Group Benefits Program. Group Disability Group Critical Illness Group Accident

Transcription

1 Group Benefits Program Group Disability Group Critical Illness Group Accident

2 DISABILITY PLAN FEATURES Weekly benefit amount up to $2,500. Personal ID card for every insured employee. Individual certificate for each insured employee. Speak to a live customer service agent when you call for claims or service. Choice of 3 elimination periods Elimination Period 7/7, 14/14, 30/30 COVERAGE WORKSHEET PLAN INFORMATION BENEFIT PERIOD 26 WEEKS ELIMINATION PERIOD 7/7 14/14 30/30 WEEKLY BENEFIT $ PAYROLL DEDUCTION BI-WEEKLY PREMIUM $ Duration of Benefits - Total Disability - 26 weeks Covers Pregnancy - paid same as sickness. BENEFITS Total Disability This convenient, affordable disability income plan will provide needed income if you become totally disabled and are unable to work due to a covered injury or illness. Partial Disability The partial disability benefit helps you transition back into full-time work after suffering a disability. If, after being totally disabled, you remain partially disabled and are only able to work part-time, this plan will continue to pay you. Waiver of Premium Premium payments are waived while you are receiving weekly payments. Premium adjusted yearly based on age and salary Benefit Period is 26 weeks BI WEEKLY RATES PER $10 OF WEEKLY BENEFIT Age 7day 14day 30day $0.65 $0.52 $ $0.68 $0.58 $ $0.60 $0.48 $ $0.45 $0.37 $ $0.44 $0.34 $ $0.44 $0.35 $ $0.50 $0.41 $ $0.70 $0.55 $ $0.94 $0.71 $ $1.02 $0.81 $0.54 Rates may be slightly different due to rounding.

3 CRITICAL ILLNESS PLAN FEATURES Lump-sum benefits paid directly to the insured following the diagnosis of each covered critical illness. Each dependent child is covered at 25 percent of the primary insured amount at no additional charge. Spouse coverage available up to $25,000 benefit amount (not to exceed one-half of employee benefit). Rates cannot be individually increased due to change in age, health or individual claim. Annual health screening benefits included. The plan is portable take your coverage with you if you leave your job. BENEFITS First Occurrence Benefit Lump Sum Benefit payable upon initial diagnosis of a covered illness. Employee benefit amounts available from $5,000 to $50,000. Additional Occurrence Benefit If an insured collects full benefits for a Critical Illness under the plan and later has one of the remaining covered illnesses/procedures, then we will pay the full benefit amount for each additional illness. Occurrences must be separated by at least 6 months. Re-Occurrence Benefit If you collect full benefits for a covered condition and are later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months (12 months treatment free for cancer). Child Coverage at no Additional Cost Each dependent child is covered at 25 percent of the primary insured amount at no additional charge. Plan is Portable Take your coverage with you if you leave your job for any reason. Spouse Coverage Available You may purchase group critical illness coverage for your spouse in amounts up to $25,000 (not to exceed one-half of employee benefit). Includes $50 Annual Health Screening Benefit! (Employee and Spouse only) An insured may receive a maximum of $50 for any one covered health screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the amount payable for the diagnosis of a critical illness. There is no limit to the number of years the insured can receive the health screening benefit; it will be paid as long as the certificate remains inforce. Covered test listed in Limitations and Exclusions. COVERED SPECIFIED CRITICAL ILLNESSES CANCER (INTERNAL OR INVASIVE) 100% HEART ATTACK 100% STROKE 100% MAJOR ORGAN TRANSPLANT 100% KIDNEY FAILURE 100% OCCUPATIONAL HIV 100% CARCINOMA IN SITU 25% CORONARY ARTERY BYPASS SURGERY 25% OCCUPATIONAL HIV 100% COMA 100% PARALYSIS 100% SEVERE BURNS 100% LOSS OF SIGHT/HEARING/SPEECH 100% NOTE: If a benefit is paid for carcinoma in situ, the internal cancer benefit will be reduced by 25%. If a benefit is paid for coronary artery bypass surgery, the heart attack benefit will be reduced by 25%. All covered conditions are subject to the definitions found in your certificate. BI WEEKLY RATES Nontobacco 5,000 10,000 20,000 30,000 40,000 50, Tobacco 5,000 10,000 20,000 30,000 40,000 50, Rates may be slightly different due to rounding. Other benefit amounts available, employee and spouse are rated separately based on age and tobacco status.

