Limited Benefit Group Cancer Indemnity Insurance GC-3 (includes Continuation Rider)

Transcription

1 Limited Beefit Group Cacer Idemity Isurace GC-3 (icludes Cotiuatio Rider) APSB-21861(FL)-1014 APSB-21861(FL)-1014 (SM) Citrus Couty School Board Citrus Couty School Board APS-1883 Geeric-EE

2 Summary of Beefits by Level* Beefit Descriptio Level II Level III Radiatio Therapy / Chemotherapy / Immuotherapy Beefit $1,000 per caledar moth of treatmet, up to $12,000 per 12 moth period $1,500 per caledar moth of treatmet, up to $18,000 per 12 moth period Hormoe Therapy Beefit $50 per treatmet, up to 12 per caledar year $50 per treatmet, up to 12 per caledar year Surgical Schedule Beefit $3,200 max per operatio; $30 per surgical uit $4,800 max per operatio; $45 per surgical uit Aesthesia Beefit 25% of the amout paid for covered surgery 25% of the amout paid for covered surgery Outpatiet Hospital or Ambulatory Surgical Ceter Beefit $400 per day of surgery $600 per day of surgery Hospital Cofiemet Beefit $200 per day, 1-90 days; $200 per day, 91+ days, i lieu of all other beefits $300 per day, 1-90 days; $300 per day, 91+ days, i lieu of all other beefits U.S. Govermet / Charity Hospital / HMO Beefit $200 per day i lieu of most other beefits $300 per day i lieu of most other beefits $150 per Cofiemet $50 per prescriptio, up to $100 per caledar moth per Covered Perso $150 per Cofiemet $50 per prescriptio, up to $150 per caledar moth per Covered Perso Blood, Plasma ad Platelets Beefit $200 per day, up to $10,000 per caledar year $250 per day, up to $12,500 per caledar year Trasportatio Beefit $.40 per mile per roud trip $.40 per mile per roud trip Lodgig Beefit $50 per day, up to 50 days per caledar year $50 per day, up to 50 days per caledar year Boe Marrow / Stem Cell Trasplat Beefit Autologous - $1,000 per caledar year No-Autologous - $3,000 per caledar year Autologous - $1,500 per caledar year No-Autologous - $4,500 per caledar year Attedig Physicia Beefit $40 per day of Cofiemet $50 per day of Cofiemet Prosthesis Beefit $2,000 per device, (icludes surgical fee); max. 1 device per site, 2 lifetime max $50 per hair prosthetic; 2 lifetime max. $3,000 per device, (icludes surgical fee); max. 1 device per site, 2 lifetime max $50 per hair prosthetic; 2 lifetime max. $300 per diagosis; additioal $300 if third opiio $300 per diagosis; additioal $300 if third opiio $200 per groud trip $2,000 per air trip; up to 2 trips per Hospital Cofiemet (ay combiatio of groud/ air) $200 per groud trip $2,000 per air trip; up to 2 trips per Hospital Cofiemet (ay combiatio of groud/ air) Exteded Care Beefit $200 per day $300 per day Home Health Care Beefit $200 per day $300 per day Hospice Care Beefit $75 per day, $13,500 lifetime max $100 per day, $18,000 lifetime max Physical / Speech Therapy Beefit $25 per visit, up to 4 visits per caledar moth, $1,000 lifetime max $25 per visit, up to 4 visits per caledar moth, $1,000 lifetime max Dread Disease Beefit $200 per day, 1-90 days of Hospital Cofiemet $300 per day, 1-90 days of Hospital Cofiemet Experimetal Treatmet Beefit Pays as ay o-experimetal beefit Pays as ay o-experimetal beefit Ipatiet Special Nursig Services Beefit $150 per day of Cofiemet $150 per day of Cofiemet Door Beefit $1,000 per doatio $1,000 per doatio Waiver of Premium Beefit Premium waived after 90 days of Primary Isured cotiuous total disability due to Cacer Premium waived after 90 days of Primary Isured cotiuous total disability due to Cacer Drugs ad Medicie Beefit Ipatiet Outpatiet Surgical Implatatio Hair Prosthesis Secod ad Third Surgical Opiio Beefit Ambulace Beefit Groud Air Refer to Beefit Highlights for more complete Beefit Descriptios ad limits o the Group Cacer Idemity Pla. *The premium ad amout of beefits provided vary depedet upo the Level selected at time of applicatio.

