The Chesapeake Life Insurance Company

Transcription

1 The Chesapeake Life Insurance Company SM Supplemental Insurance Protection Packages Accident, Illness and Hospitalization Packages Nevada CH PLUS NV 1110_1110

2 Table of Contents Accident, Illness and Hospitalization Protection Packages...1 ProtectFit Plus Accident Protection Package...4 PersonalFit Plus Personal Illness Protection Package...7 HospitalFit Plus Hospitalization Protection Package...8 Plan Terms for all Packages...9 Other Important Information...10 Outlines of Coverage...11 This brochure provides only summary information. 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 PLUS NV 1110

3 Accident, Illness, and Hospitalization Protection Packages Unexpected health events can impact both you and your finances. To help protect you and your family from the unexpected, The Chesapeake Life Insurance Company offers several plans designed to work with your existing health coverage, and help with the financial burden that can accompany an accident, critical illness, or hospital confinement. ProtectFit Plus (Accident) offers you additional protection for accidental injuries. PersonalFit Plus (Illness) offers you additional protection that can offset illness-related expenses. Supplemental insurance offers the additional protection your family needs and deserves HospitalFit Plus (Hospitalization) offers you additional protection for time spent in the hospital, providing limited coverage for inpatient and outpatient diagnostics, rehabilitation therapy and transportation. Accident, Illness, and Hospitalization protection packages are designed to FIT your life. ~ Pays a lump sum benefit directly to you to use as you choose ~ No Deductible and No Copay ~ Fully portable plans move with you ~ Multiple plan options ~ Premiums do not increase with age The Chesapeake Life Insurance Company will not provide benefits for any loss resulting from a pre-existing condition, as defined within the Exclusions and Limitations section. CH PLUS NV

4 Accident, Illness, and Hospitalization Protection Packages Supplemental Insurance Protection Packages CHOOSE FROM THREE PACKAGES Benefits ProtectFit Plus PersonalFit Plus HospitalFit Plus Inpatient Confinement Daily Hospital Daily ICU Initial Hospital and ICU Surgery Outpatient Emergency and Diagnostic Emergency Room/Urgent Care Facility Treatment Major Diagnostic Exams Lump-Sum Injury Outpatient Surgical Room Invasive Diagnostic Exams Physician-Office Visits Follow-Up and Restorative Physician Follow-up Physical Therapy Rehabilitation Unit Appliances Prosthesis Blood, Plasma, Platelets Disability Accidental Death and Dismemberment Common Carrier Accident Income Protection Waiver of Premium Transportation Ground or Water Ambulance Air Ambulance 2 CH PLUS NV 1110

5 Our plans pay in addition to your existing health insurance to give you and your family additional protection CH PLUS NV

6 ProtectFit Plus Accident Protection Package When accidents happen, they can distrupt your life in multiple ways. Our Accident Protection plan can help prepare you for the unexpected by providing financial help when you need it. ~ Pays a lump sum benefit directly to you ~ No Deductible and No Copay ~ Fully portable plan that moves with you ~ Choice of two plan options ~ Premiums do not increase with age BENEFIT SUMMARY Low Plan High Plan Inpatient Hospital Confinement (Confinement must begin within 30 days of covered accident) Lump Sum Hospital Daily Hospital Lump Sum Intensive Care Hospital Daily Intensive Care Hospital Pays when a room charge is incurred for a hospital confinement in which injuries are sustained from an accident ~ One benefit per Policy year, per insured person Pays daily amount in addition to lump sum hospital confinement benefit ~ Pays up to 365 days per insured person, per accident resulting in a room charge Pays when a room charge is incurred for an intensive care hospital confinement in which injuries are sustained from an accident ~ One benefit per Policy year, per insured person Pays daily amount in addition to the hospital confinement benefit for intensive care unit confinements ~ Payable up to 15 days per covered accident, per insured person $500 $1,000 $150 $300 $1,000 $2,000 $250 $500 Outpatient, Emergency and Diagnostic (Treatment must be received within 72 hours of initial onset of accidental injury) Lump Sum Accidental Injury Emergency Treatment Primary insured person and covered dependent spouse Covered dependent child(ren) ~ Pays for medically appropriate services received at a licensed hospital emergency room or urgent care facility for an accident ~ Pays one time per insured person, per covered accident $100 $50 $150 $100 Major Diagnostic Examinations Covered diagnostic services CT Scan MRI EEG ~ Diagnostic procedure must be performed in a hospital or urgent care center ~ One payment per Policy year, per insured person $100 $200 Continued on next page. 4 CH PLUS NV 1110

