Certificate of Insurance Individual Vision Indemnity Plan

Transcription

1 Underwritten by SafeHealth Life Insurance Company Certificate of Insurance Individual Vision Indemnity Plan This certificate contains a deductible provision. SG SHL IND V - POL 1

2 POLICYHOLDER: POLICY NUMBER: SAFEHEALTH LIFE INSURANCE COMPANY PO BOX Laguna Hills, CA INDIVIDUAL ACCIDENT AND HEALTH VISION INDEMNITY/PPO POLICY SafeHealth Life Insurance Company ( SafeHealth ) insures, subject to the provisions, limitations and other terms contained herein, certain eligible employees and their eligible dependents, and agrees to pay the benefits described herein upon receipt of due written proof of loss covered by this Policy. CONSIDERATION. This policy is issued in consideration of the payment of premiums, of the statements and agreements contained in the application of the Policyholder and of the individual applications of the insured. ADDITIONAL PAGES. The provisions, limitations and other terms set forth in this Policy are a part of this contract as fully as if appearing over the signature hereto. IN WITNESS WHEREOF SafeHealth has caused this Policy to be executed effective at 12:01 AM, Standard Time on, at the address of the Policyholder for an initial term of one year. This Policy may be renewed thereafter as herein provided. Any rate changes incurred will be based on the rates for insureds in the state in which the insured resides at the time of renewal. James E. Buncher Chairman and Chief Executive Officer Ronald I. Brendzel Senior Vice President and Secretary NOTICE OF TEN (10) DAY RIGHT TO EXAMINE POLICY You may return this Policy for cancellation within ten (10) days of its delivery to you and your premium will be fully refunded, if after examination of the Policy, you are not satisfied with it for any reason. If you return the Policy to the Company it shall be void from the beginning and you and the Company will be in the same position as if no Policy had been issued. SG SHL IND V - POL 2

3 TABLE OF CONTENTS SECTION I ELIGIBILIGY, EFFECTIVE DATES AND TERMINATION 5 SECTION II PREMIUM PAYMENT 8 SECTION III VISION BENEFITS 8 SECTION IV COORDINATION OF BENEFITS 10 SECTION V GENERAL PROVISIONS 10 SECTION VI CONTINUATION OPTIONS 14 SECTION VII - DEFINITIONS 14 SG SHL IND V - POL 3

4 Important Information Concerning Your Individual Insurance Plan Important Notice to Policyholders If you need to contact us about your insurance for any reason, please contact: SafeHealth Life Insurance Company 95 Enterprise, Suite 100 Aliso Viejo, CA If you have been unable to resolve a problem concerning your insurance coverage, after discussions with SafeHealth or its agent or other representative, you may contact: Florida Department of Financial Services Insurance Division Consumer Complaints Division State Capitol Larson Building 200 East Gaines Street, Room 637 Tallahassee, FL SG SHL IND V - POL 4

5 SECTION I ELIGIBILIGY, EFFECTIVE DATES AND TERMINATION Who May Enroll You may enroll yourself and your dependents, provided each meets eligibility requirements and Dependent Coverage requirements listed below. Dependent Coverage SafeHealth defines eligible dependents to be: Your lawful spouse or domestic partner; Your unmarried children or grandchildren through age 25 for whom you provide care (including adopted children, step-children, or other children for whom you are required to provide vision care pursuant to a court or administrative order); Your children who are incapable of self-sustaining employment and support due to a developmental disability or physical handicap and who are dependent on you for their support and maintenance. The term Dependent does not include any spouse or child who resides outside of the United States, or who is a member of the armed forces of any country. You must furnish SafeHealth with proof of dependent status, as provided by law. Please check with SafeHealth if you have questions regarding your eligibility requirements. When Coverage Begins Coverage will begin for you and your enrolled dependents on the first day of the month following the date your premium payment is received by SafeHealth. New spouses are covered the first (1st) of the month following the date of marriage. Newborn children, newborn adopted children, adopted children and foster children are covered from the moment of birth or from the moment of placement. However, you must advise us of any new dependents, including those due to birth or the placement of an adopted child within thirty (30 ) days of acquiring that dependent. If notice is given within 60 days of the birth or placement of the child, SafeHealth shall not deny coverage for the child due to the failure of the insured to timely notify SafeHealth of the birth or placement of the child. Check with SafeHealth if you have any questions about when your coverage begins. SG SHL IND V - POL 5