3 Riders Diagostic Testig Beefit Rider For a Covered Perso: Pays a idemity amout for oe medically recogized screeig test per caledar year to detect iteral Cacer. Payable without a diagosis of Cacer. Diagostic Testig Beefit $75 per test Critical Illess Rider For a Covered Perso: Pays whe diagosed after 30-day Critical Illess Waitig Period with Iteral Cacer depedig upo the Critical Illess coverage elected at time of applicatio. Pays up to the specified Maximum Beefit Amout per Covered Critical Illess, as show i the certificate policy schedule. Each beefit is a oe time paid beefit. All Critical Illess beefit amouts reduce by 50% at age 70. Level II Cacer Beefit $2,500 lump sum Level III Cacer Beefit $5,000 lump sum Optioal Hospital Itesive Care Uit Rider For a Covered Perso: Cofiemet must be due to accidet or sickess ad begi after the effective date of coverage uder this rider. A day is defied as a 24-hour period. If cofied to a ICU for a portio of a day, a pro rata share of the daily beefit will be paid. Pays $600 per day up to 30 days per cofiemet i a ICU Pays $100 i Ambulace expeses per admissio i a ICU.

4 Policy Beefit Highlights Radiatio Therapy / Chemotherapy / Immuotherapy Beefit Pays the idemity amout whe a Covered Perso receives treatmet ad icurs a charge for covered therapy or covered drugs for Radiatio Therapy, Chemotherapy, or Immuotherapy as defied i the policy/ certificate. We will pay oly oe Radiatio Therapy/Chemotherapy/ Immuotherapy beefit per caledar moth regardless of the umber of treatmets received durig the moth. Ati-ausea drugs are ot covered uder this beefit. This beefit does ot iclude ay drugs/ medicies covered uder the Drugs ad Medicie Beefit or the Hormoe Therapy Beefit. Hormoe Therapy Beefit Pays the idemity amout for hormoe therapy treatmets as defied i the policy/certificate, prescribed by a Physicia. This beefit does ot iclude drugs/medicies covered uder the Radiatio Therapy/ Chemotherapy/Immuotherapy Beefit or the Drugs ad Medicie Beefit. Surgical Beefit Pays a idemity beefit up to the Maximum Per Operatio amout show i the Schedule of Beefits i the policy/certificate whe a surgical operatio is performed o a Covered Perso for covered diagosed Cacer, Ski Cacer, or recostructive surgery due to Cacer. Beefits will be calculated by multiplyig the surgical uit value assiged to the procedure, as show i the most curret Physicia s Relative Value Table, by the Uit Dollar Amout show i the Schedule of Beefits. Two or more surgical procedures performed through the same icisio will be cosidered oe operatio ad beefits will be limited to the most expesive procedure. Diagostic surgeries that result i a egative diagosis of Cacer are ot covered uder this beefit. Boe marrow surgeries are paid uder the Boe Marrow /Stem Cell Trasplat Beefit. Surgeries required to implat a permaet prosthetic device are covered uder the Prosthesis Beefit. Aesthesia Beefit The Aesthesia beefit pays 25% of the amout paid for a covered surgery for the services of a aesthesiologist. Services of a aesthesiologist for boe marrow trasplats, Ski Cacer, or surgical prosthesis implatatio are ot covered uder this beefit. Outpatiet Hospital or Ambulatory Surgical Ceter Beefit Pays the idemity amout show towards the facility fee charges of a Ambulatory Surgical Ceter or Hospital for a outpatiet surgical procedure of a diagosed Cacer. Surgical procedures for Ski Cacer are ot covered uder this beefit. Hospital Cofiemet Beefit Pays the idemity amout show for a Covered Perso while cofied to a Hospital for at least 18 cotiuous hours for the treatmet of a covered Cacer or the treatmet of a coditio or disease directly caused by Cacer or the treatmet of Cacer. Whe the Covered Perso s Hospital Cofiemet cotiues for more tha 90 days, this beefit will be paid i lieu of all other beefits payable for the Covered Perso durig such Hospital Cofiemet begiig o the 91st day. A Hospital is ot a istitutio, or part thereof, used as: a hospice uit, icludig ay bed desigated as a hospice or a swig bed; a covalescet home; a rest or ursig facility; a rehabilitative facility; a exteded-care facility; a skilled ursig facility; or a facility primarily