4 ACCIDENT PLAN 24-Hour coverage. Guaranteed Issue no health questions asked. Benefits do not reduce as you get older. Pays regardless of Workers Compensation, medical coverage or any other insurance you may have. HOSPITAL BENEFITS EMPLOYEE SPOUSE CHILD Hospital Admission We will pay this benefit when an insured is admitted to a hospital and confined as a resident $250 $250 $250 bed patient because of injuries received in a covered accident (within 6 months of the date of the accident). We will pay this benefit once per calendar year per insured person. Hospital Confinement (per day) We will provide this benefit due to a covered accident on the first day of hospital confinement $100 $100 $100 for up to 30 days. Hospital Confinement must begin within 90 days from the date of the accident. Hospital Intensive Care (per day) Benefit paid up to 15 days per covered accident. Benefits are paid in addition to the $200 $200 $200 Hospital Confinement. Home Health Services (per day, for up to 30 days) $100 $100 $100 Benefits paid in lieu of hospital confinement, must begin within 6 months of a covered accident. Paralysis (lasting 90 days or more) Quadriplegia (4 limbs) $10,000 $10,000 $5,000 Paraplegia (2 limbs) $5,000 $5,000 $2,500

5 MAJOR INJURIES (diagnosis and treatment within 90 days) CLOSED REDUCTION OPEN REDUCTION FRACTURES (Chip fractures are paid at 10% of fracture benefit): Hip/Thigh Vertebrae (except processes) Pelvis Skull (depressed) Leg Forearm/Hand/Wrist Foot/Ankle/Knee cap Shoulder blade/collar bone Lower Jaw (Mandible) Skull (Simple) Upper Arm/Upper Jaw Facial bones (except teeth) Vertebral Processes Coccyx/Rib/Finger/Toe DISLOCATIONS (Partial dislocations are paid at 25% of dislocation benefit): Hip Knee (not knee cap) Shoulder Foot/Ankle Hand Lower Jaw Wrist Elbow Finger/Toe SPECIFIC INJURIES $4,000 $6,000 $3,600 $5,400 $3,200 $4,800 $3,000 $4,500 $2,400 $3,600 $2,000 $3,000 $2,000 $3,000 $1,600 $2,400 $1,600 $2,400 $1,400 $2,100 $1,400 $2,100 $1,200 $1,800 $800 $1,200 $320 $480 $2,700 $4,050 $1,950 $2,925 $1,500 $2,250 $1,200 $1,800 $1,050 $1,575 $900 $1,350 $750 $1,125 $600 $900 $240 $360 EMPLOYEE/SPOUSE/CHILD BURNS (treatment within 72 hours): Second Degree Less than 10% $100 At least 10%, but less than 25% $200 At least 25%, but less than 35% $500 35% or more $1,000 Third Degree Less than 10% $500 At least 10%, but less than 25% $3,000 At least 25%, but less than 35% $7,000 35% or more $10,000 First Degree burns are not covered. LACERATIONS (treatment and repair within 72 hours): Under 2" long $50 2" - 6" long $200 Over 6" long $400 Lacerations not requiring stitches $25 Multiple Lacerations: We will pay for the largest single laceration requiring stitches.

6 SPECIFIC INJURIES EMPLOYEE/SPOUSE/CHILD Ruptured Disc (treatment within 60 days; surgical repair within 1 year) $400 Tendons/Ligaments/Rotator Cuff (treatment within 60 days; surgical repair within 90 days) SINGLE If the insured fractures a bone or dislocates a joint, the amount paid will be based on the number $400 (single or multiple) of tendons or ligaments repaired. $600 MULTIPLE Torn Knee Cartilage (treatment within 60 days; surgical repair within 1 year) $500 Eye Injuries Treatment and surgical repair within 90 days $250 Concussion (a head injury resulting in electroencephalogram abnormality) $100 Coma (lasting 30 days or more) $10,000 Emergency Dental Work (per accident) Repaired with crown $150 Resulting in extraction $50 ADDITIONAL BENEFITS EMPLOYEE/SPOUSE/CHILD Ambulance If an insured requires transportation to a hospital by a professional ambulance service within $ days after a covered accident, we will pay the amount shown. Air Ambulance If an insured requires transportation to a hospital by a professional air ambulance service $500 within 90 days after a covered accident, we will pay the amount shown. Blood/Plasma and or Platelets If the insured receives blood and plasma within 90 days following a covered accident, we will pay $300 the amount shown. Appliances We will pay this benefit when you are advised by a physician to use a medical appliance due to injuries received in a covered accident. Benefits are payable for crutches, wheelchairs, leg braces, $100 back braces and walkers. Internal Injuries (resulting in open abdominal or thoracic surgery) $1,000 Exploratory Surgery (without repair, i.e. arthroscopy) $100 Accident Follow-up Treatment We will pay this benefit for up to six treatments per covered accident, per insured for follow-up treatment. The insured must have received initial treatment within 72 hours of the $50 accident and the follow-up treatment must begin within 30 days of the covered accident or discharge from the hospital. Emergency Room Treatment/Initial Doctor s Office Visit If an insured is injured in a covered accident and receive treatment within one year, we will pay up to the applicable amount for physician charges and emergency room services. The up to $150 total amount payable will not exceed the maximum shown above per accident. Initial treatment must be received within 60 days from the date of the accident.

