Loyal American Life Insurance Company LOYAL PROTECTION PLUS

Transcription

1 Loyal American Life Insurance Company LOYAL PROTECTION PLUS A Hospital Confinement Policy Form L-5400 PACKET CONTAINS: APPLICATION OUTLINE EFT FORM HIPAA FORM REPLACEMENT FORM DISCLOSURE NOTICE FORMS FOR USE IN WASHINGTON L-5400-APP-WA 9/28/12

2 APPLICATION FOR FIXED PAYMENT BENEFIT INSURANCE (HOSPITAL CONFINEMENT) - LOYAL AMERICAN LIFE INSURANCE COMPANY - P. O. Box Austin, TX THIS IS NOT AN APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE 1. Name of Applicant (Print) Last First Initial Sex Birthdate Mo. Day Year Age State of Birth Social Security No. 2. Name of Spouse (Print) Last First Initial Sex Birthdate Mo. Day Year Age State of Birth Social Security No. Resident Street Address (No P.O. Box) City State Zip Day Telephone / Evening Telephone ( ) ( ) Address: Premium Payor Last First Initial Day Telephone / Evening Telephone Name ( ) ( ) Billing Address City State Zip Best Day and Time to call: PREMIUM: Check premium payment mode selected: Annual Semi-Annual Quarterly Monthly Bank Draft Amount of Premium submitted with the Application: $ (Check must be made payable to Loyal American Life Insurance Company) THIS APPLICATION WILL REQUIRE A TELEPHONE VERIFICATION CALL TO THE APPLICANT TO VERIFY THE INFORMATION ON THE APPLICATION. COVERAGE APPLIED FOR: (Coverage must be the same for both Applicants.) BASE PLAN Hospital Confinement Benefit (A, B, C) (Choose one benefit amount) $750 $1,000 $1,250 OPTIONAL RIDERS (Choose Rider applied for and one benefit amount for each.) Skilled Nursing Facility Benefit (B, C) $75 $100 $125 At-Home Care Benefit (C) $25 $50 $75 Daily Hospital Benefit $100 $125 $150 Physician Benefit $15 $25 $50 Surgical Benefit $200 $400 $600 Ambulance Benefit (A, B, C) $50 $100 $150 Durable Medical Equipment Benefit $200 $300 $400 Accidental Death & Dismemberment Benefit $2,500 $5,000 $7,500 (Choose Beneficiary) Beneficiary (Applicant) Relationship Beneficiary (Spouse, if applying) Relationship L-5402-WA Page 1

3 QUALIFYING INFORMATION: (If any answer to questions 1 through 6 is Yes, you are not eligible for coverage.) Applicant 1. Are you currently confined in a hospital or nursing facility, or receiving the services of a home health agency?... Yes No Spouse Yes No 2. Has surgery been advised but not performed?... Yes No Yes No 3. Is surgery anticipated within the next 12 months?... Yes No Yes No 4. Are you bedridden or do you use the assistance of a wheelchair or walker?... Yes No Yes No 5. Within the past two years have you: Yes No Yes No a. Been confined to a nursing facility?... Yes No Yes No b. Been hospitalized more than 2 times?... Yes No Yes No c. Had any amputation caused by disease?... Yes No Yes No 6. Do you have now, or have you received medical advice, treatment, or been advised to have treatment, surgery, or take medication for the following conditions: a. At any time for: (1) Parkinson s Disease, Myasthenia Gravis, Multiple or Amyotrophic Lateral Sclerosis, Muscular Dystrophy, Dementia, or Alzheimer s Disease or Organic Brain Disorder?... Yes No Yes No (2) Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or Human Immunodeficiency Virus (HIV) infection?... Yes No Yes No b. Within the past 2 years for: (1) Insulin Dependent Diabetes, Uncontrolled Diabetes, Chronic Kidney Disease, Renal Insufficiency, Renal Failure, or any Kidney Disease requiring dialysis?... Yes No Yes No (2) Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Chronic Obstructive Lung Disease (COLD) excluding Asthma, or any Chronic Pulmonary Disease Requiring the use of oxygen?... Yes No Yes No (3) Lymphoma?... Internal Cancer, Leukemia, Malignant Melanoma, Hodgkin's Disease, or Yes No Yes No (4) Heart Attack, Heart or Heart Valve Surgery, Congestive Heart Failure, Peripheral Vascular Disease, Aneurysm, or Cardiac Pacemaker or Defibrillating Device?... Yes No Yes No (5) Stroke or Transient Ischemic Attack (TIA)?... Yes No Yes No (6) Cirrhosis of the Liver, Hepatitis or any disease of the pancreas or prostate not cured by surgery or treatment?... Yes No Yes No (7) Alcohol or Drug Abuse?... Yes No Yes No (8) Paget s Disease, Rheumatoid or Disabling Arthritis, Lupus or other bone or Connective tissue disorder?... Yes No Yes No OTHER INSURANCE INFORMATION: Will this policy replace any existing health insurance with any company?... Yes No If Yes, name of company Policy # Type of Policy Yes No L-5402-WA Page 2