7 ProtectFit Plus (Continued) BENEFIT SUMMARY Lump Sum Accidental Injury* Covered Injury Covered injuries Dislocation Paralysis Orthopedic Repair Fracture Brain Concussion Coma Skin Graft(s) Burns Eye Injury Laceration(s) Open Abdominal Emergency Dental Repair Wound ~ Benefit pays for injuries sustained in an accident ~ Treatment must begin within 72 hours of an accidental injury unless specifically stated differently in the schedule of benefits * Refer to the Schedule of Benefits for specific payment amount. Low Plan High Plan $25 - $6,250 $35 - $12,500 Follow-Up and Restorative Injury (Per visit, per insured person and must begin within 30 days of an accidental injury) Accidental Injury Follow up Treatment Accidental Injury Follow up Physical Therapy Hospital Rehabilitation Unit* * Paid in lieu of daily hospital confinement benefit Must follow emergency room or urgent care center treatment ~ Maximum per Policy year ~ Excludes chiropractic care Must follow emergency room or urgent care center treatment ~ Maximum per Policy year ~ Per day of rehabilitation ~ Maximum for each insured person per hospital confinement ~ Maximum per Policy year * Refer to the Schedule of Benefits for specific payment Continued amount. on next page. $25 5 visits $25 5 visits $75 30 days 60 days $35 10 visits $35 10 visits $ days 60 days Restorative Appliances* $100 $150 Prosthesis* $375 $750 Blood plasma and platelets* *Each benefit limited to one per insured person, per accident Accidental Death and Dismemberment* (Must occur within 90 days of an accident) $100 $200 Death Primary insured person and covered dependent spouse $25,000 $50,000 Covered dependent child(ren) $7,500 $15,000 Common Carrier Death Primary insured person and covered dependent spouse $75,000 $150,000 Covered dependent child(ren) $12,500 $25,000 Dismemberment Primary insured person and covered dependent spouse $1,500 - $25,000 $3,000 - $50,000 Covered dependent child(ren) $500 - $7,500 $1,000 - $15,000 Emergency Ambulance (One trip per insured person, per accident) Ground or Water $125 $250 Air $1,250 $2,500 Continued on next page. CH PLUS NV

8 ProtectFit Plus (Continued) BENEFIT SUMMARY Supplemental Disability Income Protection* (Per month) Supplemental Disability Income Protection Primary insured person and covered dependent spouse * Must be employed at time of purchase for High Plan only Covered dependent child(ren) ~ Total disability must occur within 60 days of accidental injury ~ Subject to 21-day elimination period ~ Amount payable up to 12 continuous months Low Plan High Plan $500 Form CH IP (06/09) NV 6 CH PLUS NV 1110

9 PersonalFit Plus Personal Illness Protection Package An unforeseen illness can disrupt your lifestyle. Personal Illness Protection is designed to help you with the financial burden of an unexpected health event. ~ Pays a lump sum benefit directly to you ~ No Deductible and No Copay ~ Fully portable plan that moves with you BENEFIT SUMMARY Inpatient Hospital Confinement Low Plan High Plan Lump Sum Hospital One benefit per insured person, per Policy year $175 $275 Daily Hospital Days 1 through 15 $100 $150 Days 16 through 180 ~ Per insured person, per day Surgery* (One surgical procedure per insured person, per day) Surgery Covered surgeries Bone Gynecologic Miscellaneous** Brain Heart Pancreas Breast Larynx Skin Digestive Liver Spine Ear/Nose Lungs Thyroid Eye Lymphatic Urinary ~ Payable only for insured person related to an illness ~ Examinations covered under invasive diagnostic procedure are not payable under this benefit * Refer to the Schedule of Benefits for specific payment amount ** Miscellaneous surgeries are defined in the Schedule of Benefits Physician-Office Visit $150 $250 $25 - $500 $50 - $1,000 Office Visits Includes wellness or illness visits $20 $30 ~ Per insured person, per Policy year 2 visits 3 visits ~ Per family, per Policy year 4 visits 6 visits Major Diagnostic Exam (One diagnostic exam per insured person, per Policy year) Diagnostic Exam Types of Exams CT Scan EEG Myelogram Arteriogram MRI Angiogram Thallium Stress Test ~ Payable only for insured person related to an illness Hospital Rehabilitation Unit (Paid in lieu of hospital confinement benefit) Rehabilitation ~ Not to exceed 15 days per illness ~ Not to exceed 30 days per Policy year Emergency Ambulance (One trip per insured person, per illness) $100 $175 $25 $50 Ground or Water $50 $100 Air $500 $1,000 Form CH IP (06/09) NV ~ Choice of two plan options ~ Premiums do not increase with age ~ Waiver of Premium refer to Other Important Information section CH PLUS NV

