Product Reference Guide

Transcription

1 Product Reference Guide Copyright 2006 by Aflac. All rights reserved. This information is for agent use only. It is not intended for distribution to the general public. MMC /06

2 Table of Contents Introduction... 2 Personal Accident Indemnity (PAI) Plan... 6 Wellness Benefit Pre-Existing Conditions Waiting Period Personal Accident Indemnity Plan Review Personal Disability Income Protector (PDIP) Plan Pregnancy Pre-Existing Conditions Waiting Period Personal Disability Income Protector Plan Review Personal Cancer Indemnity (PCI) Plan Wellness Benefit Waiting Period Personal Cancer Indemnity Plan Review Dental Series A Wellness Benefit Waiting Period Competitive Replacement Application Dental Series A81000 Review Personal Sickness Indemnity (PSI) Plan Pregnancy Pre-Existing Conditions Waiting Period Physician Visits Benefit Personal Sickness Indemnity Plan Review Review Answers Product Reference Guide i

3 Introduction Product Reference Guide 1

4 Introduction Introduction The purpose of this guide is to serve as a reference to discuss how Aflac s top five products pertain to the following areas: Personal Accident Indemnity Plan: Pregnancy Wellness Benefit Pre-Existing Conditions Waiting Period Personal Disability Income Protector Plan: Pregnancy Pre-Existing Conditions Waiting Period Personal Cancer Indemnity Plan: Wellness Benefit Waiting Period Dental Series A81000: Wellness Benefit Waiting Period Competitive Replacement Application Personal Sickness Indemnity: Pregnancy Pre-Existing Conditions Waiting Period Physician Visits Benefit Within each product, if state variations apply regarding the discussed topics, a copy of the policy variation will be shown. On the following page is a quick-reference sheet that marks states with exceptions. For each product, a review quiz is included to reinforce learning. Product Reference Guide 2

5 Introduction To determine Aflac s top five products, the Production Mix Report as of Week 25, 2005, was used. This guide is current as of August For policies that were introduced after this date, it is your responsibility to check for state variations. Do not assume that because a state is not listed that there are no state variations. This guide is intended as a reference piece for Aflac associates only and is not approved for sales purposes. Product Reference Guide 3

6 Aflac's Top Five Products Quick-Reference Spreadsheet States with exceptions to the standard are marked. Please refer to your specific state introduction packet for complete details. This spreadsheet is current as of August PAI AL AK AZ AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA ME MD MA MI MN MS MO Pregnancy Wellness Benefit Pre-Existing Conditions Waiting Period PDIP Pregnancy Pre-Existing Conditions Waiting Period PCI Wellness Benefit Waiting Period Dental Series Wellness Benefit Waiting Period Competitive Replacement PSI Pregnancy Pre-Existing Conditions Physician Visits Benefit Waiting Period PAI MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Pregnancy Wellness Benefit Pre-Existing Conditions Waiting Period PDIP Pregnancy Pre-Existing Conditions Waiting Period PCI Wellness Benefit Waiting Period Dental Series Wellness Benefit Waiting Period Competitive Replacement PSI Pregnancy Pre-Existing Conditions Physician Visits Benefit Waiting Period Note: States with darkened cells do not sell the product listed. Product Reference Guide 4

7 Personal Accident Indemnity (PAI) Plan Product Reference Guide 5

8 Personal Accident Indemnity (PAI) Plan Personal Accident Indemnity (PAI) Plan (Policy Series A-34000) Pregnancy The Personal Accident Indemnity Sickness Disability Rider contains the following provision for pregnancy and childbirth: Disability as a result of pregnancy and childbirth is payable to the same extent as a covered sickness. After this policy has been in force ten months, the maximum benefit period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the elimination period chosen, unless the woman furnishes proof that she remains disabled beyond these time frames. Aflac treats maternity as a sickness. Before any benefits are payable, the woman must first satisfy her elimination period. Then the benefit period and the disability benefits begin. Typically the standard disability length, as set by physicians and the insurance industry, is six weeks for noncesarean delivery and eight weeks for cesarean delivery. The elimination period is not subtracted from the benefit period. The elimination period is satisfied first and then benefits are payable for the remaining time she is considered disabled, up to the benefit period chosen. Most states have a ten-month maternity exclusion that states, We will not pay benefits for a disability that is caused by or occurs as a result of the woman giving birth within the first ten months of the effective date of the policy as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a sickness). Therefore, disability as a result of pregnancy and childbirth is excluded if the birth occurs within ten months of the effective date of the policy (as a result of a normal pregnancy). Complications of pregnancy are not excluded for the first ten months. If a woman is totally disabled because of complications of pregnancy, she would be eligible for disability benefits. Some states do not have the ten-month maternity exclusion. Please refer to your specific state introduction packet for complete details. However, all states are subject to the preexisting condition limitation provision. (In most states the pre-existing condition limitation Product Reference Guide 6