7 OTHER BENEFITS EMPLOYEE/SPOUSE/CHILD Prosthesis $500 If an insured requires the use of a prosthetic device due to injuries received in a covered accident, we will pay this benefit. Hearing aids, wigs, or dental aids, including (but not limited to) $1,000 false teeth are not covered. SINGLE DEVICE MULTIPLE DEVICES Physical Therapy We will pay this benefit for up to six treatments (one per day) per covered accident, per insured for treatment from a physical therapist. The insured must have received initial treatment within 72 hours of the accident and physical therapy must begin within 30 days of the covered $25 accident or discharge from the hospital. Treatment must take place within six months after the accident. This benefit is not payable for the same visit that the Accident Follow-up Treatment benefit is paid. Transportation If hospital treatment or diagnostic study is recommended by your physician and is not available in your city of residence, we will pay the amount shown. Transportation must begin within 90 days $300 from the date of the covered accident. The distance to the location of the hospital must be greater than 100 miles from your residence. UP TO 3 TRIPS PER INSURED Family Lodging Benefit (per night) If an insured is required to travel more than 100 miles from his home for inpatient treatment of injuries received in a covered accident, we will pay this benefit for an immediate adult family member's $100 lodging. Benefits are payable up to 30 days per accident and only while the insured is confined to the hospital. BI WEEKLY RATES Employee $4.62 Employee and Spouse $6.92 Employee and Dependent Child(ren) $9.23 Employee, Spouse, and Dependent Child(ren) $11.54 Rates may be slightly different due to rounding.