10 HospitalFit Plus Hospitalization Protection Package An unexpected hospital stay can quickly impact your life and your budget, adding a financial burden when you can least afford one. Our hospitalization protection plan can help you with the expenses related to hospital care. ~ Pays a lump sum benefit directly to you ~ No Deductible and No Copay ~ Fully portable plan that moves with you BENEFIT SUMMARY Inpatient Hospital Confinement (Per insured person; not to exceed 365 days per illness or injury) Low Plan High Plan Daily Hospital Days 1 through 7 $200 $400 Days 8 through 365 $75 $150 ~ Confinements separated by less than 30 days are considered the same confinement Outpatient Surgery Facility (Per insured person, per sickness or injury) Outpatient Surgery* With anesthesia $175 $350 * Paid in lieu of hospital confinement benefit Without anesthesia $50 $100 Invasive Diagnostic Exam (One diagnostic procedure per insured person, per day) Invasive Diagnostic Exam ~ 5 diagnostic exams per Policy year ~ Inpatient hospital or outpatient surgery facility Surgery* (One surgical procedure per insured person, per day) Surgery Covered surgeries Bone Gynecologic Miscellaneous** Brain Heart Pancreas Breast Larynx Skin Digestive Liver Spine Ear/Nose Lungs Thyroid Eye Lymphatic Urinary ~ Payable only for covered illness or injury ~ Examinations covered under invasive diagnostic procedure are not payable under this benefit * Refer to the Schedule of Benefits for specific payment amount ** Miscellaneous surgeries are defined in the Schedule of Benefits Hospital Rehabilitation Unit (Paid in lieu of hospital confinement benefit, not to exceed 30 days per Policy year) Rehabilitation Emergency Ambulance (One trip per illness or injury) Not to exceed 15 days per illness or injury per insured person, per hospitalization $125 $250 $25 - $500 $50 - $1,000 $75 $150 Ground or Water $175 $350 Air $1,750 $3,500 Form CH IP (06/09) NV ~ Choice of two plan options ~ Premiums do not increase with age ~ Waiver of Premium refer to Other Important Information section 8 CH PLUS NV 1110