9 Personal Accident Indemnity (PAI) Plan provision is 12 months before and 12 months after the effective date of coverage.) Some states do not specify the six- or eight-week disability time frame, although Aflac will continue to administer claims in this manner. States with exceptions to the standard policy are noted below. The underlined text was added to the policy and the strikethrough text was deleted. Connecticut The definition of complications of pregnancy was added for the PAI policy. F. COMPLICATIONS OF PREGNANCY: (a) conditions requiring medical treatment prior to or subsequent to the termination of a pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by pregnancy or caused by pregnancy, such as acute nephritis; nephrosis; cardiac decompensation; missed abortion; disease of the vascular, hemopoietic, nervous, or endocrine systems; and similar medical and surgical conditions of comparable severity; but that do not include false labor, occasional spotting, Physicianprescribed rest during pregnancy, morning sickness and similar conditions associated with the management of a difficult pregnancy not constituting a classifiably distinct complication of pregnancy; (b) hyperemesis gravidarum and pre-eclampsia requiring Hospital Confinement, ectopic pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible; and (c) conditions requiring medical treatment after the termination of pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by pregnancy or caused by pregnancy. (This Definition only applies if Optional Sickness Disability Rider Form Series A is purchased.) Idaho The definition of complications of pregnancy was added for the PAI Sickness Rider. D. COMPLICATIONS OF PREGNANCY: (a) conditions requiring medical treatment prior to or subsequent to the termination of a pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by pregnancy or caused by pregnancy, such as acute nephritis; nephrosis; cardiac decompensation; missed abortion; disease of the vascular, hemopoietic, nervous, or endocrine systems; and similar medical and surgical conditions of comparable severity; (b) hyperemesis gravidarum and pre-eclampsia requiring Hospital Confinement, ectopic pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible. Complications of Pregnancy do not include false labor, occasional spotting, Physician-prescribed rest during pregnancy, morning sickness and similar conditions associated with the management of a difficult pregnancy not constituting a classifiably distinct complication of pregnancy. Product Reference Guide 7

10 Personal Accident Indemnity (PAI) Plan The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy (Complications of Pregnancy will be covered to the same extent as a Sickness); or Iowa The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy, including non-elective cesarean, will be covered to the same extent as a Sickness); or Kansas The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten months, the The maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. Michigan The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or Product Reference Guide 8

11 Personal Accident Indemnity (PAI) Plan Montana The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten months, the maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. New Jersey The definition of complications of pregnancy was added for the PAI Sickness Rider. C. COMPLICATIONS OF PREGNANCY: (a) conditions requiring medical treatment prior to or subsequent to the termination of a pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by pregnancy or caused by pregnancy, such as acute nephritis; nephrosis; cardiac decompensation; missed abortion; disease of the vascular, hemopoietic, nervous, or endocrine systems; and similar medical and surgical conditions of comparable severity; but that do not include false labor, occasional spotting, physicianprescribed rest during pregnancy, morning sickness and similar conditions associated with the management of a difficult pregnancy not constituting a classifiably distinct complication of pregnancy; (b) hyperemesis gravidarum and pre-eclampsia requiring hospital confinement, ectopic pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible; and (c) conditions requiring medical treatment after the termination of pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by pregnancy or caused by pregnancy. Product Reference Guide 9

12 Personal Accident Indemnity (PAI) Plan The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy when conception occurs prior to the Effective Date of this rider. Complications of Pregnancy (including non-elective cesarean (complications of pregnancy) will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten months, the The maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. North Carolina The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten months, the The maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. Product Reference Guide 10

