GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM

Transcription

1 Academy of Nutrition and Dietetics GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM AGP-5177 E (Please make any corrections to your full name and address printed below.) TO ENROLL: Send this completed form to with your premium check payable to: ADMINISTRATOR ACDEMY GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA Name: Last First MI Add 1: QUESTIONS? Call: customerservice.service@mercer.com Add 2: City, St., Zip: Hartford Life Insurance Company Hartford, CT Member Information Phone Numbers: Home Work Address Date of Birth (MM/DD/YYYY) Sex q M q F Coverage Selection: q Member Only q Member & Spouse/Domestic Partner q Member, Spouse & Children q Member & Children Daily Benefit Selection: Member/Spouse or Domestic Partner q $165 q $154 q $143 q $132 q $121 q $110 q $99 q $88 q $77 q $66 q $55 Children q $110 q $99 q $88 q $77 q $66 q $55 When the member attains age 65, coverage reduces to a $55 per day plan. 65 And Over Selection: Member/Spouse or Domestic Partner q $55-Per-Day Plan Payment Option Selection: q Automatic Monthly Check Withdrawal q Semi-Annual Direct Bill (If you select Automatic Check Withdrawal, please complete the Automatic Monthly Check Withdrawal Request form.) The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life Insurance Company. BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE /31038/ 1018/52247

2 Please complete if insuring family members Name Birth Date Spouse/Domestic Partner Child Child Child I hereby certify that the above statements are complete and true to the best of my knowledge. I understand that the insurance applied for, when combined with all other Hospital Income Insurance in force for me may not exceed $250 per day in total benefits and that benefits under this group policy will be reduced by the excess and premiums paid for the excess will be returned. I understand that this insurance shall become effective on the date specified by the Hartford Insurance Company and only if I or my dependents are not disabled, in the Hospital, or unable to engage in all the normal activities of a person in good health and of the same age and sex. I understand that this program will not cover Pre-Existing Conditions (conditions for which I received medical advice or treatment within 12 months of this coverage) until 12 treatment free months have passed (ending on or after my effective date) or until the coverage has been in effect for 2 years. I attest that I am covered under a health benefits plan, contract or policy (also known as a "primary healthcare plan"), which satisfies minimum essential coverage of the Affordable Care Act. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. Member's Signature Date Underwritten by: Hartford Life Insurance Company Hartford, CT Hospital Indemnity Form Series includes SRP-1151, or state equivalent. Policy Number AGP-5177 HI648E April

3 Domestic Partnership Affidavit Name of Applicant Name of Domestic Partner The undersigned member and domestic partner, being of sound mind, hereby state the following: 1. That the undersigned member and domestic partner have an exclusive mutual commitment to share responsibility for each other s welfare and financial obligations and that this commitment is of at least six months duration and is expected to continue indefinitely. 2. That the undersigned member and domestic partner share a single permanent residence (attach one copy of evidence such as driver s license). 3. That the undersigned member and domestic partner are financially interdependent as demonstrated by at least two of the following (check all that apply and attach copy of evidence): q Common ownership of a motor vehicle. q Joint bank or credit accounts. q Assignment of durable power of attorney in favor of one another. q Common ownership of real estate or common leasehold interest in property. q Joint ownership or holding of stocks, bonds, or other investments. q Execution of will naming each other as executor and/or beneficiary. q Designation as beneficiary under the other s retirement or pension benefits account. 4. That the undersigned member and domestic partner (check one): q have filed a domestic partner declaration with the (City/Council/Borough) of and that such domestic partner declaration remains in effect (attach copy of declaration). q do not reside in a jurisdiction which provides for the registration of domestic partnership declarations. 5. That neither the undersigned member nor domestic partner would be able to affirm questions 1 through 4 above with respect to any person except the other. 6. That neither the undersigned member nor domestic partner has executed or filed a declaration or affidavit of domestic partner status with any other person within the past 12 months. 7. That the undersigned member and domestic partner are each no less than 18 years of age, and are under no legal disability which would prevent them from making this affidavit. 8. That neither the undersigned member nor domestic partner are now, or have been within the past six months, married to any other person, including common law marriage. 9. That the undersigned member and domestic partner are not related by blood in any degree which would prevent their marriage to each other. The undersigned member and domestic partner represent that the statements made herein are true and correct to the best of their knowledge, information and belief. Member and domestic partner understand that these statements are given for the purpose of establishing their eligibility and understand that any misrepresentation, whether or not made with intent to deceive, may result in the ineligibility of the domestic partner for coverage under such policy, and in the voiding of such coverage. The member and domestic partner agree to furnish upon the Company s request evidence to substantiate any statement made herein, and that the Company may require the member and/or domestic partner, if living, to reaffirm all statements made herein periodically and/or when a claim is submitted. In the event any coverage is voided due to any misrepresentation herein, the Company s liability shall be limited to a return of any premiums paid on behalf of the domestic partner for any period of ineligibility. Applicant s Signature Date Domestic Partner s Signature Date

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5 Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits This is not Medicare Supplement Insurance This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice other approved items and services. BEFORE YOU BUY THIS INSURANCE Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement Insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program. Form PA-9055 Printed in U.S.A.