4 INVESTIGATIVE CONSUMER REPORTS AUTHORIZATION As part of our normal procedure for processing your application, an investigative consumer report may be prepared whereby information is obtained as to the character, general reputation, personal characteristics and mode of living of persons proposed for insurance in this application. Personal interviews with friends, neighbors and associates may be used to develop this report. (In WV, no information collected concerning the sexual orientation of the proposed insured will be used to determine his or her eligibility for insurance.) You may request to be interviewed in connection with the preparation of the report. You have the right to request A Summary of Your Rights under the Fair Credit Reporting Act. Upon written request, you or your representatives have a right to receive a copy of the report and additional information about the nature and scope of the investigation. AGREEMENT I hereby apply to Loyal American Life Insurance Company (LALIC), Austin, Texas, for insurance to be issued upon the truth and completeness of the answers to the above questions to the best of my knowledge, and agree that: (1) No agent has the authority to waive the answer to any question in the application; and (2) no insurance will be effective until a policy has been issued. I have received the Outline of Coverage for the policy applied for and (if applicant is 65 or over) a Medicare Supplement Buyers Guide. CAUTION: If your answers on this application are incorrect or untrue, Loyal American Life Insurance Company has the right to deny benefits or rescind your policy, subject to the Time Limit On Certain Defenses Provision of the policy. AUTHORIZATION: I hereby authorize any health care provider, including any physician, practitioner, pharmacy, prescription vendor, pharmacy benefit manager, hospital or medically-related facility, and any insurance company, the Medical Information Bureau (MIB) or other consumer reporting agency, employer, or, except in AZ, any other organization, institution or person that has my records or knowledge of me or my dependent(s) to disclose to LALIC, or its authorized representative, any such records or information. Records or information may include medical records in their entirety, which may contain mental health records (excluding psychotherapy notes), prescription drug records, use of alcohol, or use of controlled or prohibited substances, driving records, financial and employment records. Such records or information will be used by company personnel to determine eligibility for insurance and/or benefits. LALIC may disclose such information to its reinsurer(s), precertification firm, individual benefits management firms or any other organization which performs services in connection with the insurance relationship, including, but not limited to, the insurance agent, or as lawfully required. However, LALIC shall not disclose to an agent, information received from MIB. LALIC reserves the right to require a medical examination or testing or both. There may be certain circumstances under which the information received may be disclosed to third parties who are not subject to the regulations under federal health privacy law. We contractually require such persons to agree to protect the confidentiality of the information. I understand that I have the right to request access to all personal information collected and, upon written request, I may ask LALIC to correct, amend or delete any incorrect personal information. A copy of the Company s Privacy Notice and Notice of Insurance Information Practices is available upon request. This authorization shall be valid for a period of two (2) years from the date signed to determine eligibility for insurance or for the term of coverage of the policy to determine benefits. A photocopy of this authorization shall be as valid as the original. I understand that I, or my authorized representative may receive a copy of this authorization upon request. This authorization may be revoked at any time subject to the rights of anyone who acted in reliance upon the authorization prior to notice of its revocation. This authorization may be revoked upon submission of a written notice to the Home Office. If this authorization was obtained as a condition of obtaining insurance coverage, your right to revoke also is subject to the rights of the Company under any law granting the Company the right to contest a claim under the policy or the policy itself. Revocation or failure to sign the authorization may be a basis for denying an application or eligibility for benefits. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. Dated at this day of City State By signing below, I understand and agree that this form will become part of the application. Signature of Applicant: Date: Signature of Spouse: (If applying for coverage) Date: L-5402-WA Page 3

