

3. Bunions—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve continuous months immediately prior to your membership, or did not exist for at least twelve months since the membership began.

4. Cancer—Publishable unless it is related to cancer of any type you had prior to becoming a member. (Section VII:B)

5. Carpal Tunnel Syndrome—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

6. Complications from maternity—Bills for complications to the mother may be published as a need separate from the maternity need. See Section IX:C:4,5 for details.

7. Complications from Medical Procedures not Shared—If complications arise from a medical procedure that is not publishable (e.g. a routine colonoscopy and most cosmetic surgery see VIII B.), expenses for treating the complications are publishable
unless the procedure that was the cause was not publishable due to moral reasons (e.g. Abortion VIII D.1).

8. Congenital Conditions (i.e. conditions present at birth) are treated as a maternity need for the first six months after birth, and thereafter as a regular need for a child whose mother was a member prior to conception (see Section IX), unless it is a genetic defect or hereditary disease. Genetic Defects and Hereditary Disease(whether always obvious or hidden for some time)—Will be published up to a maximum of $25,000 per condition during the life of the person when both of these criteria are met:

a. The condition may be permanently improved or cured by surgery or other treatment with a determined termination (as opposed to an indefinite length of treatment);

and

b. at least one of these is true:
1) Neither the condition nor a symptom of the condition were discovered until after the patient had been a member for one year;
2) the condition has not required treatment or produced symptoms for at least five years; or
3) the condition exists in a child who has been included in a membership from birth and the mother was included in a membership prior to the pregnancy.
4) If the condition exists in a child who was adopted, the child has been included in a membership since the adoption, and the adopting parents were unaware of the condition at the time the adoption was finalized.

9. Dental Problems—We publish
a. The breaking or injury of natural teeth and caps (but not repairs to dentures or partial plates) by accidents other than when eating and certain motor vehicle accidents. See Section VII:C.

b. Operations on bones in the mouth (not teeth)
c. Life-threatening dental problems. An example would be an allergic reaction to previous dental work materials on a life-threatening level. Publication of bills would be limited to helping with the immediate life-threatening problem only. It would NOT include subsequent routine dental work; Other than the above, we do not publish dental work on the teeth either above or below the surface of the gums, and/or routine dental work such as (but not limited to): cleanings, fillings, crowns, removal of wisdom teeth, dentures, treatment of periodontal disease, etc.

10. Diabetes—Publishable, unless it is related to diabetes of any type you had prior to becoming a member. (Section VII:B)

11. Foot Disorders—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

12. Heart Conditions—Publishable unless related to a heart condition of any type you had prior to becoming a member. See Section VII:B and the high blood pressure exception below.

13. Hemorrhoids—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

14. Hernia—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve months since the membership began. The publication of congenital hernia related expenses is controlled by the Guidelines on congenital defects. See “Congenital Defects” above.

15. High Blood Pressure—Medication for treating a chronic condition is not publishable. As long as you have not been hospitalized for high blood pressure in the past, and you have been able to control this condition through medication or diet, an incident that begins after your membership begins is publishable.

16. Pregnancy/Maternity—See Section IX for the special provisions.

17. Prostate Conditions—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

18. Sexually Transmitted Diseases (STDs)—HIV, AIDS, or other STDs contracted innocently (e.g. blood transfusions or medical procedures) will be published. We do not publish for sexually transmitted diseases, including the HIV virus and/or AIDS, when contracted sexually outside of marriage, or through irresponsible behavior such as sharing hypodermic needles for legal or illegal drugs. It is the member’s responsibility to demonstrate that the disease was contracted innocently.

19. Sleep Apnea—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

20. Temporomandibular Joint Dysfunction—Publishable after your first year of membership if submitted with a statement signed by both member and doctor verifying that symptoms of this condition did not exist for the twelve months immediately prior to your membership, or did not exist for at least twelve continuous months since the membership began.

B. Medical Services and Supplies Expenses Shared
Visits to licensed medical doctors, emergency rooms, hospitals, testing facilities and out patient surgery for conventional treatments for injuries and illnesses are generally publishable. Expenses for services rendered in any part of the world are
publishable as long as the documentation meets the requirements of Section X.L.There are special rules for some services and some services are not publishable as explained below:

1. Alternative Medical Practices (or non conventional treatments)—Non-customary, or non conventional medical treatments, are not published unless the member receives prior written approval from Samaritan Ministries. Approval is based upon factors such as the less invasive nature of the proposed treatment, demonstration that such treatment will prevent more costly conventional treatments, consistency of the treatment with what a medical doctor would prescribe for illness or injury, and the member’s acceptance of appropriate pre-conditions for publishing the expenses. Examples of alternative medical practices are chiropractic and osteopathic treatments.

2. Ambulance—Ambulance transportation to a hospital, or life flights, is published in life-threatening situations only.

3. Audiological—audiological services or tests, including hearing aids or any related examination or fitting, are not published.

