For the employees of: St. Luke s Episcopal-Presbyterian Hospital. ReliaStar Life Insurance Company, a member of the Voya family of companies

Transcription

1 Cmpass Accident Insurance Benefits at a glance Affrdable insurance that can help yu pay fr the ut-f-pcket csts yu may experience after an accident. Fr the emplyees f: St. Luke s Episcpal-Presbyterian Hspital

2 What is Accident Insurance? Accident Insurance pays yu benefits fr specific injuries and events resulting frm a cvered accident that ccurs while yu are nt at wrk, n r after yur cverage effective date. The benefit amunt depends n the type f injury and care received. Yu have the ptin t elect Accident Insurance t meet yur needs. Accident Insurance is a limited benefit plicy. It is nt health insurance and des nt satisfy the requirement f minimum essential cverage under the Affrdable Care Act. Other features f Accident Insurance include: Guaranteed issue: N medical questins r tests are required fr cverage. Flexible: Yu can use the benefit payments fr any purpse yu like. Payrll deductins: Premiums are paid thrugh cnvenient payrll deductins. Prtable: If yu leave yur current emplyer, yu can take yur cverage with yu. Hw can Accident Insurance help? Belw are a few examples f hw yur Accident Insurance benefits culd be used: Medical expenses, such as deductibles and cpays Hme healthcare csts Lst incme due t lst time at wrk Everyday expenses like utilities and grceries Wh is eligible fr Accident Insurance? Yu all active emplyees wrking 16+ hurs per week. Yur spuse* under age 70. Cverage is available nly if emplyee cverage is elected. Yur children t age 26. Cverage is available nly if emplyee cverage is elected. *The use f spuse in this dcument means a persn insured as a spuse as described in the applicable rider. Please cntact yur emplyer fr mre infrmatin. When is my cverage effective? The effective date f cverage is the date yu are eligible t begin filing claims. The injury must ccur n r after the cverage effective date Annual Enrllment Yur cverage becmes effective n January 1, 2018, fllwing the electin f cverage. Cverage fr yur spuse and/r children becmes effective n the same date as yur cverage. What accident benefits are available? The fllwing list is a summary f the benefits prvided by Accident Insurance. Yu may be required t seek care fr yur injury within a set amunt f time. Nte that there may be sme variatins by state. Fr a list f standard exclusins and limitatins, g t the end f this dcument. Fr a cmplete descriptin f yur available benefits, exclusins and limitatins, see yur certificate f insurance and any riders. Event Benefit Accident hspital care Surgery pen abdminal, thracic $1,200 Surgery explratry r withut repair $175 Bld, plasma, platelets $600 Hspital admissin $1,250 Hspital cnfinement per day, up t 365 days $375 Critical care unit cnfinement per day, up t 15 days $600 Cma duratin f 14 r mre days $17,000 Transprtatin per trip, up t 3 per accident $750

3 Ldging per day, up t 30 days $180 Family care per child per day, up t 45 days $25 Accident care Initial dctr visit $90 Urgent care facility treatment $225 Emergency rm treatment $225 Grund ambulance $360 Air ambulance $1,500 Fllw-up dctr treatment $90 Chirpractic treatment up t 6 per accident $45 Medical equipment $120 Physical r ccupatinal therapy up t 6 per accident $45 Speech therapy up t 6 per accident $45 Prsthetic device (ne) $750 Prsthetic device (tw r mre) $1,200 Majr diagnstic exam $240 Outpatient surgery (1 per accident) $225 X-ray $45 Cmmn injuries Burns secnd degree, at least 36% f the bdy $1,250 Burns 3rd degree, at least 9 but less than 35 square inches f the bdy $7,500 Burns 3rd degree, 35 r mre square inches f the bdy $15,000 Skin grafts 25% f the burn benefit Emergency dental wrk $350 crwn, $90 extractin Eye injury remval f freign bject $100 Eye injury surgery $350 Trn knee cartilage surgery with n repair r if cartilage is shaved $225 Trn knee cartilage surgical repair $800 Laceratin 1 treated n sutures $30 Laceratin 1 sutures up t 2 $60 Laceratin 1 sutures 2 6 $240 Laceratin 1 sutures ver 6 $480 Ruptured disk surgical repair $800 Tendn/ligament/rtatr cuff explratry arthrscpic surgery with n repair $425 Tendn/ligament/rtatr cuff ne, surgical repair $825 Tendn/ligament/rtatr cuff tw r mre, surgical repair $1,225 Cncussin $225 Paralysis - paraplegia $16,000 Paralysis - quadriplegia $24,000 Dislcatins Clsed/pen reductin 2 Hip jint $3,850/$7,700 Knee $2,400/$4,800 Ankle r ft bne(s) ther than tes $1,500/$3,000 Shulder $1,600/$3,200 Elbw $1,100/$2,200 Wrist $1,100/$2,200