5 AGENT S CERTIFICATE 1. List the health policies you sold to this applicant which are still in force (if this does not apply, state NONE). 2. List any other health policies you sold to this applicant in the past five (5) years which are no longer in force (if this does not apply, state NONE). 3. (a) Have you reviewed the application for correctness and omissions?... YES NO (b) Was application completed by you in the applicant s presence?... YES (c) Do you have knowledge or reason to believe the replacement of existing insurance may be involved?... YES If YES give Name of Company, reason and termination date NO NO I certify that I accurately recorded all the information supplied to me by the applicant. Signature of Licensed Resident Agent / # Print Name Signature Signature of 2 nd Licensed Resident Agent / # Print Name Signature CAUTION: Please review your answers to the questions on this application. It is important to the issuance of this policy that all questions are answered correctly and truthfully. L-5402-WA Page 4

6 Loyal American Life Insurance Company P.O. Box Austin, Texas (800) IMPORTANT INFORMATION ABOUT THE COVERAGE YOU ARE BEING OFFERED Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about fixed payment benefits. This coverage is not comprehensive health care insurance and will not cover the cost of most hospital and other medical services. This disclosure document provides a very brief description of the important features of the coverage you are considering. It is not an insurance contract and only the actual policy provisions will control. The policy itself will include in detail the rights and obligations of both you and Continental General Insurance Company. This coverage is designed to provide a benefit on the basis of a fixed dollar amount that is paid regardless of the amount that the provider charges. Benefits are not based on a percentage of the provider s charge and are paid in addition to any other health plan coverage you may have. CAUTION: If you are also covered under a High Deductible Health Plan (HDHP) and are contributing to a Health Savings Account (HSA), before you purchase this policy you should check with your tax advisor to be sure that you will continue to be eligible to contribute to the HSA if you purchase this coverage. The benefits under this policy are summarized below: Type of coverage: The policy pays a lump sum fixed amount for each period of hospital confinement. Benefit amount: The amount you select ($750,, $1,000, or $1,250) for each period of confinement. Benefit trigger: The Hospital Confinement Benefit is payable when you are confined as a resident inpatient in a hospital in excess of 24 hours because of sickness or injury. Duration of coverage: This benefit is payable once for each period of confinement. Renewability of coverage: Guaranteed Renewable For Life The policy will be renewed each time a premium is paid. It must be paid on or before the date it is due or during the 31 days that follow. OPTIONAL BENEFITS AVAILABLE: (Available for an additional premium) Skilled Nursing Facility Benefit Rider After you have satisfied a 20 day elimination period, the daily benefit you selected ($75, $100, or $125) will be paid for each day you are confined in a skilled nursing facility. This benefit is payable for up to 90 days for each period of confinement for each covered person. This confinement must immediately follow a hospital stay of at least three consecutive days. At-Home Care Benefit Rider The daily benefit you selected ($25, $50, or $75) will be paid for physician-ordered services of a certified private-duty or registered nurse. This benefit is payable for up to 30 days for each period of care. Daily Hospital Benefit Rider After you have satisfied a 3 day limitation period, the daily benefit you selected ($100, $125, or $150) will be paid for each day you are confined in a hospital. This benefit is payable for up to 21 days for each period of confinement. L-5415-WA Page 1