6 Changes to Your Coverage Termination of Benefits Your coverage may be cancelled for any reason, after not less than sixty (60) days written notice by either you or SafeHealth. Your coverage may be cancelled after not less than forty-five (45) days written notice for: Non-payment of amounts due under the contract, except no written notice will be required for failure to pay premium. Failure to establish a satisfactory vision provider/patient relationship and if it is shown that SafeHealth has, in good faith, provided you with the opportunity to select an alternative vision provider. Neither residing, living, or working in the service area or area for which SafeHealth is authorized to do business. Your coverage may be cancelled after not less than 15 days written notice for: An intentional misrepresentation, except as limited by statute. Fraud in the use of services or facilities. Your coverage may be cancelled immediately: Subject to continuation of coverage and conversion privilege provisions, if applicable, if you do not meet eligibility requirements other than the requirements that you live or work in the service area. If you fail to pay the premium through and including the final month of the contract, all coverage may be terminated at the end of the grace period, and, after the grace period has ended, you may be responsible for the usual fees for any services received from your Vision Care Provider during the period the premium went unpaid, including the grace period. Enrollment will be cancelled as of the last day for which payment has been received, subject to compliance with notice requirements. If you terminate from the Plan while vision care is being provided to you, your Vision Care Provider must complete any treatment started on you before your termination, abiding by the terms and conditions of the Plan. Renewing Your Coverage Your contract with SafeHealth to provide services is for a minimum period of twelve (12) consecutive months and renews automatically for twelve (12) additional months and until you or SafeHealth notifies the other of termination in writing. Your coverage under the Plan is guaranteed for that time period so long as you meet the eligibility requirements under the Plan. If the Contract expires, it may be renewed. If renewed, it is possible that the terms of the Plan may have been changed. If changes to benefits, co-payments or premiums SG SHL IND V - POL 6

7 have been made to a renewed contract, SafeHealth will notify you not less than forty-five (45) days before the effective date of the change. Reinstatement Receipt by SafeHealth of the proper premium payment after cancellation of the contract for non-payment shall reinstate the contract as though it had never been cancelled if such payment is received on or before the due date of the succeeding payment. Cancellation of Benefits If the required premium is not paid, your coverage may be terminated. If any applicable premium due from you is not paid timely, your benefits may be cancelled. Your coverage may be cancelled by SafeHealth upon fifteen (15) days written notice for fraud or misrepresentation or fraud in use of services or facilities. In the absence of fraud, all statements made by a Subscriber are considered representations and not warranties. During the first two (2) years, coverage can be voided for a material misrepresentation contained in the Enrollment Form. After two (2) years, coverage can be voided only in the event of a fraudulent misstatement contained in the Enrollment Form. Termination of Contract Your contract with SafeHealth is for a period of twelve (12) months and automatically renews as described previously. If your contract is terminated, your membership in the Plan will be terminated. In the event of contract termination, no further benefits will be provided to you and none of the Plan provisions will apply. If you fail to pay the premium through and including the final month of the contract, all coverage may be terminated at the end of the grace period, and you may be responsible for the usual fees for any services received from your Vision Care Provider during the period the premium went unpaid, including the grace period. Extension of benefits will be until the completion of the procedure in process, or ninety (90) days, whichever is sooner. Customer Service SafeHealth provides toll-free access to our Customer Service Associates to assist you with benefit coverage questions, resolving problems, or selecting a Vision Care Provider. SafeHealth s Customer Service can be reached Monday through Friday at (800) from 8:00 am to 9:00 pm, Eastern Time. Automated service is also provided after hours for eligibility verification. SG SHL IND V - POL 7