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7 AUTOMATIC CHECK WITHDRAWAL REQUEST: By selecting Automatic Check Withdrawal, your premium will automatically be withdrawn from your checking account. Please provide the information requested below. Checking Account Routing #: Account #: I request that you pay and charge my account debits drawn from my account by the Plan Administrator to its order. This authorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fully protected in honoring any such debits. I also agree that you may, at any time, end this agreement by giving 30 days advanced written notice to me and to the Plan Administrator. You are to treat such debit as if it were signed by me. If you dishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance. Signature of Premium Payer: Date:

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9 P HOSPITAL INCOME INSURANCE PLAN For ACDEMY Members and Their Families Acceptance Guaranteed* The cost of specialized services has, in general, risen steeply in the past ten years... especially in the medical field. As innovations are constantly developed and past procedures improved, medical expenses steadily increase. This is why the Hospital Income Insurance Plan is being made available to you. This Plan is designed to give you a benefit for an unexpected Hospital stay. Pays benefits up to $165** for each day you are Hospitalized. Pays DOUBLE BENEFITS for covered Confinements in an Intensive Care or Coronary Care Unit. Benefits paid directly to you or you may assign benefits to be paid directly to the Hospital or any other health care facility in which you receive care. Enrolling is simple... just complete the short Enrollment Form and drop it in the mail. Your acceptance is guaranteed*! Pays for every day of Hospitalization up to one full year. Pays directly to you with no restrictions on how you spend your money. A DAILY BENEFIT PAID FOR A MAXIMUM OF ONE FULL YEAR The Hospital Income Insurance Plan pays a daily benefit when you are Hospitalized due to a covered Sickness or Injury. You could receive up to $165 maximum every day you are Hospitalized for up to one full year. YOUR CHOICE OF COVERAGE Daily benefits of $55 to $165 are available to members and spouses or domestic partners in units of $11. Unmarried dependent children can be insured for $55 to $110 each... one premium covers all your children. ** If you're age 65 and over, the benefit amount reduces to $55 per day for yourself, your spouse, and applicable children. Note: The insurance applied for, when combined with all other Hospital Income Insurance you may have in force, may not exceed $250 per day in total benefits paid. Benefits under this Group Policy will be reduced by the excess amount, and premiums paid for the excess amount will be returned. NO WAITING PERIOD Benefits start on the first day of a covered Hospitalization and can continue for up to 365 days subject to the Pre-Existing Conditions Limitation. INTENSIVE CARE TREATMENT If you are Confined in an Intensive Care Unit (or Coronary Unit) before age 65, your daily benefit doubles. Under the $165-Per-Day Plan you would receive $330. Under the $110-Per-Day Plan, you would receive $220. CONVALESCENT HOME BENEFITS If your recuperation from the Sickness or Injury from which you were Hospital Confined requires convalescent home care before age 65, you would be eligible to receive one half of your daily benefit for as long as 365 days if the Maximum Payment Period has not been exhausted. Confinement must begin within 7 days following a covered Hospitalization. CONFINEMENT Confined or Confinement means being an Inpatient in a Hospital due to a covered Sickness or Injury. If successive confinements due to the same or related causes are separated by less than 180 days, the remaining benefits under the Period of Confinement will be available. If a claim results from a new Sickness or Injury, or occurs more than 90 days after Hospital Confinement, it will be treated as a new Period of Confinement. HOW DO I FILE A CLAIM? You simply request a claim form from the Insurance Administrator. You and your doctor complete the form stating why and how long you were Hospitalized. Return the form to the Insurance Administrator and they will expedite your claim for payment. Remember: if you are Confined to Intensive Care before age 65, your benefit doubles! GUARANTEE OF SATISFACTION If you are not fully satisfied with the terms of your new coverage, simply return your Certificate of Insurance to the Insurance Administrator within 30 days. Your premium will be completely refunded, minus any claims paid, with no further obligation. Your satisfaction is guaranteed 100%. 1

