For the employees of Saint Louis University. ReliaStar Life Insurance Company, a member of the Voya family of companies

Transcription

1 Cmpass Accident Insurance Cmpass Accident Enrllment 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 Saint Luis University

2 What is Accident Insurance? Accident Insurance pays yu benefits fr specific injuries and events resulting frm a cvered accident that ccurs 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 r retire, 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 30+ 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. When is my cverage effective? The effective date f cverage is the date yu are eligible t begin filing claims. The cnditin r illness must ccur n r after the cverage effective date. 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 Event Benefit Accident hspital care Dislcatins Clsed/pen reductin 2 Surgery pen abdminal, thracic $1,200 Hip jint $3,850/$7,700 Surgery explratry r withut repair $175 Knee $2,400/$4,800 Bld, plasma, platelets $600 Ankle r ft bne(s) ther than tes $1,500/$3,000 Hspital admissin $1,250 Shulder $1,600/$3,200 Hspital cnfinement per day, up t 365 days $375 Elbw $1,100/$2,200 Critical care unit cnfinement per day, up t 15 days $600 Wrist $1,100/$2,200 Rehabilitatin facility cnfinement per day, up t 90 days $200 Finger/te $275/$550 Cma duratin f 14 r mre days $17,000 Hand bne(s) ther than fingers $1,100/$2,200 Transprtatin per trip, up t three per accident $750 Lwer jaw $1,100/$2,200 Ldging per day, up t 30 days $180 Cllarbne $1,100/$2,200 Family care per child per day, up t 45 days $25 Partial dislcatins 25% f the clsed reductin amunt

3 Accident care Fractures Clsed/pen reductin 3 Initial dctr visit $90 Hip $3,000/$6,000 Urgent care facility treatment $225 Leg $2,500/$5,000 Emergency rm treatment $225 Ankle $1,800/$3,600 Grund ambulance $360 Kneecap $1,800/$3,600 Air ambulance $1,500 Ft excluding tes, heel $1,800/$3,600 Fllw-up dctr treatment $90 Upper arm $2,100/$4,200 Chirpractic treatment up t six per accident $45 Frearm, hand, wrist except fingers $1,800/$3,600 Medical equipment $120 Finger, te $240/$480 Physical r ccupatinal therapy up t six per accident $45 Vertebral bdy $3,360/$6,720 Speech therapy up t 6 per accident $45 Vertebral prcesses $1,440/$2,880 Prsthetic device (ne) $750 Pelvis except cccyx $3,200/$6,400 Prsthetic device (tw r mre) $1,200 Cccyx $400/$800 Majr diagnstic exam $240 Bnes f face except nse $1,200/$2,400 Outpatient surgery (ne per accident) $225 Nse $600/$1,200 X-ray $45 Upper jaw $1,500/$3,000 Cmmn injuries Lwer jaw $1,440/$2,880 Burns secnd degree, at least 36% f the bdy $1,250 Cllarbne $1,440/$2,880 Burns third degree, at least nine but less than 35 $7,500 Rib r ribs $400/$800 square inches f the bdy Burns third degree, 35 r mre square inches f the bdy Skin grafts Emergency dental wrk $15,000 Skull simple except bnes f face $1,400/$2,800 25% f the burn benefit $350 crwn, $90 extractin Skull depressed except bnes f face $3,000/$6,000 Sternum $360/$720 Eye injury remval f freign bject $100 Shulder blade $1,800/$3,600 Eye injury surgery $350 25% f the Trn knee cartilage surgery with n repair r if Chip fractures clsed reductin $225 cartilage is shaved amunt 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 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.