affordig custodial, educatioal care, or care or treatmet for persos sufferig from metal diseases or disorders, or care for the aged, or drug or alcohol addictio. U.S. Govermet / Charity Hospital / H.M.O. Beefit If a itemized list of services is ot available because a Covered Perso is: cofied i a charity Hospital or U.S. Govermet owed Hospital; or covered uder a Health Maiteace Orgaizatio (H.M.O.) or a Diagostic Related Group (D.R.G.) where o charges are made to the Covered Perso, the Primary Isured may covert beefits to pay the idemity amout show. This beefit will be paid i lieu of most beefits uder the policy/certificate. Drugs ad Medicies Beefit Pays the idemity amout for ati-ausea ad pai medicatio prescribed by a Physicia for a Covered Perso for treatmet of Cacer, who is also receivig Radiatio Therapy / Chemotherapy/ Immuotherapy, a covered surgery, or a Boe Marrow/Stem Cell Trasplat. This beefit does ot cover associated admiistrative charges. This beefit does ot iclude drugs/medicies covered uder the Radiatio Therapy/Chemotherapy/Immuotherapy Beefit or Hormoe Therapy Beefit. Blood, Plasma & Platelets Beefit Pays the idemity amout for blood, plasma ad platelets. This does ot iclude ay laboratory processes. Coloy stimulatig factors are ot covered uder this beefit. Beefits for Blood, Plasma ad Platelets are ONLY provided uder this beefit. Trasportatio ad Lodgig Beefits & Family Member Trasportatio ad Lodgig Beefits These beefits pay for trasportatio of a Covered Perso ad/or oe adult family member, whe the Covered Perso has bee diagosed with Cacer ad receives covered Radiatio Therapy, Chemotherapy, Immuotherapy treatmet, Boe Marrow/Stem Cell Trasplat, or surgery due to Cacer i the earest Physicia prescribed Hospital providig such treatmet that is at least 50 miles away from the Covered Perso s residece, usig the most direct route. Travel must be by scheduled bus, plae or trai, or by car ad be withi the Uited States or its Territories. Beefits will be provided for oly oe mode of trasportatio per roud trip (maximum beefit of up to 1,000 miles per roud trip) ad will be paid for up to 12 roud trips per Caledar Year. Beefits for travel of the Covered Perso ad/or family member will be paid: oce per Covered Perso s Hospital Cofiemet; or oly o days of the Covered Perso s outpatiet specialized treatmet. Beefits for lodgig of the Covered Perso ad/or family member will be paid: oce per Covered Perso s Hospital Cofiemet; or oly o days of the Covered Perso s outpatiet specialized treatmet. If the family member ad the Covered Perso travel i the same car or lodge i the same room, beefits for travel ad lodgig will oly be paid uder the Trasportatio ad Lodgig Beefit for the patiet. Boe Marrow Beefit / Stem Cell Trasplat Beefit Pays the idemity amout whe a boe marrow trasplat or peripheral blood stem cell trasplat is performed o a Covered Perso as treatmet for a diagosed Cacer. This beefit will ot be paid for the harvest of boe marrow or stem cells from a door. This beefit is payable i or out of the Hospital. Attedig Physicia Beefit Pays the idemity amout for oe Physicia s visit per day whe a Covered Perso requires the services of a Physicia, other tha a surgeo while Hospital Cofied for the treatmet of Cacer. Prosthesis Beefit ad Hair Prosthesis Beefit Pays the idemity amout for a surgically implated prosthetic device received due to Cacer that maifested after the 30th day followig the Effective Date, provided it was prescribed by a Physicia as a direct result of surgery for Cacer. This beefit does ot cover prosthetic related supplies. Temporary prosthetic devices used as tissue expaders are covered uder the Surgical Beefit. Hair Prosthesis beefit pays the idemity amout for a Covered Perso s hair prosthesis eeded as a direct result of Cacer or the treatmet of Cacer. Secod & Third Surgical Opiio Beefit Pays the idemity amout oce per diagosis for a Covered Perso s secod surgical opiio ad if the secod disagrees with the first, we will pay a third opiio, whe the attedig Physicia recommeds surgery for the treatmet of Cacer. Surgical opiios for recostructive, Ski Cacer, or prosthesis surgeries are ot covered uder this beefit.