11 Plan Terms for all Packages Accidental Injury (ProtectFit Plus only) Sudden, non-recurrent, traumatic, accidental and unanticipated damage to the body, not of gradual onset requiring immediate medical attention, and not contributed to, directly or indirectly, by a sickness. The accidental injury must first occur after the insured person s coverage has become effective and while the coverage is in force under the Policy. Ambulance A ground, water or air vehicle which is licensed as required by law, as an ambulance, and is equipped to transport sick or injured people. Confined/Confinement An insured person s medically necessary admission to and subsequent continued stay in a hospital for which a daily charge for room and board is made for each day of confinement with no discharge or interruption in such hospital stay. Covered Dependent An eligible dependent, as defined by your state, whose coverage has become effective under the Policy and has not terminated. Hospital An institution operated pursuant to its license for the care and treatment of sick and injured persons for which a charge is made that the insured person is legally obligated to pay. The institution must: Maintain on its premises organized facilities for medical, diagnostic and surgical care for sick and injured persons on an inpatient basis Maintain a staff of one or more duly licensed physicians Provide 24-hour nursing care by or under the supervision of a registered graduate professional nurse (R.N.) and Is accredited as a hospital by the joint commission on accreditation of hospitals. The term "hospital" does not include: A hospice unit, including any bed designated as a hospice or a swing bed, a convalescent home, a rest or nursing facility; an extended care facility, a skilled nursing facility or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders; care for the aged, or care for persons addicted to drugs or alcohol and Any military or veteran's hospital, soldier's home or any hospital contracted for or operated by the federal government or any agencies thereof for the treatment of members or former members of the armed forces, unless the insured person is legally required to pay for services in the absence of this insurance coverage. Insured Person You or a covered dependent under the Policy. Invasive Diagnostic Exam (HospitalFit Plus only) An arthroscopy, bronchoscopy, colonoscopy, cystoscopy, gastroscopy, laryngoscopy, sigmoidoscopy, esophagoscopy, laparoscopy, or mediastinoscopy procedure that is performed on an insured person as a result of an illness or injury in a hospital or outpatient surgery facility. Policy Year Each consecutive 12-month period beginning with your effective date of coverage. Pre-Existing (PersonalFit Plus and HospitalFit Plus only) A medical condition not excluded by name or specific description for which Medical advice, consultation, or treatment was recommended by or received from a physician within the 12-month period before the effective date of coverage or Symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 12-month period before the effective date of coverage. Sickness (PersonalFit Plus and HospitalFit Plus only) An illness or disease. Surgery The performance of generally accepted operative and cutting procedures, including surgical diagnostic procedures, specialized instrumentation, endoscopic examinations, and other invasive procedures while an insured person is under local or general anesthesia The correction of fractures and dislocations and Any of the procedures designated by current procedural terminology codes as surgery. Injury (PersonalFit Plus and HospitalFit Plus only) Bodily harm caused by an accident resulting in unforeseen trauma requiring immediate medical attention and is not contributed to, directly or indirectly, by a sickness. CH PLUS NV

12 Other Important Information Coverage Begins Once your application is approved, the effective date of coverage for you and your eligible dependents listed on the application and accepted by us will be the Policy date shown on the Policy schedule. Waiver of Premium (PersonalFit Plus and HospitalFit Plus only) We will waive all monthly premiums due for the Policy during your extended hospital confinement. The waiver of premium begins after you have been hospital confined for a period of at least 30 consecutive days. Premiums will resume under this Policy when you are no longer receiving a hospital confinement benefit under this Policy. Once premiums are resumed under the Policy, any new hospital confinements will be subject to a 30 day continued confinement without discharge, before premiums will be waived. Health Savings Account Eligibility In the event that you qualify for a Health Savings Account (HSA), and you are or will be making contributions to your Account, please note that the purchase of the PersonalFit Plus or HospitalFit Plus Plans may cause you to lose your eligibility for the tax advantages of contributing to an HSA. Therefore, we recommend that you consult your tax advisor if you are considering purchasing this plan and you are or will be making contribution to an HSA account. Your covered dependent s coverage will terminate under the Policy: On the date your coverage terminates At the end of the month following the date such dependent ceases to be an eligible dependent At the end of the month following the date of our receipt of your request of termination On the date the covered dependent: a) performs an act or practice that constitutes fraud or b) has made an intentional misrepresentation of material fact, relating in any way to the coverage provided under the Policy, including claims for benefits under the Policy. Premium will only be refunded for any full months paid beyond the termination date. The attainment of the limiting age for an eligible dependent will not cause coverage to terminate while that person is and continues to be: Incapable of self-sustaining employment by reason of mental retardation or physical handicap and Chiefly dependent on you for support and maintenance. For the purpose of this provision chiefly dependent means the eligible dependent receives the majority of his or her financial support from you. We require that you provide written proof that the dependent child is a disabled and dependent person within 31 days after his or her attainment of the limiting age. Thereafter, we may require such written proof not more frequently than annually after the two-year period following the child s attainment of the limiting age. In the absence of such proof, we may terminate the coverage of such person after the attainment of the limiting age. Claim Submission You must notify the company in order for your claim to be considered. Refer to your policy materials for the claim form and additional instructions. Termination of Coverage Your coverage will terminate and no benefits will be payable under the Policy: At the end of the month for which premium has been paid On the date you reach age 65 At the end of the month following the date of our receipt of your request of termination On the date of fraud or material 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, or On the date an insured person is no longer a permanent resident of the United States. Premium will only be refunded for any full months paid beyond the termination date. 10 CH PLUS NV 1110