8 LIMITATIONS AND EXCLUSIONS Disability (residents and physicians not eligible for this plan) Benefits will not be paid for disability due to: 1. any act of war, declared or undeclared, or participation in an insurrection, rebellion, or riot; 2. an intentionally self-inflicted injury; 3. a commission of, or attempt to commit, an assault, battery, or felony, or engagement in any illegal occupation; 4. loss of professional license, occupational license or certification; 5. commission of a crime under state or federal law; 6. an injury arising from any employment; 7. injury or sickness covered by Worker s Compensation. We will not pay a benefit for any period of disability during which and employee is incarcerated. An employee s coverage is subject to the payment of premium. PRE-EXISTING CONDITION LIMITATION If the employee has a pre-existing condition then we will not pay benefits for any claim (Period of Disability) starting within 12 months of the effective date of the employees coverage which is due to such pre-existing condition. A claim for benefits (Period of Disability) starting after 12 months from the Effective Date of the employees coverage will not be reduced or denied on the grounds that it is caused by a Pre-existing condition. TAKE OVER PRE-EXISTING CONDITION LIMITATION When the policy becomes effective, we will provide coverage for an employee if: he/she is not in active employment because of a sickness or injury; and he/she was covered by the prior policy. An employee s payment will be limited to the amount that would have been paid by the prior carrier. We will reduce an employee s payment by any amount for which his/her prior carrier is liable. We may send a payment if an employee s disability results from a pre-existing condition if he/she was: in active employment and insured under the policy on its effective date; and insured by the prior policy at the time of change. In order to receive a payment an employee must satisfy the pre-existing condition provision under our policy; or the prior carrier s policy, if benefit would have been paid had that policy remained in force. If an employee does not satisfy Item 1 or 2 above, we will not make any payments. If an employee satisfies Item 1, we will determine his/her payments according to our policy provisions. If an employee satisfied Item 2, we will administer his/her claim according to our policy provisions. However, his/her payment will be the lesser of: 1. the weekly benefit that would have been payable under the terms of the prior policy if it had remained in force; or 2. the weekly payment under our policy. An employee s benefits will end on the earlier of the following dates: 1. the end of the maximum benefit period under the policy; or 2. the date benefits would have ended under the prior policy if it had remained in force. If an employee changes to a shorter elimination period or an increase in benefit amount during the initial enrollment or subsequent open enrollment, then the employee will be subject to the 12 month pre-existing condition limitation. Critical Illness This plan contains a 30-day Waiting Period. This means a 25% benefit is payable for any insured who has been diagnosed with a specified critical Illness before their coverage has been in force 30 days from the Effective Date shown in the Rider Schedule; or at your option, you may elect to void this rider from the beginning and receive a full refund of premium. PRE-EXISTING CONDITIONS LIMITATION Pre-existing Condition means a sickness or physical condition which, within the 12-month period prior to an Insured s Effective Date resulted in the Insured receiving medical advice or treatment. We will not pay benefits for any Critical Illness starting within 12 months of an Insured s Effective Date which is caused by, contributed to, or resulting from a Pre-existing Condition. A claim for benefits for loss starting after 12 months from an Insured s Effective Date will not be reduced or denied on the grounds that it is caused by a Pre-existing Condition. A Critical Illness will no longer be considered Pre-existing at the end of 12 consecutive months starting and ending after an Insured s Effective Date. EXCLUSIONS We won t pay for loss due to: 1. Intentionally self inflicted injury or action. 2. Suicide or attempted suicide while sane or insane. 3. Illegal activities or participation in an illegal occupation. 4. War -declared or undeclared or military conflicts, participation in an insurrection or riot, civil commotion or state of belligerence. 5. Substance Abuse. Diagnosis must be made and treatment received in the United States. OCCUPATIONAL HIV EXCLUSIONS 1. No benefits will be paid for Occupational HIV resulting from a needle stick or sharp injury or a mucous membrane exposure to blood or bloodstained bodily fluid, which occurred prior to the effective date of this rider. 2. We will not pay for any cost incurred for HIV tests or any related testing. 3. No benefits will be paid for HIV contracted outside the United States. ADDITIONAL BENEFITS (Coma, Paralysis, Severe Burns, Loss of sight, speech or hearing) LIMITATIONS AND EXCLUSIONS This Rider contains a 30-day Waiting Period. This means a 25% benefit is payable for any insured who has been diagnosed with a specified critical Illness before their coverage has been in force 30 days from the Effective Date shown in the Rider Schedule; or at your option, you may elect to void this rider from the beginning and receive a full refund of premium. 1. No benefits will be paid if the Specified Critical Illness is a result of: a. Intentionally self inflicted injury or action; b. Suicide or attempted suicide while sane or insane; c. Illegal activities or participation in an illegal occupation; d. War, declared or undeclared, or military conflicts, participation in an insurrection or riot, civil commotion or state of belligerence; or e. Substance abuse. 2. No benefits will be paid for loss which occurred prior to the effective date of this Rider. 3. No benefits will be paid for diagnosis made outside the United States. Covered Health Screening Tests Mammography Colonoscopy Pap smear Breast ultrasound Chest x-ray PSA (blood test for prostate cancer) Stress test on a bicycle or treadmill Bone marrow testing CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Accident We will not pay benefits for an injury that is caused by or occurs as the result of: 1. Being exposed to war or armed conflict; 2. Flying; 3. Hazardous avocations; 4. Illegal activities; 5. Racing; 6. Sickness; 7. Participating in any professional or semi-professional organized sport; 8. Suicide or self-inflicted injuries. Fractures If more than one fracture requiring open or closed reduction occurs in any one accident, we will pay the scheduled benefit for each fracture, not to exceed 150 percent of the scheduled benefit amount with for the bone fractured with the highest dollar value. Benefits for chip fractures are payable at 10 percent of the scheduled amount shown for the affected bone. Dislocations If more than one dislocation requiring open or closed reduction occurs in any one accident, we will pay the scheduled benefit for each dislocation, not to exceed 150 percent of the scheduled benefit amount for the bone fractured with the highest dollar value. Benefits for partial dislocations are payable at 25 percent of the scheduled amount shown for the affected joint. If the insured fractures a bone and dislocates a joint in the same accident, we will pay for both. However, we will pay no more than 150 percent of the scheduled benefit amount for the bone fractured or joint dislocated with the highest dollar value. Benefits are payable for only the first dislocation of a joint. We will not pay benefits for a recurring dislocation of the same joint. Joints dislocated prior to the effective date of coverage will not be covered should they become dislocated while coverage is in force. This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. This brochure is subject to the terms, conditions, and limitations of policy form series CA7700- MP. FOR CLAIMS AND CUSTOMER SERVICE: CALL TOLL FREE Underwritten by: CEA (blood test for colon cancer) Flexible sigmoidoscopy Hemocult stool analysis Serum protein electrophoresis (blood test for myeloma) Thermography Fasting blood glucose test, blood test for triglycerides or serum cholesterol test to determine level of HDL and LDL Maricopa BR 4/08