8 SECTION II PREMIUM PAYMENT Payment of Premium You are responsible for paying SafeHealth for your coverage on a monthly or annual basis, as may be applicable. The Premium Payment is not the same as a co-payment. The amount of premium payable will be based on the applicable premium indicated on your enrollment form. The Company may upon 60 days advance notice to the Policyholder, change the Table of Premiums. SECTION III VISION BENEFITS Choice of Vision Provider/ Receiving Care If a Covered Person wants to see a contracted vision provider (in-network provider), please refer to the Directory of Participating Vision Care Providers. By using an in-network provider, a Covered Person s specific benefits will be those noted as In-Network Coverage on the Summary of Benefits. A Covered Person may obtain a Vision Care Provider Directory by calling our Customer Service Department at (800) or by visiting If a Covered Person wishes to see a licensed provider not listed in our directory for covered vision services, a Covered Person may do so. By receiving services from an out-of-network provider, a Covered Person s specific benefits will be those noted as Out-of-Network Coverage on the Summary of Benefits and may be less than would be received from an in-network vision provider. New Patient and Routine Services Making a Vision Appointment Once a Covered Person s coverage begins, the Covered Person may contact the vision provider of choice to schedule an appointment. SafeHealth Participating Vision Care Provider Offices are open in accordance with their individual practice needs. When scheduling an appointment, the Covered Person should identify himself/herself as a SafeHealth member. Referrals for Vision Specialty Care A Covered Person may choose to receive benefits from any SafeHealth vision provider, including contracted ophthalmologists. A list of SafeHealth participating vision care providers may be found online at or obtained by calling Customer Service ( ) for assistance. Treatment by a non-participating vision provider is covered at the out of network reimbursement level shown on the Vision Summary of Benefits. SG SHL IND V - POL 8

9 Financial Responsibility Deductible Deductible refers to the fixed dollar amount that a Covered Person may be responsible for each calendar year or contract year prior to any benefits being received. The Deductible, if any, is set forth on the Summary of Benefits. Vision Co-payments The Vision benefits available under this plan are set forth in the Summary of Benefits. The Benefit may be a percentage amount or a Maximum Benefit Allowance. A Covered Person will be responsible for all fees and charges in excess of the percentage amount and/or Maximum Benefit Allowance listed in the Summary of Benefits (as well as the deductible, if any). See Covered Vision Services and Materials for more information. Certain covered charges may be payable under the Policy only if the service or material is furnished by a contracted Vision Care Provider. If this is the case, it will be indicated in the Summary of Benefits. It is the Covered Person s responsibility to determine if a Vision Care Provider is a contracted (in-network) provider at the time that the service or material is provided. Identification Card The Covered Person should present the identification card to a Vision Provider before receiving services. Covered Vision Services and Materials Subject to the Service Intervals and Maximum Benefit Allowances indicated in the Summary of Benefits, the following will be covered charges under the Plan: 1. One complete visual examination. Dilation is included as a covered service when provided by the contracted Vision Care Provider. Corrective lenses, frames, and Medically necessary or non-medically necessary contact lenses are not covered under the Plan. If a Covered Person chooses to purchase these materials from a participating vision provider, fees will be as little as eighty percent (80%) of the contracted vision provider s usual fees and paid by the member. If a Covered Person chooses to purchase these materials from a non-participating vision provider, fees will be the usual fees of that provider and paid by the member. Please refer to the Summary of Benefits for the Exclusions and Limitations applicable to the vision plan. SG SHL IND V - POL 9

10 Exclusions and Limitations Please refer to the Summary of Benefits for the Exclusions and Limitations applicable to the vision plan. SECTION IV COORDINATION OF BENEFITS Coordination of Benefits If you are covered for benefits by more than one plan, SafeHealth will always pay eligible benefits as the primary plan without regard to payments to be made by another plan. SECTION V GENERAL PROVISIONS Entire Contract SafeHealth typically contracts directly with an individual, such as you to provide benefits. Your application, Enrollment Form, this Policy and any attachments or inserts including the Schedule of Benefits with Exclusions and Limitations, constitutes the entire agreement between the parties. To be valid, any change in the contract must be approved by an officer of SafeHealth and attached to it. No agent may change the Contract or waive any of the provisions. Should any provision herein not conform to applicable laws, it shall be construed as if it were in full compliance thereof. If any provision of this contract is held to be illegal or invalid for any reason, such decision shall not affect the validity of the remaining provisions of this contract, but such remaining provisions shall continue in full force and effect unless the illegality and invalidity prevent the accomplishment of the objectives and purposes of this contract. Incontestability All statements made on your Enrollment Form shall be considered representations and not warranties. The statements are considered to be truthful and are made to the best of your knowledge and belief. A statement may not be used in a contest to void, cancel, or non-renew your coverage or reduce benefits unless: (1) it is in a written enrollment application signed by you; and (2) a signed copy of the enrollment application is or has been furnished to you or your representative. This contract may only be contested for fraud or intentional misrepresentation of material fact made on the enrollment application. The statements and information contained in the Member s Enrollment Form are represented by Member to be true and correct and incorporated into this contract. The member also recognizes that SafeHealth has issued this contract in reliance on those statements and information. This contract replaces and cancels all other contracts, if any, issued to the Member. SG SHL IND V - POL 10