4 Finger/te $275/$550 Hand bne(s) ther than fingers $1,100/$2,200 Lwer jaw $1,100/$2,200 Cllarbne $1,100/$2,200 Partial dislcatins 25% f the clsed reductin amunt Fractures Clsed/pen reductin 3 Hip $3,000/$6,000 Leg $2,500/$5,000 Ankle $1,800/$3,600 Kneecap $1,800/$3,600 Ft excluding tes, heel $1,800/$3,600 Upper arm $2,100/$4,200 Frearm, hand, wrist except fingers $1,800/$3,600 Finger, te $240/$480 Vertebral bdy $3,360/$6,720 Vertebral prcesses $1,440/$2,880 Pelvis except cccyx $3,200/$6,400 Cccyx $400/$800 Bnes f face except nse $1,200/$2,400 Nse $600/$1,200 Upper jaw $1,500/$3,000 Lwer jaw $1,440/$2,880 Cllarbne $1,440/$2,880 Rib r ribs $400/$800 Skull simple except bnes f face $1,400/$2,800 Skull depressed except bnes f face $3,000/$6,000 Sternum $360/$720 Shulder blade $1,800/$3,600 Chip fractures 25% f the clsed reductin amunt 1 Laceratin benefits are a ttal f all laceratins per accident. 2 Clsed Reductin f Dislcatin = Nn-surgical reductin f a cmpletely separated jint. Open Reductin f Dislcatin = Surgical reductin f a cmpletely separated jint. 3 Clsed Reductin f Fracture = Nn-surgical. Open Reductin f Fracture = Surgical.

5 Meet Nancy Nancy wrks full-time while raising tw energetic children and playing in a summer sftball league. While sliding int hme base, she brke his ankle and tre her ACL. Frtunately, the accident didn t break Nancy s bank accunt - and the family vacatin was saved. Benefits paid by Nancy s Accident Insurance Out-f-Pcket Csts Accident Insurance Benefit Urgent care facility treatment $400 $225 X-ray and MRI $300 $285 Tendn/ligament/rtatr cuff surgery $2,500 $825 Brken ankle, clsed reductin $2,000 $1,800 Medical equipment $150 $120 Fllw-up dctr visit $125 $90 Physical therapy (6 sessins) $300 $270 Ttal $5,775 $3,615 This is an example f hw cverage culd wrk. The amunts shwn are an example nly. Actual csts/results may vary. What des my Accident Insurance include? The benefits listed belw are included with yur Accident Insurance cverage. Fr a list f standard exclusins and limitatins, please refer t the end f this dcument. Fr a cmplete descriptin f yur available benefits, exclusins and limitatins, see yur certificate f insurance and any riders. Sprts Accident Benefit: If yur accident ccurs while participating in an rganized sprting activity as defined in the certificate, the Accident Hspital Care, Accident Care r Cmmn Injuries benefit will be increased by 25%, t a maximum additinal benefit f $1000. If yur spuse and/r children are/is cvered fr Accident Insurance, their cverage includes this benefit. This benefit nly applies t the events in the table abve. It des nt apply t any f the additinal benefits/cverage utlined in this sectin. Health System Benefit: If the services fr yur cvered accident are prvided at a facility that is wned by yur emplyer/rganizatin, the Accident Hspital Care, Accident Care r Cmmn Injuries benefit will be increased by 25%, t a maximum additinal benefit f $1000. If yur spuse and/r children are/is cvered fr Accident Insurance, their cverage includes this benefit. This benefit nly applies t the events in the table abve. It des nt apply t any f the additinal benefits/cverage utlined in this sectin. Wellness Benefit: This prvides an annual benefit payment if yu cmplete a health screening test. Yu may nly receive a benefit payment nce per year, even if yu cmplete multiple health screening tests. Examples f health screening tests include but are nt limited t: Pap test, serum chlesterl test fr HDL and LDL levels, mammgraphy, clnscpy, and stress test n bicycle r treadmill. The annual benefit amunt is $50 fr cmpleting a health screening test. If yur spuse and/r children are/is cvered fr Accident Insurance, they are als cvered fr the Wellness Benefit. Yur spuse s benefit amunt is als $50. The benefit fr child cverage is 50% f yur benefit amunt per child with an annual maximum f $100 fr all children.