13 THE CHESAPEAKE LIFE INSURANCE COMPANY A Stock Company (Hereinafter called: the Company, We, Our or Us) Home Office: Oklahoma City, Oklahoma Administrative Office: P.O. Box North Richland Hills, Texas Customer Service: ACCIDENTAL INJURY ONLY INSURANCE POLICY OUTLINE OF COVERAGE FOR FORM CH IP (06/09) NV 1. READ YOUR POLICY CAREFULLY! This Outline of Coverage provides a very brief description of some of the important features of Your Policy. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both You and Us. It is, therefore, important that You READ YOUR POLICY CAREFULLY. 2. ACCIDENTAL INJURY ONLY COVERAGE This coverage is designed to provide You or Your Covered Dependents with coverage for certain losses resulting from Accidental Injuries that First Occur after Your coverage has become effective and while the coverage is in force under the Policy. The Policy does not provide benefits for loss from Sickness. 3. BENEFITS. The Policy provides the lump sum indemnity Benefit Amount shown in the Policy Schedule for the following benefits. All benefits are subject to the Benefit Amount shown in the Policy Schedule, any benefit limitations shown in the Policy Schedule, the Elimination Periods shown in the Policy Schedule, if any, the Exclusions and Limitations shown below, and all other provisions of the Policy. INPATIENT HOSPITAL CONFINEMENT BENEFIT OUTPATIENT EMERGENCY/DIAGNOSTIC LUMP-SUM ACCIDENTAL INJURY BENEFIT: Dislocation Benefit Burn Benefit Skin Grafts Benefit Eye Injury Benefit Laceration Benefit Fractures Benefit Brain Concussion Benefit Emergency Dental Repairs Benefit Coma Benefit Paralysis Benefit Miscellaneous Surgery Procedures Benefit FOLLOW-UP / RESTORATIVE: Accidental Injury Follow-up Treatment Benefit Accidental Injury Follow-up Physical Therapy Benefit Hospital Rehabilitation Unit Benefit Appliance Benefit Prosthesis Benefit Blood Plasma/Platelets Benefit ACCIDENTAL DEATH AND DISMEMBERMENT: Death Benefit Common Carrier Death Benefit Dismemberment Benefit TRANSPORTATION: Emergency Ground/Water Ambulance Benefit Emergency Air Ambulance Benefit SUPPLEMENTAL DISABILITY INCOME PROTECTION BENEFIT, if applicable CH IP (06/09) OC NV CH PLUS NV

14 4. EXCLUSIONS AND LIMITATIONS. We will not provide any benefits for loss caused by, resulting from or in connection with: 1. Sickness, including but not limited to pregnancy and childbirth; 2. Any care not Medically Necessary (except as specifically provided herein) or benefits which are not specifically provided for in the Policy; 3. Hospital Confinement for childbirth, including routine or normal newborn child care; 4. Accidental Injuries that do not First Occur while the Policy is in force for the Insured Person; 5. Any act of war, declared or undeclared; 6. Active military duty in the service or any country; 7. Participation in a riot, civil commotion or insurrection; 8. Suicide, attempted suicide, or any intentionally self-inflicted injury, while sane or insane; 9. Mental or nervous disorders; 10. Having Cosmetic Surgery or other elective procedures that are not Medically Necessary; 11. Operating any motorized passenger vehicle for wage, compensation or profit; 12. Directly or indirectly engaging in an illegal occupation or illegal activity or Your being incarcerated; 13. Committing or trying to commit a felony; 14. Mountaineering using ropes and/or other equipment, parachuting, hang gliding, officiating or coaching racing any type of vehicle in an organized or unorganized event, sky diving, scuba diving below 50 feet motorized racing, para-sailing, experimental aviation, ultra-light flying, base jumping, bungee jumping, heli-skiing or heli-snowboarding; and 15. Travel in or descent from any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a commercial airline (other than a charter airline) certified by the U.S. Federa Aviation Administration (FAA), on a regularly scheduled passenger trip. 5. RENEWAL CONDITIONS. The Policy is guaranteed renewable to age 65, subject to the Company s right to discontinue or terminate the coverage as provided in the TERMINATION OF COVERAGE section of the Policy. The Company reserves the right to change the applicable table of premium rates on a Class Basis. 6. PREMIUMS. We reserve the right to change the table of premiums, on a Class Basis, becoming due unde the Policy at any time and from time to time, with approval by the Division of Insurance; provided, We have given You written notice of at least 60 days prior to the effective date of the new rates. Such change will be on a Class Basis. CH IP (06/09) OC NV 12 CH PLUS NV 1110

