The Chesapeake Life Insurance Company

Transcription

1 The Chesapeake Life Insurance Company SM Supplemental Dental and Vision Insurance Plans CH DV 1110_1110 R

2 Table of Contents Dental Insurance Plans...1 Dental Exclusions and Limitations...2 Vision Plan: Exams and Eyewear...4 Vision Exclusions and Limitations...6 Other Important Information...7 State Variations...8 This brochure provides only summary information and the benefits may vary by state. The information contained herein is accurate at the time of print. These plans are not intended as a replacement for accident and sickness health insurance and should not be construed as such. For a complete listing of benefits, exclusions and limitations, please refer to your Policy. In the event of any discrepancies contained in this brochure, the terms and conditions contained in the Policy documents shall govern. ii CH DV 1110

3 Dental Insurance Plans * The Chesapeake Life Insurance Company is committed to providing dental coverage that fits your needs. Our three dental plans provide a range of coverage and services, plus additional savings when you use a participating dental service provider from CAREINGTON's Maximum Care TM Network. Value and Flexibility: Your Maximum Care Advantages Chesapeake offers flexible dental plans that provide benefits on a scheduled basis and allow you to choose your own dentist. However, for optimum value, our plans also include access to savings for all dental procedures when you use any one of over 135,000 Maximum Care dental care access points nationwide. ~ Save an average of 15% to 60% on most dental procedures ~ Orthodontics savings of 5% to 20% for both children and adults ~ In-network cosmetic procedures receive a 5% to 20% savings with no waiting period Core Five Solutions, a CAREINGTON International Company (CAREINGTON) administers the dental insurance plans on behalf of Chesapeake through their extensive Maximum Care Network. Refer to your dental Policy, upon receipt, for details, exclusions and limitations. To get started, follow these simple steps: 1) Locate a Maximum Care provider near you (Mon. Fri., 7AM 7PM CST) dental.chesapeakeplus.com 2) Schedule an appointment with a participating provider and present your ID card which includes the Maximum Care logo. Your Maximum Care provider does the rest * This program is administered by Core Five Solutions, 7400 Gaylord Pkwy., Frisco, TX 74034, and has no liability for providing or guaranteeing service or the quality of service. DENTAL INSURANCE OPTIONS GOLD Diagnosis Category Preventive/Diagnostic (No deductible for preventive and diagnostics and no waiting period for most services) Basic Restorative Major Restorative Orthodontia (Adolescent and Adult) Deductible Annual Maximum SILVER Diagnosis Category Preventive/Diagnostic (No deductible for preventive and diagnostics and no waiting period for most services) Basic Restorative Major Restorative Orthodontia (Adolescent and Adult) Deductible Annual Maximum BRONZE Diagnosis Category Preventive/Diagnostic (No deductible for preventive and diagnostics and no waiting period for most services) Basic Restorative Major Restorative Orthodontia (Adolescent and Adult) Deductible Annual Maximum Package Benefit Covered Benefits $1,200 Lifetime maximum ($50/Month maximum reimbursement) $100 Lifetime per person $1,200 per person (excludes orthodontics) Package Benefit Covered Benefits In-Network Discount Only $100 Calendar year, per person $1,000 per person Package Benefit Covered Benefit In-Network Discount Only All insurance benefits are subject to the scheduled benefit amounts, deductible, benefit maximums, waiting periods, and exclusions and limitations. If more than one type of service can be used to treat a condition, we have the right to base benefits on the least expensive service that is within the range of professionally adequate standards of dental practice. Procedure fees will not be reduced for any dental provider who is not in the network. CH DV

