PRODUCT INFORMATION APPROVED FOR POLICY TYPE
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1 HOSPITAL INTENSIVE CARE MARKETPLACE BULLETIN PRODUCT INFORMATION APPROVED FOR POLICY TYPE Plan Code Policy Form Ages ELIGIBILITY 5JD, 5JE, 5JF Same As Plan Codes 0-60; for Family or Single Parent Individual (Bank Draft) Worksite Advantage (Payroll Deduction) Worksite Advantage Section 125 (Pretax Savings) Accident and Health Term Life Whole Life Annuity Medicare Supplement y An individual cannot be covered by more than one Liberty National policy. y Worksite eligibility requirements apply to worksite sales. Refer to the Worksite Advantage Agent Reference Guide R y For family coverage, a child is less than 21 years of age, unmarried, and lives with or is primarily dependent upon the primary insured for support. Legally adopted children and stepchildren are eligible for family coverage. y Insured children remain covered until the earliest of: the child s marriage, age 21, or when they are no longer dependent on the primary insured if not living with the primary insured. Coverage on mentally or physically incapacitated children may continue even longer. Coverage on full-time students may continue to age 25. y Guaranteed renewable until the policy holder is 65 or eligible for Medicare due to age, as long as premiums are paid on time. LIMITATIONS, EXCLUSIONS, AND EXCEPTIONS No benefits will be paid for medical treatment: y Caused by mental or emotional disorders. y Resulting from war or act of war. y Involving preexisting conditions for two years after the effective date of the policy. y For which no charge is normally made in the absence of insurance, except for U.S. government hospitals, Medicare, Medicaid, and Champus. y For the first day of confinement in an ICU due to sickness (Not applicable in South Carolina). y Occurring or beginning within the first 30 days of life for children born within 10 months of the effective date of the policy (Not applicable in South Carolina; children are covered at birth.). PRODUCT OVERVIEW y Benefits for confinement in Intensive Care Unit due to sickness or injury. y Benefit amounts are increased if the confinement is a result of an automobile or travel accident. y Policy pays additional benefits for regular hospital room, blood, and ambulance service. See policy for full details and descriptions. y Intensive Care Unit (ICU) is defined in the policy as: Those special intensive care areas of the hospital which, at the time of admission to the hospital, are also separate and apart from the surgical recovery room and from the rooms, beds, and wards customarily used for 1 HIC MPB Liberty National Life Insurance Company. All rights reserved. LNL
2 patient confinement. The term Intensive Care Unit does not include lesser treatment units such as progressive or intermediate care units, private monitored rooms, isolation units, observation, or telemetry units. In addition, such intensive care units must have 24-hour nursing attendance by nurses assigned on a full-time basis exclusively to such unit, and such units contain a special apparatus used in the treatment of the critically ill. Further, such intensive care facilities or units must be under direct professional supervision and/or direction of a full-time physician director or a standing intensive care committee of the medical staff of the hospital. Intensive care units also include special care units where such units meet the other standards set forth above. The following types of accommodations are special care units: Surgical Intensive Care Unit; Coronary Intensive Care Unit; Burn Unit; Pediatric Intensive Care Unit; Neonatal Care Unit; Trauma Unit; or Medical Intensive Care Unit. BENEFIT OVERVIEW There is no maximum limit for total benefits paid on this policy. Coverage can be purchased in one or two units. Benefits : 1 Unit 2 Units Daily Intensive Care $300 ($ 250 in South Carolina) $600 ($ 500 in South Carolina) Per day up to 30 days for each ICU confinement (other than automobile and travel accidents) beginning the first day for accidental bodily injury and the second day for sickness. Benefits are limited to payment for a total of 30 days for each period of hospital confinement in an intensive care unit. If less than 30 days separates two periods of hospital confinement for which benefits are payable under this policy, then for the purpose of calculating daily benefits, such second period of hospital confinement is considered a continuation of the prior period. Periods of hospital confinement in an ICU resulting from different and unrelated causes are considered to be separate periods of hospital confinement. These benefit amounts double if ICU confinement is a result of an automobile or travel accident. Automobile and Travel Accident $300 ($ 250 in South Carolina) $600 ($ 500 in South Carolina) y Policy pays an additional daily