7 Physician Benefit Rider The amount you selected ($15, $25, or $50) will be paid for each physician office visit for sickness or Injury. This benefit is limited to one visit per day per covered person, and pays for up to 100 visits per calendar year for all covered persons. Surgical Benefit Rider The amount you selected ($$200, $400, or $600) will be paid for all surgery performed in any 24-hour period. This benefit has a calendar year limit of ten surgical benefits per covered person. Accidental Death & Dismemberment Rider The Accidental Death and Dismemberment benefit amount you selected ($2,500, $5,000, or $10,000) will be paid for each covered person if a covered person suffers loss of life, sight or limb(s) due to injuries received in a covered accident. This benefit is limited to one benefit per each covered person. Ambulance Benefit Rider The amount you selected ($50, $100, or $150) will be paid or ambulance transportation during a period of confinement up to three times per calendar year for each covered person. This benefit has a lifetime maximum of $2,500.00, per covered person. Durable Medical Equipment Rider The amount you selected ($200, $300, or $400) will be paid for qualified durable medical equipment purchased following a covered confinement. This benefit is limited to one benefit per covered person, per calendar year. The lifetime maximum benefit is $2,500, per covered person. Policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described above include the following: EXCLUSIONS AND LIMITATIONS Exclusions Benefits are not provided for: (1) mental, nervous, psychotic or psychoneurotic deficiencies or disorders without demonstrable organic disease; (2) alcoholism, drug addiction, or chemical dependency (unless the drug addiction or chemical dependency is a result of medication prescribed by a Physician); (3) attempt at suicide or intentionally selfinflicted injury; (4) treatment provided in a Veteran s Administration or government facility, unless you or your estate are charged for the Confinement; (5) Confinement or care provided outside the United States; (6) services rendered by a family member while confined or for which no charge is made in the absence of insurance; (7) Confinement resulting from war or any act of war, declared or undeclared; (8) Any expense or loss that is incurred while this policy is not in force. Pre-existing Condition Limitation A pre-existing condition is a condition for which medical advice was given or treatment was recommended by a physician within 6 months before the policy date. If the loss occurs within the first 6 months after the policy date, benefits are not payable if the loss is due to a pre-existing condition. DELIVERED to the applicant this day of, 20, by Signature of Agent, Solicitor or Broker Printed Name of Agent, Solicitor or Broker Company Name L-5415-WA Page 2

8 PRE-AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER LOYAL AMERICAN LIFE INSURANCE COMPANY PO BOX AUSTIN, TX Proposed Insured s Name Policy Number (if available) Financial Institution Name and Telephone Number Financial Institution Address 9-digit Routing Number Account Number Requested Withdrawal Date (1st - 28th) Withdraw Payment: Monthly Quarterly Semi-annually Annually Type of Account: Personal Checking Account Personal Savings Account Corporate/Business Checking Name of Employer Group Purpose for submitting this Authorization (check appropriate box(es)): New authorization Change in financial institution Change in checking/savings account Change in existing coverage For Checking Account: Please tape a VOIDED check in this box. For Savings Account: Please attach a letter from the bank stating the account and routing number of your savings account. APPLICANT INFORMATION FOR FINANCIAL INSTITUTIONS: As a convenience to me, I hereby request and authorize you to pay and charge to my account, drafts drawn on my account by and payable to Loyal American Life Insurance Company provided there are sufficient funds in said account to pay the same on presentation. Such drafts will bear my printed name. I also authorize Loyal American Life Insurance Company and any financial institution it uses to initiate credit entries to my account or to provide refund of premium or association fees (if applicable). I authorize you to accept and to credit these entries to my account. In the event Loyal American Life Insurance Company mistakenly deposits funds into my account, I authorize Loyal American Life Insurance to debit my account for an amount not to exceed the original amount of credit. This authorization shall remain in effect until revoked by me in writing, and until you actually receive such notice. I agree that you shall be fully protected in honoring any such draft. I agree that your rights in respect to any such draft shall be the same as if it were a check signed personally by me. I further agree that if any such draft is dishonored, whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. APPLICANT INFORMATION FOR LOYAL AMERICAN LIFE INSURANCE COMPANY: It is understood that the drafts will be drawn on or about the requested date each month. The presentation of such drafts to the above Financial Institution shall constitute notice of premiums being due upon the contract and associations fees (if applicable), and no other notice of premiums or association fees (if applicable) due will be given. No premium or association fee (if applicable) shall be deemed to have been paid unless and until actual payment of the draft drawn for such premium or association fee (if applicable) payment has been received by Loyal American Life Insurance Company. The cancelled draft will constitute receipt of premium or association fee (if applicable) payment. The privilege of paying premiums and association fees (if applicable) under this Plan may be revoked by Loyal American Life Insurance Company if any draft is not paid upon presentation. The payment of premiums and associations fees (if applicable) under this Plan may be terminated by the Contract Owner, Financial Institution Depositor if other than Contract Owner, or by Loyal American Life Insurance Company upon 30 days written notice. Name of Payor (if other than Insured) Payor s Address Print name of Depositor (as it appears on account) Signature of Depositor Date ly-eft return to company 06/12