5 Ambulace Beefit Pays the idemity amout per trip for either licesed air or groud ambulace trasportatio of a Covered Perso to a Hospital or from oe medical facility to aother where the Covered Perso is admitted as a Ipatiet ad Hospital cofied for at least 18 cosecutive hours for treatmet of Cacer. Exteded Care Facility Beefit Pays the idemity amout for each day room ad board charges are icurred while a Covered Perso is cofied i a Exteded Care Facility due to Cacer at the directio of a Physicia that begis withi 14 days after a covered Hospital Cofiemet. Paid for up to the same umber of days beefits were paid for the Covered Perso s precedig Hospital Cofiemet. Home Health Care Beefit Pays the idemity amout for a Covered Perso s Home Health Care, as described i the policy/certificate, required due to Cacer whe prescribed by a Physicia i lieu of Hospital Cofiemet. This beefit does ot iclude physical therapy or speech therapy. This beefit does ot iclude: utritio couselig; medical social services; medical supplies; prosthesis or orthopedic appliaces; retal or purchase of durable medical equipmet; drugs or medicies; child care; meals or house-keepig services. This beefit will be paid for up to the same umber of days beefits were paid for the Covered Perso s precedig Hospital Cofiemet. If the Covered Perso qualifies for coverage uder the Hospice Care Beefit, the Hospice Care Beefit will be paid i lieu of this beefit. Hospice Care Beefit Pays the idemity amout for Hospice Care directed by a licesed Hospice orgaizatio, as defied i the policy/certificate, of a Covered Perso expected to live six moths or less due to Cacer. This beefit does ot iclude: well baby care; voluteer services; meals; housekeepig services; or family support after the death of the Covered Perso. Physical or Speech Therapy Beefit Pays the idemity amout if a Physicia advises a Covered Perso to seek physical therapy or speech therapy. Physical or speech therapy must be performed by a caregiver licesed i physical or speech therapy ad be eeded as a result of Cacer or the treatmet of Cacer. We will pay for oe treatmet per day up to four treatmets per caledar moth per Covered Perso for ay combiatio of physical or speech therapy up to a lifetime maximum of $1,000. Dread Disease Beefit Pays the idemity amout for each period of Hospital Cofiemet of a Covered Perso for treatmet of Dread Disease, as defied i the policy/certificate. Beefits for Dread Disease are ONLY provided uder this provisio of the policy/certificate. Experimetal Treatmet Beefit Pays beefits for Experimetal Treatmet, as defied i the policy/ certificate, the same as ay other o-experimetal treatmet covered uder this policy/certificate. This beefit does ot provide coverage for treatmets received outside of the Uited States or its Territories. Ipatiet Special Nursig Services Beefit Pays the idemity amout show for full-time special ursig care (other tha that regularly furished by a Hospital) while a Covered Perso is Hospital Cofied for treatmet of Cacer. Full-time meas at least eight cosecutive hours durig a 24-hour period. Care must be provided by a Nurse, as defied i this policy/certificate; be prescribed by a Physicia; ad be Medically Necessary for the treatmet of Cacer. Door Beefit Pays the idemity amout show for a covered surgery if expeses are icurred by a door o behalf of a Covered Perso due to a Boe Marrow Trasplat or Stem Cell Trasplat. This beefit will be paid regardless of where the surgery is performed. Blood door expeses are ot covered uder this beefit. Waiver of Premium Beefit If the Primary Isured becomes disabled due to Cacer ad remais so for 90 cotiuous days, we will pay all premiums due after the 90th day so log as the Primary Isured remais disabled. Disabled meas for the first 12 moths of disability the Primary Isured s iability because of Cacer is: uable to perform the material ad substatial duties of your regular occupatio; ad uder the care of a Physicia for the treatmet of Cacer. After the first 12 moths of cotiuous disability, the term disabled meas that the Primary Isured due to Cacer is: uable to work at ay job for which the Primary Isured is qualified by educatio, traiig, or experiece; ad uder the care of a Physicia for the treatmet of Cacer. This policy/certificate must be i force at the time disability begis ad the Primary Isured must be uder age 65. Cotiuatio Rider Cotiuatio Coverage is cotiued whe the Isured (You) cease employmet with the employer through whom You origially became isured uder the Policy. You will have the optio to cotiue this Certificate (icludig ay Riders, if applicable) by payig the premiums directly to Us at Our home office. Premiums must be paid withi thirty-oe (31) days after employmet with your employer termiates. Premium rates required uder this Cotiuatio provisio will be the same rates as those charged uder the Employer s Policy as if You had cotiued employmet. We will bill You for these premiums after You otify Us to cotiue this coverage. Coverage will cotiue util the earlier of: (1) the Policy uder which You origially became isured eds; or (2) You stop payig premiums uder this optio (subject to the terms of the Grace Period). Coversio If the Employer s Policy is termiated, this Certificate will termiate. Upo termiatio of the Employer s Policy, the employee (You) will be etitled to covert to a idividual policy of isurace issued by Us without evidece of isurability provided the required premiums have bee paid o your behalf ad You otified Us i writig withi thirtyoe (31) days of the Employer s Policy termiatio. Premiums for the idividual policy of isurace will be figured from the premium rate table i effect o the date of coversio. Subject to the terms of this provisio, a covered child who ceases to be eligible may covert to a idividual policy of isurace ad a covered spouse who ceases to be eligible for coverage because of divorce or aulmet may covert to a idividual policy. Terms of this provisio iclude: (1) Applicatio for the idividual policy ad paymet of the first premium must be made withi 60 days after coverage ceases uder the Policy/Certificate. Premiums will be figured from the premium rate table i effect o the date of coversio. (2) The idividual policy will be issued without proof of isurability. It will provide beefits that most early approximate those of the Policy/Certificate. (3) The idividual policy will take effect the day after coverage ceases uder the Policy/Certificate. However, o beefits will be payable uder the idividual policy for ay loss for which beefits are payable uder the Policy/Certificate. (4) The Pre-Existig Coditio Limitatio ad Time Limit o Certai Defeses provisios for the idividual policy will be figured from the Covered Perso's Effective Date of coverage uder the Policy/Certificate. (5) Ay beefit maximums will be figured from the Effective Date of the Policy/Certificate. This rider is subject to all the provisios of the Policy ad Certificate to which it is attached that are ot i coflict with this rider. See the policy/certificate for more iformatio regardig the beefits listed above.

6 Limitatios ad Exclusios Eligibility This policy/certificate will be issued oly to those persos who meet America Public Life Isurace Compay s isurability requiremets. The policy/certificate ad the Iteral Cacer coverage uder the Critical Illess Rider will ot be issued to ayoe who has bee diagosed or treated for Cacer i the previous te years. The Heart Attack or Stroke coverage uder the Critical Illess Rider will ot be issued to ayoe who has bee diagosed or treated for ay heart or stroke related coditios. The Hospital Itesive Care Uit Rider will ot cover heart coditios for a period of two years followig the Effective Date of coverage for ayoe who has bee diagosed or treated for ay heart related coditio prior to the 30th day followig the Covered Perso s Effective Date of coverage. If You are workig either uder cotract to or as a Full Time Employee for the Policyholder, or You are a member i or employed by the associatio, You are eligible for isurace provided You qualify for coverage as defied i the Master Applicatio. You must apply for isurace withi thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do ot apply withi thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additioal uderwritig by Us. Cacer meas a disease which is maifested by autoomous growth (maligacy) i which there is ucotrolled growth, fuctio, or spread (local or distat) of cells i ay part of the body. This icludes Cacer i situ ad maligat tumors. It does ot iclude other coditios which may be cosidered precacerous or havig maligat potetial such as: leukoplakia; hyperplasia; acquired immue deficiecy sydrome (AIDS) polycythemia; actiic keratosis; myelodysplastic ad o-maligat myeloproliferative disorders; aplastic aemia; atypia; o-maligat moocloal gamopathy; carcioid; or pre-maligat lesios, beig tumors or polyps. Base Policy All diagosis of Cacer must be positively diagosed by a legally licesed doctor of medicie certified by the America Board of Pathology or America Board of Osteopathic Pathology. This policy/certificate pays oly for loss resultig from defiitive cacer treatmet icludig direct extesio, metastatic spread or recurrece. Proof must be submitted to support each claim. This policy/certificate also covers other coditios or diseases directly caused by Cacer or the treatmet of Cacer. This policy/certificate does ot cover ay other disease, sickess or icapacity, which existed prior to the diagosis of Cacer, eve though after cotractig Cacer it may have bee complicated, aggravated or affected by Cacer or the treatmet of Cacer except for coditios specifically stated i the Dread Disease Beefit. No beefits are payable for ay Covered Perso for ay loss icurred durig the first year of this policy/certificate as a result of a Pre-Existig Coditio. A Pre-Existig Coditio is a Cacer or Dread Disease for which, withi 6 moths prior to the Covered Perso's Effective Date of coverage, medical advice, or treatmet, icludig prescribed medicatios, was recommeded by or received from a member of the medical professio, or for which coditios maifested i such a maer as would cause a ordiarily prudet perso to seek diagosis, medical advice or treatmet. No beefits are payable for ay loss icurred