4 Dental Exclusions and Limitations (May vary by state) Choose your own dentist from thousands of participating providers nationwide We will not provide any benefits for any loss caused by or resulting from: Any portion of a charge for any service not listed as a covered expense in the Policy schedule/schedule of benefits Care, treatment, services or supplies that exceed the scheduled benefit amount Treatment of disturbances of the temporomandibular joint (TMJ) A service not furnished by a dentist, unless by a dental hygienist under the dentist s supervision and x-rays ordered by the dentist Cosmetic procedures, unless due to an injury or for congenital or developmental malformation. Facing on crowns, or pontics, posterior to the second bicuspid is considered cosmetic The replacement of full and partial dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function Implants, replacement of lost or stolen appliances, replacement of orthodontic retainers, athletic mouthguards, precision or semi-precision attachments, denture duplication, or splinting Plaque control, completion of claim forms; broken appointments, prescription or take-home fluoride, or diagnostic photographs Replacement of any prosthetic appliance, crown, inlay, or onlay restoration, or fixed bridge within five years of the date of the last replacement, unless due to an injury An initial placement of a partial or full removable denture or fixed bridge work if it involves the replacement of one or more natural teeth lost before coverage was effective under the Policy. This limitation does not apply if replacement includes a natural tooth extracted while covered under the Policy Services not completed by the end of the month in which coverage terminates Procedures that are begun, but not completed Those services for which there would be no charge in the absence of insurance or for any service or treatment provided without charge Services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the Armed Forces of any country or combination of countries Care or treatment of a condition for which benefits are payable under any Workers Compensation Act or similar law Charges that are applied toward the satisfaction of a deductible, if any (does not apply to Bronze Plan) Orthodontic procedures (does not apply to Gold Plan) Covered expenses for which an insured person is not legally obligated to pay The Dental Insurance Plans above are underwritten by The Chesapeake Life Insurance Company. Form CH IP (1/08), or its state variation. 2 CH DV 1110

5 Save on eye care and eyewear at thousands of participating providers nationwide CH DV

6 Vision Plan: Exams and Eyewear * Chesapeake understands that regular scheduled eye examinations play a crucial role in ensuring healthy vision and overall good health. By offering the vision plan with EyeMed Vision Care's Select Network, you save on both eye care and eyewear needs. You benefit from lower out-ofpocket costs on routine eye examinations and materials. It s easy and convenient! Save on eye care and eyewear at thousands of participating providers nationwide. The chart in the following column is a brief overview of your covered benefit plan and additional savings. You have the ability to choose from thousands of independent and optical retail providers nationwide. EyeMed Vision Care providers are located in many large retail stores such as JCPenney, Target, Sears, LensCrafters, Pearle Vision and other independent private practitioners. To locate a provider, follow these simple steps: 1) Call Eyemed Vision Care direct at (Mon.-Sat., 8AM-11PM; Sun., 11AM-8PM) 2) Log on to ~Locate a Provider ~In the drop box, choose the Select network ~Enter your zip code, then you will see a listing of providers near you or NETWORK EYE EXAMS 100% NON-NETWORK EYE EXAMS 100% up to $30 Comprehensive eye examination including dilation, as necessary. (Limited to one exam per 12-month period with option to purchase eyeglasses or contact lenses. Any other procedures are the responsibility of the member.) LENSES OVERVIEW Lenses Services Single, Bifocal, Trifocal Vision Lenses Member Cost (When using a network provider) $0 copay Standard uncoated plastic lenses are covered at 100% once every 12 months at participating EyeMed Vision Care's Select Network of providers. This includes single, bifocal or trifocal lenses. (Contact lenses are available in lieu of eyeglasses every 12 months.) Contact Lenses Non-Disposable $0 up to $40 15% off balance over $40 Disposable $0 up to $40 Therapeutic $0 Standard contact lens fitting Spherical clear contact lenses in conventional wear and planned replacement (examples include but not limited to disposable, frequent replacement, etc.). Premium contact lens fitting all lens designs, supplies, and specialty fittings other than standard contact lenses (examples include toric, multifocal, etc.). Contact lens examinations require additional fees. * The savings program is administered by EyeMed Vision Care, 4000 Luxottica Place, Mason, OH 45040, and has no liability for providing or guaranteeing service or the quality of service. 4 CH DV 1110