15 THE CHESAPEAKE LIFE INSURANCE COMPANY A Stock Company (Hereinafter called: the Company, We, Our or Us) Home Office: Oklahoma City, Oklahoma Administrative Office: P.O. Box North Richland Hills, Texas Customer Service: SICKNESS-ONLY SCHEDULED INDEMNITY POLICY OUTLINE OF COVERAGE FOR FORM CH IP (06/09) NV 1. READ YOUR POLICY CAREFULLY! This Outline of Coverage provides a very brief description of some of the important features of Your Policy. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both You and Us. It is, therefore, important that You READ YOUR POLICY CAREFULLY. 2. SICKNESS-ONLY SCHEDULED INDEMNITY COVERAGE This coverage is designed to provide You or Your Covered Dependents with coverage for certain losses resulting from a Sickness occurring after Your coverage has become effective and while coverage is in force under the Policy. The Policy does not provide benefits for loss from Injury. 3. BENEFITS. The Policy provides the lump sum indemnity Benefit Amount shown in the Policy Schedule for the following benefits. All benefits are subject to [the Waiting Period shown in the Policy Schedule,] the Benefit Amount shown in the Policy Schedule, any benefit limitations shown in the Policy Schedule, the Exclusions and Limitations listed below, and all other provisions of the Policy. INPATIENT HOSPITAL CONFINEMENT BENEFIT SURGERY BENEFIT: Bone Brain Breast Digestive Ear/Nose Eye Gynecologic Heart Larynx Liver Lungs Lymphatic Miscellaneous Pancreas Skin Spine Thyroid Urinary PHYSICIAN OFFICE VISIT BENEFIT MAJOR DIAGNOSTIC EXAM BENEFIT HOSPITAL REHABILITATION UNIT BENEFIT EMERGENCY GROUND/WATER AMBULANCE BENEFIT EMERGENCY AIR AMBULANCE BENEFIT CH IP (06/09) OC NV CH PLUS NV

16 4. EXCLUSIONS AND LIMITATIONS. We will not provide any benefits for loss caused by, resulting from or in connection with: 1. An Injury; 2. Any care not Medically Necessary or benefits which are not specifically provided for in this Policy; 3. Any act of war, declared or undeclared; 4. Active military duty in the service or any country; 5. Participation in a riot, civil commotion or insurrection; 6. Suicide, attempted suicide, or any intentionally self-inflicted injury, while sane or insane; 7. Mental or nervous disorders; 8. Having Cosmetic Surgery or other elective procedures that are not Medically Necessary; 9. Directly or indirectly engaging in an illegal occupation or illegal activity or Your being incarcerated; 10. Committing or trying to commit a felony; 11. Normal pregnancy, except for complications of pregnancy while Hospital Confined; and 12. Hospital Confinement for routine or normal newborn child care. Pre-Existing Condition Limitation We will not provide benefits for any loss resulting from a Pre-Existing Condition, as defined, unless the loss is incurred at least 6 months after the Effective Date of Coverage for an Insured Person. 5. RENEWAL CONDITIONS. The Policy is guaranteed renewable to age 65, subject to the Company s right to discontinue or terminate the coverage as provided in the TERMINATION OF COVERAGE section of the Policy. The Company reserves the right to change the applicable table of premium rates on a Class Basis. 6. PREMIUMS. We reserve the right to change the table of premiums, on a Class Basis, becoming due under the Policy at any time and from time to time, with approval by the Division of Insurance; provided, We have given You written notice of at least 60 days prior to the effective date of the new rates. Such change will be on a Class Basis CH IP (06/09) OC NV 14 CH PLUS NV 1110