11 Notice and Proof of Claim Written notice of any claim must be given to SafeHealth within 90 days after the occurrence or commencement of any covered loss (or 180 days if services are received by a non-contracted Provider), or as soon thereafter as reasonably possible. SafeHealth shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than 1 year from the time specified unless the claimant was legally incapacitated. Notice may be given to SafeHealth Life Insurance Company, 95 Enterprise, Suite 100, Aliso Viejo, CA Upon enrollment SafeHealth will furnish you with forms for filing proof of loss. If SafeHealth does not furnish you with the usual form, you can comply with the requirements for furnishing proof of loss by giving written proof. Such written proof must cover the occurrence, the character and the extent of the loss. SafeHealth does not require claim forms. Eligibility of Medicaid Not Considered SafeHealth shall not consider the availability or eligibility for medical assistance under Medicaid, when considering eligibility for coverage or making payments under this Policy. Payment of Vision Claims All out-of-network vision benefits will be paid directly to the Covered Person unless otherwise directed. SafeHealth does not require that vision services be rendered by a particular provider. After receiving written proof of loss, SafeHealth will pay all benefits then due for vision care services. Benefits for any other loss covered by this policy will be paid as soon as the insurer receives proper written proof. SafeHealth will acknowledge proof of claim within 15 working days of receipt (2 working days, if the claim is submitted electronically). Payment for all uncontested claims will be made within 45 days notice of such claim so long as such claim is a clean claim in accordance with state statutes and regulations. If the claim is contested, upon receipt of the additional information, SafeHealth will make payment within 60 days. SafeHealth shall pay or deny any claim no later than 120 days after receiving the claim. If any benefits are payable to the estate of or to an insured who is a minor or otherwise is unable to give a valid release, SafeHealth may pay such benefits up to $ to any relatives by blood or marriage who they believe is entitled to payment. If SafeHealth makes payment in good faith pursuant to this provision, they will not have to pay those benefits again. Any accrued benefits unpaid at the time of death of a Covered Person will be paid to his or her estate, except as may be provided in any specific benefits of this Policy, or any attached Riders or Endorsements. SG SHL IND V - POL 11

12 Procedures for Review of Claims which are Denied in Whole or in Part Within 60 days after a Covered Person or his/her beneficiary received a written notice of denial of a claim, in whole or in part, he/she or his/her duly authorized representative may: 1. Request us, in writing, to review the claim. 2. Review pertinent documents. 3. Submit issues and documents, in writing, to us. Upon written request for review, we will reply no later than 30 days after the receipt of a request. In the event special circumstances require an extension of time for processing, a decision will be made as soon as possible but no later than 60 days after the receipt of a request for review. The decision made upon review shall be in writing and shall include specific reasons for the determination, with specific references to the pertinent plan provisions on which determination is based. Complaint Procedures General Information If you are dissatisfied with the manner in which SafeHealth has made a determination under the Policy, such as denial of a claim, a Covered Person is to initiate complaint procedures through SafeHealth s internal complaint process. This process must be completed before requesting arbitration for final and binding resolution of the complaint. If a complaint concerns the outcome of your treatment by a provider or the quality of care given by a Vision Care Provider, a Covered Person should, if appropriate, attempt to resolve the complaint directly with the Vision Care Provider. First Step Internal Review If, after discussion with SafeHealth s Customer Service Department, a Covered person is dissatisfied with the determination of a policy or procedure, or a review of a denied claim, he or she may appeal the determination by calling or writing the Company s complaint and appeals unit at the following address: SafeHealth Life Insurance Company 95 Enterprise, Suite 100 Aliso Viejo, CA SafeHealth can assist in writing your complaint or appeal, or the Company can provide the Covered Person with a complaint and appeal form. The complaint or appeal should include any additional information that the Company should consider and an itemized statement as to the amount in dispute. SG SHL IND V - POL 12