4. Chiropractic—All chiropractic services will be treated as an “Alternative Medical Practice”—See above

5. Colonoscopy—Routine colonoscopies, like all routine tests and checkups
(See #21 below) are not published. A colonoscopy will be published when
prescribed due to symptoms for a condition not evident prior to your membership.

6. Cosmetic Surgery—Cosmetic surgery for disfiguration caused by amputation, disease (excluding acne), or an accident not involving a licensed motorized vehicle, and breast reconstruction following a mastectomy is publishable. All other elective cosmetic surgery done primarily for non-health reasons, including breast reduction or enhancement operations, is not publishable. See section VIII.A.7 for cosmetic surgery related to a congenital defect.

7. Dental—See “Dental Problems” (Section VIII:A:8).

8. Fertility—Fertility treatment or testing is not published. 9. Hospitalization—The costs of a hospital room are published, but not for a private room unless (a) all rooms at the facility are private, or (b) a doctor prescribes intensive care or quarantine.

10. Medical Equipment—Purchase or rental of medical equipment (such as hospital beds, oxygen, respirators, special shoes, orthotics, braces, crutches, etc.) only if the member receives prior written approval from Samaritan Ministries by demonstrating that the purchase or rental would result in an overall savings in cost. (For example, allowing for earlier release from the hospital.) 11. Naturopathic—Naturopathic procedures, adjustments, manipulations, ultrasound and similar treatments will be treated as “Alternative Medical Practice”—See above. However, medical treatments provided by a Doctor of Naturopathy that meet all other requirements will be published.

12. Newborn care—See the special Guidelines (Section IX:C).

13. Nutritionists—Services of nutritionists, dietary consultants, or herbalists including education, or educational materials (or the non- prescription products that they may recommend) are not publishable unless the member is hospitalized and the service provider who prescribes the treatment is on the hospital staff.

14. Optical—Optometric services or tests including eyeglasses, contacts, eye refraction, visual therapy, or any related examination or fitting are not published.

15. Organ Transplants—Routine (not experimental) organ transplants, unless a problem was evident prior to membership.

16. Osteopathic—Osteopathic procedures, adjustments, manipulations, ultrasound and similar treatments will be treated as a “Alternative Medical Practice”—See above. However, medical treatments provided by a Doctor of Osteopathy that meet all other requirements will be published.

17. Physical Therapy—Injury related physical therapy is published (a) while the patient is in the hospital for the initial visit, (b) for a period of 45 days from when the patient is released from a hospital or (c) a period of 45 days beginning with the first visit to the physical therapist if you were not hospitalized.

18. Prescriptions—Prescribed medication related to a qualifying medical
condition is published for 60 days from the first prescription. All medication,
prescribed or not, administered during inpatient hospital stays will be
published and does not count toward the 60 day limit. Exceptions: We do
not publish the cost of prescriptions for maintenance of chronic or recurring
conditions (e.g. diabetes, eczema, blood pressure control) beyond a one time 60 day period. Subsequent publication of a prescription for maintenance of the same condition will occur only when there is a new need. (See VI A.4.) We do not publish expenses for psychotropic medications for chemical imbalances that cannot be verified by laboratory tests.

19. Prosthetics—The costs of prosthetics are published except for artificial hair, teeth (except see “Dental Problems” in Section VIII:A), eyes, breasts (except see Cosmetic Surgery), etc.

20. Sterilization—Sterilization such as tubal ligation and vasectomy or the reversal of the same is not published.

21.Tests and Checkups—Tests are publishable only when prescribed by a medical doctor because of symptoms that are evident for a condition that was not evident prior to becoming a member. Routine follow-up tests or checkups after a condition is declared arrested or cured are not published.

22. Transplants—See “Organ Transplants.”

23.Visiting Nurses—Bills for visiting nurses providing medical care ordered by a doctor for 45 days after being released from the hospital are published.

24. Weight Reduction—Weight reduction programs, diet centers, clinics, staples in the stomach, balloons inserted in the stomach, jaw wiring, or any other procedures relating to weight reduction are not publishable.

C. Treatment for Injuries Involving Motorized Vehicles
Most needs for vehicle related injuries are not shared in the basic ministry, but members may choose to share in those needs through a separate optional program, SamaritanMV™ (see page 26). Based on the Guidelines below, some needs for vehicle related injuries may be shared in the basic ministry, depending on the following: the type of vehicle; whether the member was a driver, passenger, or bystander; whether the vehicle and/or driver was licensed; and whether the activity was work-related (not recreational). Bills must be submitted to any responsible or liable party before they will be considered for publication (See Guidelines VI:B).

A “motorized vehicle” is any vehicle with an engine/motor used for transportation, work or recreation. A “licensed” vehicle is one that requires a government issued license to be operated in a public way (e.g. bus, cars, motorcycles, boats, and aircraft).