13 Personal Accident Indemnity (PAI) Plan Oklahoma The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten months, the The maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. South Carolina The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten nine months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or The benefits are different for the PAI Sickness Rider regarding maternity. Disability due to pregnancy and childbirth is payable to the same extent as a covered Sickness. After this rider has been in force ten nine months, the maximum Benefit Period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the Elimination Period, unless you furnish proof that you remain disabled, as defined above, beyond these time frames. Tennessee The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including elective cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or Product Reference Guide 11

14 Personal Accident Indemnity (PAI) Plan Texas The maternity limitation and exclusion is different for the PAI Sickness Rider. 1. Giving birth if the pregnancy is a normal pregnancy and the pregnancy began prior to the Effective Date of the rider (complications of pregnancy will be covered to the same extent as a Sickness); or Vermont The maternity limitation and exclusion is different for the PAI Sickness Rider. 2. Giving birth within the first ten months of the Effective Date of this rider as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a Sickness); or Product Reference Guide 12

15 Personal Accident Indemnity (PAI) Plan Wellness Benefit After the Personal Accident Indemnity policy has been in force for 12 months, Aflac will pay $60 for the insured or any one family member to undergo a covered routine examination or other covered preventive testing during the following policy year. This benefit is payable only once per policy each 12-month period following the policy anniversary date. The following services will be covered: annual physical examinations, dental exams, mammograms, Pap smears, eye examinations, immunizations, flexible sigmoidoscopies, prostate specific antigen tests (PSAs), ultrasounds, and blood screenings. The Wellness Benefit is not payable for a procedure performed during the first policy year. Aflac will mail automated letters to remind policyholders when they are eligible for the Wellness Benefit. The Wellness Benefit may vary by state. Please refer to your specific state introduction packet for complete details. Product Reference Guide 13

16 Personal Accident Indemnity (PAI) Plan States with exceptions to the standard policy are noted below. The underlined text was added to the policy and the strikethrough text was deleted. Connecticut The Wellness Benefit is different for the PAI policy. Benefit Benefits A is a and B are preventive benefits; the death, Dismemberment, or Injury of a covered person is not required for this benefit these benefits to be payable. A. WELLNESS BENEFIT: After this policy has been in force for 12 months, we will pay $60 (sixty dollars) if you or any one family member undergoes routine examinations or other preventive testing during the following policy year. Services covered are: annual physical examinations, dental exams, mammograms, Pap smears, eye examinations, immunizations, flexible sigmoidoscopies, prostatespecific antigen tests (PSAs), ultrasounds, and blood screenings. This benefit will become available following each anniversary of the policy's Effective Date for service received during the following policy year and is payable only once per policy each 12-month period following your policy anniversary date. Eligible family members are your spouse and the dependent children of either you or your spouse. Service must be under the supervision of or recommended by a Physician, received while your policy is in force, and a charge must be incurred. B. MAMMOGRAPHY BENEFIT: We will pay $70 (seventy dollars) per calendar year for each covered person when a charge is incurred for an annual screening, prescribed by a Physician, by low dose mammography for the presence of occult breast cancer. Massachusetts There is no Wellness Benefit for the PAI policy. Montana The Wellness Benefit is different for the PAI policy. A. WELLNESS BENEFIT: After this policy has been in force for 12 months, we will pay $60 (sixty dollars) if you or any one family member undergoes routine examinations or other preventive testing during the following policy year. Services covered are: annual physical examinations, dental exams, mammograms, Pap smears, eye examinations, immunizations, flexible sigmoidoscopies, prostatespecific antigen tests (PSAs), ultrasounds, and blood screenings. This benefit will become available following each anniversary of the policy's Effective Date for service received during the following policy year and is payable only once per policy each 12-month period following your policy anniversary date. Eligible family members are your spouse and the dependent children of either you or your spouse. Service must be under the supervision of or recommended by a Physician, received while your policy is in force, and a charge must be incurred. B. MAMMOGRAPHY BENEFIT: We will pay actual charges up to $70 for an annual screening, prescribed by a Physician, by low dose mammography. Product Reference Guide 15