durig the first year of the policy as a result of a Pre-Existig Coditio. Routie follow-up care to determie whether a breast cacer has recurred i a perso who has bee previously determied to be free of breast cacer does ot costitute medical advice, diagosis, care, or treatmet for purposes of determiig preexistig coditios uless evidece of breast cacer is foud durig or as a result of the follow-up care. Pre-Existig Coditios specifically amed or described as excluded i a waiver rider attached to this cotract are ever covered. This policy/certificate cotais a 30-day waitig period durig which o beefits will be paid uder this policy/certificate. If ay Covered Perso has a Specified Disease diagosed before the ed of the 30-day period immediately followig the Covered Perso s Effective Date, coverage for that perso will apply oly to loss that is icurred after oe year from the Effective Date of such perso s coverage. If ay Covered Perso is diagosed as havig a Specified Disease durig the 30-day period immediately followig the Effective Date, you may elect to void the policy/ certificate from the begiig ad receive a full refud of premium. All beefits payable oly up to the maximum amout listed i the Schedule of Beefits i the policy/certificate. Diagostic Testig Beefit Rider We will pay the idemity amout for oe geerally medically recogized iteral Cacer screeig test per Covered Perso per Caledar Year. Screeig test iclude, but are ot limited to: mammogram; breast ultrasoud; breast thermography; breast cacer blood test (CA 15-3); colo cacer blood test (CEA); prostate-specific atige blood test (PSA); flexible sigmoidoscopy; colooscopy; virtual colooscopy; ovaria cacer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specime; serum protei electrophoresis (blood test for myeloma); Thi Prep Pap test. Screeig tests payable uder this beefit will ONLY be paid uder this beefit. Beefits will oly be paid for tests performed after the 30-day period followig the Covered Perso s effective date of coverage. Critical Illess Rider Beefits will oly be paid for a Covered Critical Illess as show o the Policy/Certificate Schedule page i the policy. No beefits will be provided for ay loss caused by or resultig from: itetioally self-iflicted bodily ijury, suicide or attempted suicide, whether sae or isae; or alcoholism or drug addictio; or ay act of war, whether declared or udeclared; or ay act related to war; or military service for ay coutry at war; or a Pre- Existig Coditio; or a Covered Critical Illess whe the Date of Diagosis occurs durig the Waitig Period, if applicable; or participatio i ay activity or evet while itoxicated or uder the ifluece of ay arcotic uless admiistered by a Physicia or take accordig to the Physicia s istructios; or participatio i, or attemptig to participate i a feloy, riot or isurrectio (A feloy is as defied by the law of the jurisdictio i which the activity takes place). Iteral Cacer does ot iclude: other coditios that may be cosidered pre-cacerous or havig maligat potetial such as: acquired immue deficiecy sydrome (AIDS); or actiic keratosis; or myelodysplastic ad o-maligat myeloproliferative disorders; or aplastic aemia; or atypia; or o-maligat moocloal gamopathy; or Leukoplakia; or Hyperplasia; or Carcioid; or Polycythemia; or carcioma i situ or ay ski cacer other tha ivasive maligat melaoma ito the dermis or deeper. For a Pre-Existig Coditio o beefits are payable. Pre- Existig Coditio, as used i this rider meas ay sickess or coditio for which prior to the Effective Date of coverage, medical advice, cosultatio or treatmet, icludig prescribed medicatios, was recommeded by or received from a member of the medical professio, or for which symptoms maifested i such a maer as would cause a ordiarily prudet perso to seek diagosis, medical advice or treatmet. Routie follow-up care to determie whether a breast cacer has recurred i a perso who has bee previously determied to be free of breast cacer does ot costitute medical advice, diagosis, care, or treatmet for purposes of determiig preexistig coditios uless evidece of breast cacer is foud durig or as a result of the follow-up care. Hospital Itesive Care Uit Rider No beefits will be provided durig the first two years of this rider for Hospital Itesive Care Uit cofiemet caused by ay heart coditio whe ay heart coditio was diagosed or treated prior to the 30th day followig the Covered Perso s Effective Date of this rider. The heart coditio causig the cofiemet eed ot be the same coditio diagosed or treated prior to the Effective Date. No beefits will be provided if the loss results from: attempted suicide, whether sae or isae; or itetioal selfijury; or alcoholism or drug addictio; or ay act of war, whether declared or udeclared; or ay act related to war; or military service for ay coutry at war. No beefits will be paid for cofiemets i uits such as: Surgical Recovery Rooms, Progressive Care, Bur Uits, Itermediate Care, Private Moitored Rooms, Observatio Uits, Telemetry Uits or Psychiatric Uits ot ivolvig itesive medical care; or other facilities which do ot meet the stadards for Itesive Care Uit as defied i the Rider.