17 THE CHESAPEAKE LIFE INSURANCE COMPANY A Stock Company (Hereinafter called: the Company, We, Our or Us) Home Office: Oklahoma City, Oklahoma Administrative Office: P.O. Box North Richland Hills, Texas Customer Service: HOSPITAL AND SURGICAL INDEMNITY POLICY OUTLINE OF COVERAGE FOR FORM CH IP (06/09) NV 1. READ YOUR POLICY CAREFULLY! This Outline of Coverage provides a very brief description of some of the important features of Your Policy. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both You and Us. It is, therefore, important that You READ YOUR POLICY CAREFULLY. 2. HOSPITAL AND SURGICAL INDEMNITY COVERAGE This coverage is designed to provide You or Your Covered Dependents with coverage for hospital and surgical expenses incurred as a result of a covered Sickness or Injury. 3. BENEFITS. The Policy provides the lump sum indemnity Benefit Amount shown in the Policy Schedule for the following benefits. All benefits are subject to the Benefit Amount shown in the Policy Schedule, any benefit limitations shown in the Policy Schedule, the Exclusions and Limitations listed below, and all other provisions of the Policy. INPATIENT HOSPITAL CONFINEMENT BENEFIT OUTPATIENT SURGERY FACILITY BENEFIT INVASIVE DIAGNOSTIC EXAM BENEFIT SURGERY BENEFIT: Bone Brain Breast Digestive Ear/Nose Eye Gynecologic Heart Larynx Liver Lungs Lymphatic Miscellaneous Pancreas Skin Spine Thyroid Urinary HOSPITAL REHABILITATION UNIT BENEFIT EMERGENCY GROUND/WATER AMBULANCE BENEFIT EMERGENCY AIR AMBULANCE BENEFIT CH IP (06/09) OC NV (03/10) CH PLUS NV

18 4. EXCLUSIONS AND LIMITATIONS. We will not provide any benefits for loss caused by, resulting from or in connection with: 1. Any care not Medically Necessary or benefits which are not specifically provided for in the Policy; 2. Any act of war, declared or undeclared; 3. Active military duty in the service or any country; 4. Participation in a riot, civil commotion or insurrection; 5. Suicide, attempted suicide, or any intentionally self-inflicted injury, while sane or insane; 6. Mental or nervous disorders; 7. Having Cosmetic Surgery or other elective procedures that are not Medically Necessary; 8. Operating any motorized passenger vehicle for wage, compensation or profit; 9. Directly or indirectly engaging in an illegal occupation or illegal activity or Your being incarcerated; 10. Committing or trying to commit a felony; 11. Normal pregnancy, except for complications of pregnancy while Hospital Confined; 12. Hospital Confinement for routine or normal newborn child care; 13. Mountaineering using ropes and/or other equipment, parachuting, hang gliding, officiating or coaching, racing any type of vehicle in an organized or unorganized event, sky diving, scuba diving below 50 feet, motorized racing, para-sailing, experimental aviation, ultra-light flying, base jumping, bungee jumping, heli-skiing or heli-snowboarding; and 14. Travel in or descent from any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a commercial airline (other than a charter airline) certified by the U.S. Federal Aviation Administration (FAA), on a regularly scheduled passenger trip. Pre-Existing Condition Limitation We will not provide benefits for any loss resulting from a Pre-Existing Condition, as defined, unless the loss is incurred at least 6 months after the Effective Date of Coverage for an Insured Person. 5. RENEWAL CONDITIONS. The Policy is guaranteed renewable to age 65, subject to the Company s right to discontinue or terminate the coverage as provided in the TERMINATION OF COVERAGE section of the Policy. The Company reserves the right to change the applicable table of premium rates on a Class Basis. 6. PREMIUMS. We reserve the right to change the table of premiums, on a Class Basis, becoming due under the Policy at any time and from time to time, with approval by the Division of Insurance; provided, We have given You written notice of at least 60 days prior to the effective date of the new rates. Such change will be on a Class Basis. CH IP (06/09) OC NV (03/10) 16 CH PLUS NV 1110

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20 The Chesapeake Life Insurance Company The Chesapeake Life Insurance Company CH PLUS NV 1110_1110