17 Personal Accident Indemnity (PAI) Plan New Jersey The Wellness Benefit is different for the PAI policy. A. WELLNESS BENEFIT: After this policy has been in force for 12 months, we We will pay $60 (sixty dollars) if you or any one family member undergoes routine examinations or other preventive testing during the following policy year. Services covered are: annual physical examinations, dental exams, mammograms, Pap smears, eye examinations, immunizations, flexible sigmoidoscopies, prostate-specific antigen tests (PSAs), ultrasounds, and blood screenings. This benefit will become available following each anniversary of the policy s Effective Date for service received during the following policy year and is payable only once per policy each 12-month period following your policy anniversary date. Eligible family members are your spouse and the dependent children of either you or your spouse. Service must be under the supervision of or recommended by a Physician, received while your policy is in force, and a charge must be incurred. We will pay the following benefits as applicable if a covered person s death, Dismemberment, or Injury is caused by a covered accident that occurs on or off the job. Death, Dismemberment, or Injury must be independent of disease or bodily infirmity, or of any cause other than a covered accident. A covered accident must also occur while coverage is in force and is subject to the limitations and exclusions. New York There is no Wellness Benefit for the PAI policy. Product Reference Guide 16

18 Personal Accident Indemnity (PAI) Plan Pennsylvania The Wellness Benefit is different for the PAI policy. Benefit A is a preventive benefit; the death, Dismemberment, or Injury of a covered person is not required for this benefit to be payable. A. WELLNESS BENEFIT: After this policy has been in force for 12 months, we will pay $60 (sixty dollars) if you or any one family member undergoes routine examinations or other preventive testing during the following policy year. Services covered are: annual physical examinations, dental exams, mammograms, Pap smears, eye examinations, immunizations, flexible sigmoidoscopies, prostatespecific antigen tests (PSAs), ultrasounds, and blood screenings. This benefit will become available following each anniversary of the policy's Effective Date for service received during the following policy year and is payable only once per policy each 12-month period following your policy anniversary date. Eligible family members are your spouse and the dependent children of either you or your spouse. Service must be under the supervision of or medically recommended by a Physician, received while your policy is in force, and a charge must be incurred. We will pay the following benefits as applicable if a covered person s death, Dismemberment, or Injury is caused by a covered accident that occurs on or off the job. Death, Dismemberment, or Injury must be independent of disease or bodily infirmity, or of any cause other than a covered accident. A covered accident must also occur while coverage is in force and is subject to the limitations and exclusions. Product Reference Guide 17

19 Personal Accident Indemnity (PAI) Plan Pre-Existing Conditions A pre-existing condition is a sickness (including pregnancy) or an injury for which, within the 12-month period before the effective date of coverage, medical advice, consultation, or treatment was recommended or received, or for which symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Under the Personal Accident Indemnity Disability Riders, disability caused by a pre-existing condition or injuries to a pre-existing condition will not be covered unless it begins more than 12 months after the effective date of coverage. The Personal Accident Indemnity Sickness Disability Rider is also subject to a pre-existing condition provision. The pre-existing condition provision states, Disability or hospitalization caused by a pre-existing condition will not be covered unless it begins more than 12 months after the effective date of coverage. The pre-existing conditions provision may vary by state. Please refer to your specific state introduction packet for complete details. States with exceptions to the standard policy are noted below. The underlined text was added to the policy and the strikethrough text was deleted. Alaska The definition of pre-existing condition is different for the PAI Sickness Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre-Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. If the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the Effective Date of coverage. Product Reference Guide 18

20 Personal Accident Indemnity (PAI) Plan Connecticut The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended by or received from a Physician, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. If you are replacing another disability policy that was in force within 60 days of the effective date of this rider, we will credit this provision with the period of time the previous coverage was in force. D.C. The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Florida The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause from a prudent person to seek diagnosis, care, or treatment member of the medical profession. Product Reference Guide 19

21 Personal Accident Indemnity (PAI) Plan Georgia The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than during the first 12 months after the Effective Date of coverage. A Pre-Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Idaho The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-six month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause from a prudent person to seek diagnosis, care, or treatment Physician. This rider does not cover losses caused by or resulting from donating an organ within the first 12 months of the Effective Date of this rider. Illinois The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, is an Injury or Sickness which was diagnosed by, or for which medical advice, consultation, or treatment was recommended or received from a legally qualified Physician, or in the opinion of a Physician, symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Maryland The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. A Pre-Existing Condition does not include a condition admitted in the application which was not excluded by a signed waiver rider. Product Reference Guide 20

22 Personal Accident Indemnity (PAI) Plan Montana The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. North Carolina The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause from a prudent person to seek diagnosis, care, or treatment Physician. This rider has a 30-day waiting period for Sickness. If the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 30 days after the Effective Date of coverage. North Dakota The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received. or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Product Reference Guide 21