7 Vision Plan: Exams and Eyewear (continued) ADDITIONAL SAVINGS PROVIDED BY EYEMED VISION CARE EyeMed Vision Care Select Network saves you money on all of your eye care and eyewear needs. From frames and lens options to nonprescription glasses and sunglasses, members and their families never have to pay full price with the discounts provided by this vision plan. Best of all, members can use these benefits as often as you like at any participating provider location. It is one more way that Chesapeake and EyeMed promotes vision wellness for our members. ADDITIONAL SAVINGS 1 Frames Services Member Cost 60% of retail Standard Polycarbonate $40 Standard Scratch-Resistance $15 Tints (Solid and Gradient) $15 Standard Progressive Lenses $65 UV Coating $15 Standard Anti-Reflective $45 Other Lens Options Nonprescription glasses and sunglasses Services LASIK or PRK Vision Correction 80% of retail 80% of retail Member Cost 15% off retail or 5% off promotional price 1 EyeMed is a discount program only and not insurance. This program provides discounts only at certain contracted providers. You are obligated to pay all health care fees at the time of service, but will receive a discount from those providers who have contracted with the discount plan organization. The program does not make payments directly to the providers of medical services. Members will receive a 20% discount on remaining balance at participating providers beyond plan coverage, which may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed s Providers professional services or contact lenses. Discounts do not apply for benefits provided by other group benefit plans. Allowances are a one-time use benefit; no remaining balance. Broken materials are not covered. Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the insurance benefit has been used. Initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at Contact lens benefit allowance is not applicable to this service. CH DV

8 Vision Exclusions and Limitations (May vary by state) Regular eye exams play a crucial role in ensuring healthy vision Benefits will not be provided under the Policy for expenses associated with the following: Orthoptic or vision training and any associated supplemental testing Plano lenses Lens coating Two pair of glasses, in lieu of bifocals or trifocals Medical or surgical treatment of the eyes Any type of corrective vision surgery, including LASIK surgery Any eye examination, or any corrective eyewear, required by an employer as a condition of employment Any services or supplies when paid under any Workers Compensation or similar law No-line bifocal or progressive lenses Photochromic, transition, or polycarbonate lenses Lenticular lenses Sub-normal vision aids or non-prescription lenses Services rendered or supplies purchased outside the U.S. or Canada, unless the insured person resides in the U.S. or Canada and the charges are incurred while on a business or pleasure trip Eyeglasses when the change in prescription is less than.5 Diopter Experimental or investigational or non-conventional treatment or device Eyeglass lens treatments, including add-ons, UV coating, anti-reflective coating, scratch resistant coating, tinting, edge polishing Oversized lenses High index lenses of any material type Fitting for contact lenses Follow-up visits Frames for corrective spectacle lenses Charges incurred after the Policy has terminated or coverage has ended The Vision Benefit Program benefits above are underwritten by The Chesapeake Life Insurance Company. Form CH IP (05/07), or its state variation. Benefits subject to change without notice. EyeMed Exclusions & Limitations Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing Aniseikonic lenses Medical and/or surgical treatment of the eye, eyes or supporting structures Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan Services provided as a result of any Workers Compensation Law Plano nonprescription lenses and nonprescription sunglasses (except for 20% discount) Services or materials provided by any other group benefit providing for vision care Two pair of glasses in lieu of bifocals or trifocals 6 CH DV 1110

9 Other Important Information Renewability Your Policy is guaranteed renewable up to age 65, subject to Chesapeake s right to discontinue or terminate coverage as provided in the termination of coverage section of the Policy. Premium Changes Chesapeake reserves the right to change the table of premiums, on a class basis, becoming due under the plan at any time and from time to time, provided Chesapeake has given the Policyholder written notice of at least 31 days prior to the effective date of the new rates. The premium may also change due to an increase in the attained age of the insured person. Your Policy is guaranteed renewable up to age 65 Termination of Coverage Your coverage will terminate and no benefits will be paid under the Policy or any attached riders: At the end of the period for which premium has been paid If your mode of premium is monthly, at the end of the period through which premium has been paid following our receipt of your request of termination If your mode of premium is other than monthly, upon the next monthly anniversary day following our receipt of your request of termination. Premium will be refunded for any amounts paid beyond the termination date On the date of fraud or misrepresentation by you On the date we elect to discontinue this plan or type of coverage On the date we elect to discontinue all coverage in your state On the date an insured person is no longer a permanent resident of the United States or On the date you reach the age of 65, (or become eligible for Medicare, whichever comes first, applies to Vision plan only). Covered Dependents: Your covered dependent s coverage will terminate under the Policy on: The date your coverage terminates The date such dependent ceases to be an eligible dependent or The date we receive your written request to terminate a covered dependent s coverage. CH DV