7 Limitatios ad Exclusios cotiued Coditioally Reewable This policy/certificate is coditioally reewable at the optio of the Policyholder. We must give the Policyholder at least 60 days writte otice prior to cacellatio. We caot chage Your coverage because of a chage i Your age or health. We ca chage Your premiums if We chage premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days writte otice before We chage Your premiums. Termiatio of Coverage Your Isurace coverage will ed o the earliest of these dates: (a) the date You o loger qualify as a Isured; (b) the last day of the period for which a premium has bee paid, subject to the Grace Period; (c) the date the Policy termiates (See Coversio provisio); (d) the date You retire; (e) the date You cease employmet, or termiate Your cotract with the employer through whom You origially became isured uder the Policy (See Coversio provisio); or (f) the date We receive Your writte request for termiatio, or upo the date specified i the writte request. Termiatio of Depedet(s) Isurace coverage o Your Depedet(s) will ed o the earliest of these dates: (a) the date the coverage uder the Certificate termiates; (b) the date the Depedet o loger meets the defiitio of Depedet, as defied i the Policy/Certificate (See Coversio provisio); (c) the date We receive Your writte request for termiatio, or upo the date specified i the writte request. Termiatio of Rider Coverage This rider termiates: (a) whe Your coverage termiates uder the Policy/Certificate to which this Rider is attached; or, (b) whe ay premium for this rider is ot paid before the ed of the Grace Period; or, (c) whe You give Us a writte request to do so. Coverage o a Depedet termiates uder this rider whe such perso ceases to meet the defiitio of Depedet, as defied i the Policy.

8 GC-3 Group Cacer Idemity Isurace Group Cacer Semi-Mothly Premiums* By Level Level II (icludes Diagostic Testig Beefit & Critical Illess Riders) Level II without Itesive Care Uit Rider Level II with Itesive Care Uit Rider Idividual 1 Paret Family $11.90 $16.60 $21.15 Idividual 1 Paret Family $13.55 $18.85 $24.60 Level III (icludes Diagostic Testig Beefit & Critical Illess Riders) Level III without Itesive Care Uit Rider Level III with Itesive Care Uit Rider Idividual 1 Paret Family $17.10 $23.70 $30.20 Idividual 1 Paret Family $18.75 $25.95 $33.65 Uderwritte by: 2305 Lakelad Drive Flowood, MS (800) *The premium ad amout of beefits provided vary depedet upo the Level selected at time of applicatio. This is a brief descriptio of the coverage. For actual beefits ad other provisios, please refer to the policy. This coverage does ot replace Workers Compesatio Isurace. This product is iappropriate for people who are eligible for Medicaid coverage. This policy is cosidered a employee welfare beefit pla established ad/or maitaied by a associatio or employer iteded to be covered by ERISA, ad will be admiistered ad eforced uder ERISA. Group policies issued to govermetal etities ad muicipalities may be exempt from ERISA guidelies. Policy Form GC-3 series Florida Limited Beefit Group Cacer Idemity Isurace. Employee Brochure (12/13) Citrus Couty School Board Semi-Mothly