18 1. “ Adverse Benefit Determination ” means a total or partial denial of a C laim. For a Non - Grandfathered Plan, a retroactive rescission of coverage due to fraud or misrepresentation shall be treated as an Adverse Benefit Determination . 2. “Appeal” means a c laimant’s written request for review of an Adverse Benefit Determination in accordance with the Appeal Section below . 3. “Claim” means any request for a benefit under a Welfare Benefit P rogram, made by a c laimant or representative that complies with the reasonable procedures for making benefit c laims under such Benefit P rogram. 4. “ Concurrent Care Claim” means a c laim for an ongoing course of treatment to be provided over a period of time or number of treatments. Any reduction or termination by a Benefit P rogram of the course of treatment (other than by plan amendment or termination) before the end of the period of time or number of treatments origin ally approved is considered an Adverse Benefit Determination . 5. “Final Adverse Benefit Determination” means an Adverse Benefit Determination issued in connection with the last stage of Appeal as set forth in the Appeal Section below . 6. “Non - Gran dfathered Plan” means a Welfare Benefit P rogram that is (1) subject to Title I of the Patient Protection and Affordable Care Act of 2010, as amended, and (2) does not meet the requirements for “grandfathered status” within the meaning of that Act. 7. “Post - Service Claim” means any Claim that is not a Pre - Service Claim, an Urgent Care Claim or a Concurrent Care Claim . 8. “ Pre - Service Claim ” means any claim for a benefit under a Health Benefit P rogr am that conditions receipt of the benefit, in whole or in part, on approval in advance of obtaining medical care. 9. “Urgent Care Claim ” means a special type of Pre - Service Claim for medical care or treatment with respect to which the time frame for a non - urgent care determination could seriously jeopar dize the life or health of the c laimant; or the ability of the c laimant to regain maximum function; or in the opinion of the attending or consultin g physician, would subject the c laimant to severe pain that could not be adequately managed without the care or treatm ent that is the subject of the c laim. A physician wit h knowledge of the c laimant’s medica l conditi on may determine if a C laim is one involving urgent c are. If there is no such physician, an individual acting on behalf of the Health Benefit P rogram applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine may make the determination.