10 WHO MAY ENROLL Members and spouses or domestic partners under age 65 can choose up to $165 per day in benefits; those 65 and over may enroll in the $55-Per-Day Plan only. Unmarried dependent children from birth to 21 years of age (25 if a full-time student) qualify for up to $110 per day of coverage. Acceptance is guaranteed* as long as you are not on full-time active military duty. Please contact the Administrator for a Domestic Partner Affidavit. This coverage is available only for residents of the United States excluding AZ, ID, CO, LA, MD, ME, MN, MT, NM, NV, OR, SC, SD, TX, UT, VT, WA and WV. EFFECTIVE DATE Coverage will become effective on the first of the month following receipt of your Enrollment Form and check. If you are Confined for treatment on that date, coverage starts the day following final discharge. How To Calculate Your Cost: All premiums are based on member's age. Multiply the premium listed below by the number of $11 daily units you desire. (Example: For Member Only coverage of $110 per day at age 37, multiply $1.20 x 10 = $12.00.) For direct bill semi-annual rates, multiply this number by 6. Add the additional premiums for spouse and/or children's coverage. $12.00 x 6 = $72.00 = $72.00 Remember all children are covered for one premium. Member's Age MONTHLY PREMIUMS FOR EACH $11 PER DAY UNIT OF COVERAGE Member's Cost Spouse's Cost Child(ren) Cost Under 35 $0.92 $1.29 $ & Over** All premiums, including those for spouse or domestic partner and children, are based on the member's age when insurance becomes effective and on attained age on renewal dates. At the premium due date following the member's 65 th birthday, all coverage converts to a maximum of $55 per day. Note: Maximum children's coverage is $110 per day; dependent's coverage cannot exceed member's coverage. The member must enroll if family members are to be covered. **Members age 65 and over may enroll in the $55-Per Day Plan only. You cannot be singled out for a rate increase because of your health or age. Rates and/or benefits may be changed for all members of your insurance classification only. If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. HOW TO ENROLL 1. Complete the enclosed Enrollment Form. 2. Indicate the Coverage Selection of your choice. If you select Automatic Monthly Check Withdrawal, please include your first month's premium along with a blank voided check. 3. Mail your completed Enrollment Form along with your first monthly or semi-annual premium check (and blank voided check, if applicable) to the Group Insurance Administrator: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA INJURIES AND SICKNESSES which originate after the effective date of your insurance are covered immediately. PRE-EXISTING CONDITIONS LIMITATION During the first two years of coverage, losses incurred for Pre-Existing Conditions are not covered. Pre-Existing Condition means any Injury or Sickness including pregnancy; diagnosed or undiagnosed, for which you have received medical care within the 12-month period prior to your coverage effective date or the date of an increase in coverage. During that time, benefits for all other accidents or illnesses will be paid under the policy provisions. You are urged to consider this limitation before dropping any coverage you may have until the waiting period is over. INDIVIDUAL TERMINATIONS AND REDUCTIONS Your coverage continues regardless of age as long as you remain a member of your Association, pay your premiums when due, do not enter full-time military duty, and the Master Policy remains in force. At age 65, all coverage converts to a maximum of the $55-Per-Day Plan. Dependent coverage ends; for your spouse, the date you become legally separated or divorced, premiums are not paid, your coverage terminates, or for child coverage, the date the covered child no longer qualifies as an Eligible Child, premiums are not paid, your coverage terminates. EXCLUSIONS The Policy does not cover: intentionally self-inflicted injuries, suicide or attempted suicide, whether sane or insane, (in Missouri or Colorado while sane); any loss caused or contributed to by war or act of war, whether war is declared or not; any loss which occurs while the Covered Person is in any of the armed forces, whether land, water or air of any country or international authority; pregnancy or childbirth, except Complications of Pregnancy; Confinement in a Veterans Administration or any other National Government owned or operated Hospital. Hospital does not mean a nursing home, convalescent home, or Skilled Nursing Facility; a place for rest, custodial care, or for the aged; a clinic; a place for the treatment of mental illness, alcoholism, or drug addiction. A place for the treatment of Mental, Nervous or Emotional Disorders will be regarded as a Hospital Benefit is part of an institution that meets the above requirements and it is listed in the American Hospital Association Guide as a general Hospital. 2

11 *This policy is guaranteed acceptance, but it does contain a Pre-Existing Conditions Limitation. Please refer to this brochure for more information on exclusions and limitations, such as Pre-Existing Conditions. HOSPITAL INCOME INSURANCE PLAN Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC Underwritten by: Hartford Life Insurance Company Hartford, CT The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life Insurance Company. This brochure explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. THIS IS A HOSPITAL CONFINEMENT INDEMNITY POLICY. THE POLICY PROVIDES LIMITED BENEFITS. This limited health benefit plan (1) does not constitute major medical coverage, and (2) does not satisfy the individual mandate of the Affordable Care Act (ACA) because the coverage does not meet the requirements of minimum essential coverage. This policy provides limited benefits health insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of Financial Services. Hospital Indemnity Form Series includes SRP-1151, or state equivalent. Policy Number AGP /18 ed. HI648P-31029P Copyright 2018 Mercer LLC. All rights reserved. 3

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