6 Accidental Death and Dismemberment (AD&D) cverage: If yu are severely injured r die as a result f a cvered accident, an AD&D benefit may be payable t yu r yur beneficiary. If yur spuse and/r children are/is cvered fr Accident Insurance, their cverage includes AD&D. Accidental Death Benefits Benefit Cmmn Carrier: If the death ccurs as a result f a cvered accident n a cmmn carrier, a higher benefit will be payable. Cmmn carrier means any cmmercial transprtatin that perates n a regularly scheduled basis between predetermined pints r cities. Emplyee $85,000 Spuse $40,000 Children $20,000 Other accident Emplyee $40,000 Spuse $15,000 Children $8,000 Accidental Dismemberment Benefits Lss f bth hand r bth feet r sight in bth eyes $24,000 Lss f ne hand r ne ft AND the sight f ne eye $18,000 Lss f ne hand AND ne ft $18,000 Lss f ne hand OR ne ft $10,000 Lss f tw r mre fingers r tes $1,500 Lss f ne finger r ne te $1,000 Catastrphic Accident cverage: If yu are severely injured in a cvered accident, Catastrphic Accident cverage may prvide an additinal benefit payment. Nte that yu will be eligible t receive this benefit payment 365 days after the cvered accident. Lss is limited t ttal and permanent lss f any f the fllwing: bth hands r bth feet, the use f bth arms r bth legs, ne hand and ne ft, ne arm and ne leg, the sight f bth eyes, hearing in bth ears, r the ability t speak. If yur spuse and/r children are/is cvered fr Accident Insurance, their cverage includes Catastrphic Accident cverage. Catastrphic Accident Benefits Benefit Emplyee $100,000 Spuse $50,000 Children $25,000 Hme Mdificatin Benefit $2,500 Vehicle Mdificatin Benefit $2,500