23 Personal Accident Indemnity (PAI) Plan New Jersey The definition of pre-existing condition is different for the PAI Sickness Rider, Accident Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 during the first 24 months after the Effective Date of coverage. A Pre-Existing Condition is a Sickness either misrepresented or not revealed on the application and for which, within the 12-month period before the symptoms existed prior to the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would cause an ordinarily cause a prudent person to seek diagnosis, care, or treatment or for which medical advice or treatment was recommended by or received from a Physician. If you are replacing another disability policy that was in force within 60 days of the Effective Date of this rider, we will credit this provision with the period of time the previous coverage was in force. New Mexico The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than six months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness condition for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause from a prudent person to seek diagnosis, provider of health care, or treatment services within six months preceding the Effective Date of coverage of an Insured person. New York The definition of pre-existing condition was removed from the PAI Accident Rider and Spouse Rider. Pennsylvania The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was medically recommended by a Physician or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment from a Physician within the 12-month period before the Effective Date of coverage. Product Reference Guide 22

24 Personal Accident Indemnity (PAI) Plan South Carolina The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition or reinjuries to a Pre- Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre-Existing Condition is a Sickness for which, within the 12-month period before condition misrepresented or not revealed in the application and which symptoms existed prior to the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would cause an ordinarily cause a prudent person to seek diagnosis, care, or treatment or for which medical advice or treatment was recommended by or received from a Physician. This policy does not cover losses caused by or resulting from donating an organ within the first 12 months of the Effective Date of this policy. Vermont The definition of pre-existing condition is different for the PAI Sickness Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. This policy does not cover losses caused by or resulting from donating an organ within the first 12 months of the Effective Date of this policy. Virginia The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Product Reference Guide 23

25 Personal Accident Indemnity (PAI) Plan Wisconsin The definition of pre-existing condition is different for the PAI Sickness Rider, Off-the-Job Rider, On-the-Job Rider, and Spouse Rider. Disability or hospitalization caused by a Pre-Existing Condition will not be covered unless it begins more than 12 months after the Effective Date of coverage. A Pre- Existing Condition is a Sickness for which, within the 12-month period before the Effective Date of coverage, medical advice, consultation, or treatment was recommended or received, or symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Any Pre-Existing Condition admitted in the application is covered from the Effective Date of the policy unless excluded by specific name and description. Product Reference Guide 24

26 Personal Accident Indemnity (PAI) Plan Waiting Period The waiting period is defined as the period after the effective date of coverage for which benefits are not payable. The Personal Accident Indemnity Sickness Disability Rider has a 30-day waiting period. If the disease or disorder is first manifested or treated within the first 30 days after the effective date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the effective date of coverage. Some states do not have the 30-day waiting period. Please refer to your specific state introduction packet for complete details. States with exceptions to the standard policy are noted below. The underlined text was added to the policy and the strikethrough text was deleted. Arizona There is no 30-day waiting period for the PAI policy. Idaho There is no 30-day waiting period for the PAI policy. Kansas There is no 30-day waiting period for the PAI policy. Louisiana There is no 30-day waiting period for the PAI policy. Maine There is no 30-day waiting period for the PAI policy. Product Reference Guide 25

27 Personal Accident Indemnity (PAI) Plan Michigan There is no 30-day waiting period for the PAI policy. The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or treated more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase Sickness only applies if the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the Effective Date of coverage issued. Missouri There is no 30-day waiting period for the PAI policy. Montana There is no 30-day waiting period for the PAI policy. The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested diagnosed or treated more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the Effective Date of coverage. Sickness also includes a pregnancy which starts after your Effective Date of coverage and while coverage is in force. New Hampshire There is no 30-day waiting period for the PAI policy. New Jersey The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or treated results in loss commencing more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If This definition only applies if you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the Effective Date of coverage. Product Reference Guide 26

28 Personal Accident Indemnity (PAI) Plan Oklahoma The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or treated more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability resulting from Sickness will not be covered unless it begins for losses incurred more than 12 months 30 days after the your Effective Date of coverage. Pennsylvania The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or medically treated or medically diagnosed more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 months after the Effective Date of coverage. New Mexico The definition of sickness is different for the PAI policy. W. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or treated more than 30 days after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability will not be covered unless it begins more than 12 six months after the Effective Date of coverage. South Dakota There is no 30-day waiting period for the PAI policy. Product Reference Guide 27