10 State Variations The information provided below summarizes the major variations in coverage by state from those described in this brochure. The exclusions and limitations of the Policy also apply. Please refer to your Policy, upon receipt, for complete details. ARKANSAS: For Vision - Non-network lenses are covered at 75%:, and non-network contact lenses are covered at 100% up to $30 for nondisposable and disposable, and 75% for therapeutic. COLORADO: For Vision - The Termination of Coverage is revised to read: Your coverage will terminate and no benefits will be payable under the Policy and any attached riders: Due to non-payment of the required premium If your mode of premium is monthly, at the end of the period through which premium has been paid following our receipt of your request of termination If your mode of premium is other than monthly, upon the next monthly anniversary day following our receipt of your request of termination. Premium will be refunded for any amounts paid beyond the termination date Due to fraud or misrepresentation of material fact by you If we elect to discontinue offering and non-renew all coverage in Colorado. In such case we will provide notice of the decision to discontinue or not to renew coverage to all policyholders and covered persons and to the Insurance Commissioner in each state in which an affected individual is known to reside at least 180 days prior to the discontinuance or non-renewal of the plan by us. We will also discontinue and nonrenew all of our individual plans in Colorado. We will provide notice to the Insurance Commissioner under this paragraph at least three working days prior to the notice to the affected individuals. If we discontinue coverage completely from a market segment and otherwise remain in the market, we will continue to provide coverage through the first renewal period not to exceed 12 months after the notice described in the preceding paragraph has expired If the Insurance Commissioner finds that the continuation of the coverage would not be in the best interest of the policyholders, the plan is obsolete, or would impair our ability to meet our obligations. Once the Insurance Commissioner has made such a finding, we will provide notice to each covered individual provided coverage of this type of such discontinuation at least 90 days prior to the date of discontinuation and will provide each affected covered individual the opportunity to purchase any other individual vision plan being offered by us. In exercising this option, we will act uniformly without regard to any health status related factor of the enrolled individual or individuals who may become eligible for such coverage, or On the date you reach the age of 65, or become eligible for Medicare, whichever comes first. CONNECTICUT: For Vision - Non-network comprehensive eye exams are covered at 50%; non-network lenses are covered at 50%; and non-network contact lenses are covered at 50% up to $40 for disposable and non-disposable, and 50% for therapeutic. Under the Termination of Coverage section, provision 4 is revised to read: "On the date of fraud on a claim, or on the date of any misrepresentation by you (subject to the Incontestability provision)." ILLINOIS: For Dental - The plan is not available. For Vision - Non-network single vision lenses are covered at 50% up to $25; non-network bifocal lenses are covered at 50% up to $40; nonnetwork trifocal lenses are covered at 50% up to $55; and non-network contact lenses are covered at 50% up to $20 for non-disposable and disposable, and 50% for therapeutic. LOUISIANA: For Both Plans - Under the Premium Changes section, "31 days" is revised to "45 days," and the following is added: "Such rates will not increase more than once each six-month period, following the initial twelve-month period." The Termination of Coverage section is deleted and replaced with: "We may non-renew or discontinue your insurance coverage only on one or more of the following: You have failed to pay premiums or contributions in accordance with the terms of the insurance coverage or we have not received timely premium payments You have performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of coverage We are ceasing to offer this type of coverage in the individual market. In such event, we will: a) provide notice to each covered individual provided coverage of this type in such market of such discontinuation at least 90 days prior to the date of the discontinuation of such coverage b) offer to each individual in the individual market provided coverage of this type, the option to purchase any other individual insurance coverage currently being offered by us for individuals in such market c) in exercising the option to discontinue coverage of this type, and in offering the option to purchase any other insurance coverage currently being offered by us for individuals in such market, we will not consider any health status-related factor of enrolled individuals or individuals who may become eligible for such coverage d) prior to providing the notice required of ceasing to offer such insurance product to covered individuals, we will file notice and the product being discontinued with the Commissioner of Insurance We are ceasing to elect to discontinue all health insurance coverage in the individual market in this state. In such event, we will: a) provide notice to the applicable state authority and to each individual of such discontinuation at least 180 days prior to the date of the expiration of such coverage b) discontinue all health insurance issued in the state of such market and the insurance coverage in such market will not be renewed c) prior to providing the 180 days notice of our intent to discontinue all health insurance coverage in the individual market, we will file such notice and such insurance products with the Commissioner of Insurance d) in the case of our discontinuance of insurance products in the individual market, will not provide for the issuance of any health insurance coverage in this market and this state during the five year period beginning from the date of the discontinuance of the last health insurance coverage not renewed or Upon attainment of age 65 (or become eligible for Medicare, whichever comes first; applies to Vision only). MISSISSIPPI: For Both Plans - The Premium Changes section is revised by changing 31 days to 60 days. NEW MEXICO: For Vision - The Premium Changes section is revised by changing 31 days to 60 days. 8 CH DV 1110