7 What ptinal benefits are available? Yu may chse t include the ptinal benefits belw with yur Accident Insurance cverage. Fr a list f standard exclusins and limitatins, please refer t the end f this dcument. Fr a cmplete descriptin f yur available benefits, exclusins and limitatins, see yur certificate f insurance and any riders. Spuse* Accident Insurance: If yu have cverage n yurself, yu may enrll yur spuse, as lng as yur spuse is under age 70 and is nt cvered under yur emplyer s plan as an emplyee. Yur spuse will be cvered fr the same Accident benefits as yu are. Guaranteed issue: N medical questins r tests are required fr cverage. *The use f spuse in this dcument means a persn insured as a spuse as described in the applicable rider. Please cntact yur emplyer fr mre infrmatin. Children s** Accident Insurance: If yu have cverage n yurself, yur natural children, stepchildren, adpted children r children fr whm yu are a legal guardian are eligible t be cvered under yur emplyer s plan, up t the age f 26. Yur children will be cvered fr the same Accident benefits as yu are. Guaranteed issue: N medical questins r tests are required fr cverage. One premium amunt cvers all f yur eligible children. If bth yu and yur spuse are cvered under yur emplyer s plan as an emplyee, then nly ne, but nt bth, may cver the same children fr Accident Insurance. If the parent wh is cvering the children stps being insured as an emplyee, then the ther parent may apply fr children s cverage. **The definitin f child may vary by state. Please cntact yur emplyer fr mre infrmatin. Hw much des Accident Insurance cst? All emplyees pay the same rate, n matter their age. See the chart belw fr the premium amunts. Rates shwn are guaranteed until January 1, Mnthly Rates Emplyee Emplyee and Spuse Emplyee and Children Family $13.87 $23.22 $27.36 $36.71 Exclusins and Limitatins* Exclusins fr the Certificate, Spuse Accident Insurance, and Children s Accident Insurance and AD&D are listed belw. (These may vary by state.) Benefits are nt payable fr any lss caused in whle r directly by any f the fllwing*: Participatin r attempt t participate in a felny r illegal activity. An accident while the cvered persn is perating a mtrized vehicle while intxicated. Intxicatin means the cvered persn s bld alchl cntent meets r exceeds the legal presumptin f intxicatin under the laws f the state where the accident ccurred. Suicide, attempted suicide r any intentinally self-inflicted injury, while sane r insane. War r any act f war, whether declared r undeclared, ther than acts f terrrism. Lss sustained while n active duty as a member f the armed frces f any natin. We will refund, upn written ntice f such service, any premium which has been accepted fr any perid nt cvered as a result f this exclusin. Alchlism, drug abuse, r misuse f alchl r taking f drugs, ther than under the directin f a dctr. Riding in r driving any mtr-driven vehicle in a race, stunt shw r speed test. Operating, r training t perate, r service as a crew member f, r jumping, parachuting r falling frm, any aircraft r ht air balln, including thse which are nt mtr-driven. Flying as a fare-paying passenger is nt excluded. Perfrming these acts as part f yur emplyment with the Emplyer is nt excluded.

8 Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing r any similar activities. Practicing fr, r participating in, any semi-prfessinal r prfessinal cmpetitive athletic cntests fr which any type f cmpensatin r remuneratin is received. Any sickness r declining prcess caused by a sickness. Wrk fr pay, prfit r gain. Exclusins and limitatins fr Catastrphic Accident cverage (may vary by state) are the same as the exclusins in the Certificate, plus: The catastrphic accident benefit is nt payable if the cvered persn is in a cma at the end f the 365 day perid fllwing a cvered accident. The catastrphic accident benefit reduces t 50% at age 65 and t 25% f the initial benefit amunt at age 70. Hw d I enrll? Yu will be able t enrll fr benefits Octber 18, 2017 Nvember 3, Watch fr mre details cming sn. Wh d I cntact with questins? Fr mre infrmatin, please call Vya Emplyee Benefits Custmer Service at (877) r lg n t This is a summary f benefits nly. A cmplete descriptin f benefits, limitatins, exclusins and terminatin f cverage will be prvided in the certificate f insurance and riders. All cverage is subject t the terms and cnditins f the grup plicy. If there is any discrepancy between this dcument and the grup plicy dcuments, the plicy dcuments will gvern. T keep cverage in frce, premiums are payable up t the date f cverage terminatin. Accident Insurance is underwritten by ReliaStar Life Insurance Cmpany (Minneaplis, MN), a member f the Vya family f cmpanies. Plicy Frm #RL-ACC3-POL-16; Certificate Frm #RL- ACC3-CERT-16; and Rider Frms: Spuse Accident Rider Frm #RL-ACC3-SPR-16, Children's Accident Rider Frm #RL-ACC3- CHR-16, Wellness Benefit Rider Frm #RL-ACC3-WELL-16, Accidental Death & Dismemberment (AD&D) Rider Frm #RL-ACC3- ADR-16, Catastrphic Accident Rider Frm #RL-ACC3-CAR-16. Frm numbers, prvisins and availability may vary by state. CN St. Luke s Episcpal-Presbyterian Hspital, Grup # , Acct #002 Date Prepared: 09/11/ /01/2017