9 AUTHORIZATION FORM FOR DISCLOSURE OF AN APPLICANT S PROTECTED HEALTH INFORMATION I hereby authorize the disclosure of protected health information about me as described below. 1. The Company, as used in this authorization, shall mean American Retirement Life Insurance Company; or Central Reserve Life Insurance Company; or Loyal American Life Insurance Company ; or Provident American Life & Health Insurance Company. 2. I authorize any licensed physician, medical practitioner, hospital, clinic, Pharmacy Benefit Manager, or other medical or medically-related facility, the U. S. Veterans Administration and Selective Service System, insurance company, the Medical Information Bureau, or any other organization, institution, or person that has any records or information available as to the diagnosis, treatment, and prognosis with respect to any physical or mental condition and/or treatment relating to me or my family to disclose to the Company s underwriting, new business, claims, sales agents, and premium accounting representatives any such records or information. 3. The protected health information described above will be disclosed to the Company to determine my or my family s eligibility to obtain coverage under the policy for which I/we have applied, and to determine the rates and terms which apply to the policy. 4. I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by the Company in reliance on this authorization, by sending a written revocation to the Company s Privacy Officer at P. O. Box 26580, Austin, Texas I understand that the information which will be provided under this authorization is necessary for the Company to determine my eligibility for coverage under the policy and that the Company will condition its approval and issuance of the policy on my providing this authorization, and my application may be denied if I refuse to provide this authorization. 6. I understand that if the person or entity that receives my protected health information is not a health care provider or health plan covered by the federal privacy regulations, the information may be re-disclosed by such person or entity and will likely no longer be protected by the federal privacy regulations. 7. I understand that a photocopy, facsimile copy, or other electronic copy of this authorization shall be considered as effective and valid as the original. I also understand that I or my personal representative am entitled to receive a copy of this authorization upon request. This authorization will expire twenty-four (24) months from the date it is signed. 8. If you are the representative of an applicant, describe the scope of your authority to act on the applicant s behalf: Applicant s Name Name of Applicant s Personal Representative, if applicable Applicant s Social Security Number Relationship of Personal Representative to the Applicant Signature of Applicant Date Signature of Personal Representative Date Signature of Company s Agent Date HIPAA ( ) A signed copy of this form will be provided with the policy if issued and any other time upon request.

10 LOYAL AMERICAN LIFE INSURANCE COMPANY P. O. Box Austin, TX (800) A Stock Company NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and health insurance and replace it with a policy to be issued by Loyal American Life Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy. (1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. (2) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage. (3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: (Date) (Applicant s Signature) HOME OFFICE COPY L-5412

11 LOYAL AMERICAN LIFE INSURANCE COMPANY P. O. Box Austin, TX (800) A Stock Company NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and health insurance and replace it with a policy to be issued by Loyal American Life Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy. (1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. (2) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage. (3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: (Date) (Applicant s Signature) APPLICANT S COPY L-5412

12 IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: the benefits stated in the policy and coverage for the same event is provided by Medicare Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice outpatient prescription drugs if you are enrolled in Medicare Part D other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program SHIP. L-5413