13 SafeHealth will notify the Covered person in writing of the results of SafeHealth s review and the basis of the Company s decision within 30 days of receipt of the complaint. Second Step Internal Committee Hearing The final internal level of appeal available to a Covered Person is a hearing before the Company s complaint committee. Requests for an appeal to the committee should be made in writing within 45 days of the Company s notification to the Covered Person of the Company s first level determination. The Company will advise the Covered Person of the committee s determination within 30 days of receipt of the request for the second level appeal. Waiver of Rights If SafeHealth fails or chooses not to enforce any provision of this Policy, such omission will not affect SafeHealth s right to do so at a later date, or to enforce any other provision. Legal Actions No action at law or in equity may be brought to recover benefits prior to the expiration of 60 days after written Proof of Loss has been furnished. No such action may be brought after a period of 5 years (or the period required by law, if longer) after the written proof of loss is required to be given. Physical Exam The Company has the right to have any Covered person examined at SafeHealth s expense while a claim is pending. Right of Recovery Whenever SafeHealth has made payments in excess of the benefits payable under the Policy, SafeHealth has the right to recover the excess from any persons to, or for, or with respect to whom, such payments were made, or from any other insurers, health care service plans or other organizations. Conformity with State Statutes Any provision of the Policy which, on its effective date, is in conflict with the laws of the state, in which the Policy was delivered or issued for delivery, is amended to conform to the minimum requirements of such laws. Policy Non-Participation The Policy is not in lieu of and does not affect any requirements for coverage by workers compensation insurance. SG SHL IND V - POL 13

14 SECTION VI CONTINUATION OPTIONS Conversion Privilege/Continuation of Coverage Contact SafeHealth s Customer Service at (800) to check availability of a Plan in your area and for further information and details. SECTION VII - DEFINITIONS Definitions These definitions apply when the following terms are used, unless otherwise defined where they are used. Not all defined terms are used in their usual meaning and some have meanings that limit their application; therefore, please refer to this Definitions section for a helpful understanding of the defined terms that are capitalized. Arbitration A non-court proceeding which is used to solve legal disputes. It is usually held before an attorney or judge who weighs the evidence and renders a binding decision, which has the force of law. Arbitration is an efficient alternative to a trial court proceeding for resolving legal disputes. Calendar Year A twelve (12) month period beginning on January 1 and ending on December 31 of that same year. Close Relative A Covered Person s spouse, children, parents, brothers, and sisters; and b) any other person who is part of a Covered Person s household. Company SafeHealth Life Insurance Company. Contracted (Preferred or In-Network) Vision Provider A Vision Care Provider who has a written contract with SafeHealth to furnish services and supplies and accepts reimbursements at the negotiated rate. Co-payment The amount listed on the Schedule of Benefits for covered services that the member is required to pay at the time of treatment. Covered Person/Member You or your dependent(s) who is/are covered under the Plan. Covered Vision Services Charges for Covered Services and Materials. With respect to Contracted Vision Providers, Covered Vision Charges means the Negotiated Rate. With respect to Non-Participating Vision Providers, charges in excess of SafeHealth s Maximum Benefit Allowance will not be considered Covered Charges under the plan. SG SHL IND V - POL 14

15 Covered Vision Services and Materials The services and materials indicated in this Plan that are payable or eligible for reimbursement, subject to any benefit limitations and maximums, under the Plan. Deductible The amount of covered charges that must be paid by a Covered Person in each Calendar Year before payment is made by SafeHealth. Dependent Eligible family member of a subscriber who is enrolled in SafeHealth. (See Dependent Coverage). Maximum Benefit Allowance The maximum amount SafeHealth will allow for covered services and materials provided by a Vision Care Provider. Preferred (contracted or in-network) Provider A Vision Provider who has a written contract with SafeHealth to furnish services and supplies and accepts reimbursement at the negotiated rate. Termination of Benefits A member s loss of program eligibility and disenrollment from the Plan. Reason(s) for termination of benefits are detailed within this document. Vision Care Provider or Vision Provider An eye care professional who is an optometrist, ophthalmologist, or registered dispensing optician, who: 1. Is licensed as such by the proper authorities of the state in which he or she practices; 2. Is acting within the scope of such license; and 3. Is not a relative or member of the household of the Covered Person. Vision Service Interval A period of consecutive months, as shown in the Summary of Benefits, in which a Covered Person may receive covered services and materials. This period starts on the Covered Person s effective date of coverage and then a subsequent service interval starts after vision services or materials are received. Once Covered Vision Services and Materials are received during any service interval, additional services are not covered during the same service interval and are subject to an additional charge. Usual Fee The fee usually charged by the Provider to his or her private patients for a given service or material. SG SHL IND V - POL 15