4 Meet Jhn Jhn wrks full-time while raising tw energetic children and playing in a summer sftball league. While sliding int hme base, he brke his ankle and tre his ACL. Frtunately, the accident didn t break Jhn s bank accunt - and the family vacatin was saved. Benefits paid by Jhn s Accident Insurance Out-f-Pcket Csts Accident Insurance Benefit Urgent care facility treatment $400 $225 Tendn/ligament/rtatr cuff surgery $1,000 $825 Brken ankle, clsed reductin $1,500 $1,800 Medical equipment $150 $120 Fllw-up dctr visit $125 $90 Physical therapy (6 sessins) $300 $270 Ttal $3,475 $3,330 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. 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 $100 fr cmpleting a health screening test. If yur spuse and/r children are cvered fr Accident Insurance, they are als cvered fr the Wellness Benefit. Yur spuse s benefit amunt is als $100. The benefit fr child cverage is 50% f yur benefit amunt per child with an annual maximum f $200 fr all children. Sickness Hspital Cnfinement cverage: If yu are cnfined t a hspital due t a cvered sickness, a daily benefit may be payable fr each day yu are in the hspital. If yur spuse and/r children are/is cvered fr Accident Insurance, their cverage includes Sickness Hspital Cnfinement cverage. Cverage amunts: Emplyee: $100 per day fr up t 30 days. Spuse: $100 per day fr up t 30 days. Children: $75 per day fr up t 30 days. 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 $1,000. 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.

5 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. 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. Hw much des Accident Insurance cst? All emplyees within the same class pay the same rate, n matter their age. See the charts belw fr the premium amunts. Rates shwn are guaranteed until January 1, The cst belw includes Accident Insurance premium and a fee fr Vya Travel Assistance. Bi-Weekly Rates (26 Pay Perids) Emplyee Emplyee and Spuse Emplyee and Children Family $8.50 $15.04 $16.66 $23.20 Mnthly Rates (12 Pay Perids) Emplyee Emplyee and Spuse Emplyee and Children Family $18.42 $32.59 $36.09 $50.26 Exclusins and Limitatins* Exclusins fr the Certificate, Spuse Accident Insurance, and Children s Accident Insurance 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.

6 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. 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. Exclusins and limitatins fr Sickness Hspital Cnfinement cverage (may vary by state) are listed belw. Benefits are nt payable if any f the fllwing are true: Services are received in an emergency rm r fr utpatient treatment r fr a hspital stay fr which there is n charge fr rm and bard. Cnfinement is the result f alchlism r drug abuse. Cnfinement is the result f dental care r elective prcedures. Cnfinement is due t psychiatric r psychlgical cnditins. Cnfinement is due t birth, if the cvered persn is a newbrn child, unless the newbrn has an eligible sickness. What are pre-existing cnditins and are they cvered*? A pre-existing cnditin means a sickness which, within the 12 mnth perid prir t the Sickness Hspital Cnfinement cverage effective date r any increase in cverage fr each cvered persn, resulted in the cvered persn receiving medical treatment, cnsultatin, care r services (including diagnstic measures). Fr the first 12 mnths fllwing the Sickness Hspital Cnfinement cverage effective date r any increase in cverage fr each cvered persn, benefits are nt payable fr any hspital cnfinement resulting frm a pre-existing cnditin. If the hspital cnfinement begins mre than 12 mnths after the cverage effective date r an increase in cverage fr the cvered persn, benefits are payable fr any eligible hspital cnfinement even if resulting frm a pre-existing cnditin. *Definitin and limitatins/exclusins may vary by state. Are there additinal nn-insurance services available? Travel Assistance: When traveling mre than 100 miles frm hme, Vya Travel Assistance ffers enhanced security fr yur leisure and business trips. Yu and yur dependents can take advantage f fur types f services: pre-trip infrmatin, emergency persnal services, medical assistance services and emergency transprtatin services. Vya Travel Assistance services are prvided by Eurp Assistance USA, Bethesda, MD.

7 Wh d I cntact with questins? Fr mre infrmatin, please call Vya Emplyee Benefits Custmer Service at (877) 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 and Sickness Hspital Cnfinement Rider Frm #RL-ACC3-HCR-16. Frm numbers, prvisins and availability may vary by state. CN Saint Luis University, Grup # , Acct #0001 Date Prepared: 10/30/ /01/2017