29 Personal Accident Indemnity (PAI) Plan Virginia The definition of sickness is different for the PAI policy. Y. SICKNESS: a disease, disorder, infection, or any other abnormal physical condition that is not caused by an Injury that is first manifested or treated more than 30 days or more after your Effective Date of coverage and while coverage is in force. "Sickness" includes diseases or conditions resulting from insect bites or infestations by microorganisms. If you purchase the Optional Sickness Disability Rider Series A-34052, and the disease or disorder is first manifested or treated within the first 30 days after your Effective Date of coverage, any resulting disability resulting from Sickness will not be covered unless it begins for losses incurred 30 days or more than 12 months after the your Effective Date of coverage. Product Reference Guide 28

30 Personal Accident Indemnity (PAI) Plan Personal Accident Indemnity Plan Review 1. True or False. Before any benefits are payable on the Personal Accident Indemnity Sickness Disability Rider, the insured must first satisfy his or her elimination period. 2. Fill in the Blank. Most states have a -month maternity exclusion that excludes giving birth within the first months of the effective date of the policy as a result of a normal pregnancy, including cesarean. 3. Fill in the Blank. In most states the pre-existing condition provision is months before and months after the effective date of coverage. 4. True or False. Under the Personal Accident Indemnity plan, the Wellness Benefit is payable for dental exams. 5. Multiple Choice. The Personal Accident Indemnity plan has a Wellness Benefit. a. $40 b. $50 c. $60 d. None of the above 6. True or False. The Wellness Benefit is payable for the insured and each family member covered by the Personal Accident Indemnity plan. Product Reference Guide 29

31 Personal Accident Indemnity (PAI) Plan 7. Multiple Choice. After coverage has been in force for months, the Personal Accident Indemnity plan will pay a Wellness Benefit. a. 6 b. 9 c. 12 d. None of the above 8. True or False. Under the Personal Accident Indemnity policy, the Wellness Benefit is not payable for treatment received during the first year after the policy effective date. 9. True or False. Disability caused by a pre-existing condition or injuries to a pre-existing condition will not be covered unless it begins more than 12 months after the effective date of coverage. 10. Multiple Choice. The Personal Accident Indemnity Sickness Disability Rider has a -day waiting period. a. 30 b. 60 c. 90 d. None of the above Review answers can be found at the end of this guide. For additional information regarding the Personal Accident Indemnity plan, refer to the field sales guide, M1044B, and your state s administrative guidelines. Product Reference Guide 30

32 Personal Disability Income Protector (PDIP) Plan Product Reference Guide 31

33 Personal Disability Income Protector (PDIP) Plan Personal Disability Income Protector (PDIP) Plan (Policy Series A-57400) Pregnancy The Personal Disability Income Protector Plan contains the following provision for pregnancy and childbirth: Disability as a result of pregnancy and childbirth is payable to the same extent as a covered sickness. After this policy has been in force ten months, the maximum benefit period allowed for childbirth is six weeks for noncesarean delivery and eight weeks for cesarean delivery, less the elimination period chosen, unless the woman furnishes proof that she remains disabled beyond these time frames. Aflac treats maternity as a sickness. Before any benefits are payable, the woman must first satisfy her elimination period. Then the benefit period and the disability benefits begin. Typically the standard disability length, as set by physicians and the insurance industry, is six weeks for noncesarean delivery and eight weeks for cesarean delivery. The elimination period is not subtracted from the benefit period. The elimination period is satisfied first and then benefits are payable for the remaining time she is considered disabled, up to the benefit period chosen. Most states have a ten-month maternity exclusion that states: We will not pay benefits for a disability that is caused by or occurs as a result of the woman s giving birth within the first ten months of the effective date of the policy as a result of a normal pregnancy, including cesarean (complications of pregnancy will be covered to the same extent as a sickness). Therefore, disability as a result of pregnancy and childbirth is excluded if the birth occurs within ten months of the effective date of the policy (as a result of a normal pregnancy). Complications of pregnancy are not excluded for the first ten months. If a woman is totally disabled as a result of complications of pregnancy, she would be eligible for disability benefits. Some states do not have the ten-month maternity exclusion. Please refer to your specific state introduction packet for complete details. However, all states are subject to the preexisting condition limitation provision. (In most states, the pre-existing condition limitation Product Reference Guide 32