11 State Variations (Continued) NORTH CAROLINA: For Dental and Vision - Under the Termination of Coverage section, provisions #5-6 have the following added: we will provide you with a 180 day notice in the event we terminate this plan. The Premium Changes section is revised to read: We reserve the right to change the table of premiums, on a class basis, becoming due under the Policy not more frequently than once in any 12 month period, provided we have given you written notice of at least 45 days prior to the effective date of the new rates and the new rates are approved by the North Carolina Department of Insurance. Such change will be on a class basis. For Dental - Under the Termination of Coverage section, provision #4 is deleted entirely. Under the Exclusions and Limitations section, exclusion #15 is revised to read: services or supplies for the treatment of an occupational injury or sickness which are paid under the North Carolina Workers Compensation Act only to the extent that such services or supplies are the liability of the employee, employer or workers compensation insurance carrier according to a final adjudication under the North Carolina Workers Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreements under the North Carolina Workers Compensation Act, and exclusion #17 is revised to read: orthodontic procedures unless in association with congenital defects or anomalies for covered dependent newborn children. For Vision - Non-network eye exams and lenses are covered at 70%; non-network contact lenses are covered at 70% up to $30 for disposable and non-disposable, and 70% for therapeutic. Under the Termination of Coverage section, provision #1 is revised by adding "grace" before "period" and "not" before "been paid," and provision #4 is revised by deleting "fraud or." Under the Exclusions and Limitations section, exclusion #8 is revised to read: "Any injury or sickness arising out of, or in the course of, employment for wage or profit, for which benefits are paid under the Worker's Compensation Act, Occupational Disease Act, or similar act or law and if determined by a final adjudication of the claim, the employee, employer or Workers Compensation Carrier under such article or by an order of the North Carolina Industrial Commission, is liable/responsible for such changes, unless the insured is self-employed.". OHIO: For Vision - Non-network lenses are covered at 50% and nonnetwork contact lenses are covered 100% up to $20 for disposable, nondisposable and 50% for therapeutic. TENNESSEE: For Dental - Under the Exclusions and Limitations section, exclusion #11 is revised to read: services not completed in accordance with the termination of coverage provisions. For Vision - The Premium Changes section is revised to read The premium for this Policy may change in amount by reason of an increase in the attained age of the insured person. WISCONSIN: For Both Plans - The Premium Changes section is revised by changing 31 days to 60 days. NO STATE VARIATIONS: Alabama, Alaska, Arizona, District of Columbia, Indiana, Iowa, Michigan, Missouri, Nebraska and Wyoming Supplemental Dental and Vision Plans offer the additional coverage your family needs CH DV

12 The Chesapeake Life Insurance Company The Chesapeake Life Insurance Company CH DV 1110_1110 R