benefit of $300 per unit of coverage if: Benefits are payable under the Daily ICU benefit; and If a covered person s initial ICU confinement is for treatment of an accidental bodily injury resulting from an automobile or travel accident. y Benefit paid only if initial ICU confinement begins within 48 hours of the automobile or travel accident. y Benefit is payable for the same number of days as the initial ICU confinement. y Subsequent confinements for the same automobile or travel accident are paid only under the Daily ICU Benefit. For example; (based on 1 unit) if a person is confined to the ICU as a result of an automobile or travel accident and the confinement is within 48 hours of the automobile or travel accident, they receive a $300 daily benefit per unit of coverage under the Automobile and Travel Accident Benefit in addition to the benefit amount to which they are entitled under the Daily ICU Benefit. Regular Hospital Room $50 ($25 in South Carolina) $100 ($50 in South Carolina) Per day for confinement in a regular hospital room up to the same number of covered days of ICU confinement. For example, (based on two units) if a person is in ICU for two covered days, they receive $100 per day for up to two days of regular room confinement occurring during the same hospitalization. Blood $50 $100 For whole blood or blood components administered during a hospital stay involving an ICU confinement. Ambulance $50 $100 For a professional ambulance or air ambulance when a covered insured is transported to the hospital for an ICU confinement. 2 HIC MPB LNL
3 REPLACEMENTS A replacement occurs when new accident or health insurance is purchased and existing accident or health insurance is terminated (lapsed, surrendered, etc); or amended to reduce benefits or shorten the term of coverage. When a replacement occurs, the replacement question on the application must be answered Yes. The number of the policy you are replacing must be written next to the replacement question. If accident or health replacement forms are required in your state, the appropriate form should be completed and attached to the application. Replacement of existing Torchmark Corporation subsidiary policies is not allowed. Torchmark subsidiaries include: American Income Life Insurance Company, Family Heritage Life Insurance Company, First United American Life Insurance Company, Globe Life And Accident Insurance Company, Liberty National Life Insurance Company, National Income Life Insurance Company, and United American Insurance Company. MAILING ADDRESS Paper and Home Office Verification Sheet Liberty National Life Insurance Company Attn: New Business 100 Concourse Pkwy, Ste. 350 Hoover, AL SUPPLIES AND TOOLS MUST BE RETURNED TO THE HOME OFFICE (your state s version) A-372 Replacement Notice Arbitration Agreement (AL & MS) R-3423 Bank Draft Authorization R-3616 or Payroll Deduction Form (for worksite sales) R-3231 R-3637 Home Office Verification Sheet AVAILABLE FOR THE CONSUMER Laptop Sales Presentation eapp (availability varies by state) Product Brochure Outline of Coverage (requirement varies by state) (must be left with applicant) AVAILABLE FOR AGENT TRAINING Agent s Instruction Guide Marketplace Bulletin Agent Training PowerPoint (available on Laptop on Demand) Worksite Advantage Agent Reference Guide R-3631 Sample Policy State Guide to Brochures Rate Cards R-3691 (Individual) R-3290 (Worksite) 3 HIC MPB LNL
4 STATE APPROVAL & REQUIRED FORMS CHART STATES Brochure HOSPITAL INTENSIVE CARE Outline of Coverage Replacement Notice Alabama A-372 ED R-3118-A Alaska Arizona Arkansas A-372-A ED R-3118 California Colorado Connecticut Delaware District of Columbia Florida Georgia A-372 ED R-3118 Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky H-97-C H-98-C, H-99-C H-66-C H-67-C, H-84-C Louisiana A-372-A ED R-3118 Maine Maryland Massachusetts Michigan Minnesota Mississippi A-372 ED R-3118-A Missouri A ED R-3118 Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina A ED R-3118 North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina A ED R South Dakota H-102-C H-103-C, H-104-C R-3650 State special rate card. R Tennessee A-372-T ED R-3118 Texas Utah State Specific Policy Exceptions Policy Forms 5JJ, 5JL, 5JK Special benefits amounts. Children covered from birth. 2 day wait period for sickness is waived. State special rate card. CONTINUED 4 HIC MPB LNL
5 STATES Vermont Brochure HOSPITAL INTENSIVE CARE Outline of Coverage Replacement Notice Virginia A ED R-3118 R-3650 Washington West Virginia Wisconsin Wyoming State Specific Policy Exceptions 5 HIC MPB LNL
PRODUCT INFORMATION APPROVED FOR POLICY TYPE
MARKETPLACE BULLETIN INTENSIVE CARE PROTECTOR PRODUCT INFORMATION APPROVED FOR POLICY TYPE Plan Code Policy Form Issue Ages PRODUCT OVERVIEW 5JP, 5JQ, 5JR Same As Plan Codes 0-60; 15-60 for Family or Single
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