The Chesapeake Life Insurance Company SM Supplemental Insurance Protection Packages lllness and Hospitalization Packages Georgia CH PLUS GA 311_311
Table of Contents Illness and Hospitalization Protection Packages...1 PersonalFit Plus Personal Illness Protection Package...2 HospitalFit Plus Hospitalization Protection Package...3 Plan Terms for all Packages...4 Other Important Information...5 Outlines of Coverage...6 This brochure provides only summary information. The information contained herein is accurate at the time of print. These plans are not intended as a replacement for accident and sickness health insurance and should not be construed as such. For a complete listing of benefits, exclusions and limitations, please refer to your Policy. In the event of any discrepancies contained in this brochure, the terms and conditions contained in the Policy documents shall govern. ii CH PLUS GA 311
Illness and Hospitalization Protection Packages Unexpected health events can impact both you and your finances. To help protect you and your family from the unexpected, The Chesapeake Life Insurance Company offers several plans designed to work with your existing health coverage, and help with the financial burden that can accompany a critical illness or hospital confinement. PersonalFit Plus (Illness) offers you additional protection that can offset illness-related expenses. HospitalFit Plus (Hospitalization) offers you additional protection for time spent in the hospital, providing limited coverage for inpatient and outpatient diagnostics, rehabilitation therapy and transportation. Illness and Hospitalization protection packages are designed to FIT your life. ~ Pays a lump sum benefit directly to use as you choose ~ No Deductible and No Copay ~ Fully portable plans move with you ~ Multiple plan options ~ Premiums do not increase with age CHOOSE FROM TWO PACKAGES Benefits PersonalFit Plus HospitalFit Plus Inpatient Confinement Daily Hospital Surgery Outpatient Emergency and Diagnostic Major Diagnostic Exams Outpatient Surgical Room Invasive Diagnostic Exams Physician-Office Visits Follow-Up and Restorative Rehabilitation Unit Disability Waiver of Premium Transportation Ground or Water Ambulance Air Ambulance The Chesapeake Life Insurance Company will not provide benefits for any loss resulting from a pre-existing condition, as defined within the Exclusions and Limitations section. CH PLUS GA 311 1
PersonalFit Plus Personal Illness Protection Package An unforeseen illness can disrupt your lifestyle. Personal Illness Protection is designed to help you with the financial burden of an unexpected health event. ~ Pays a lump sum benefit directly to you ~ No Deductible and No Copay ~ Fully portable plan that moves with you BENEFIT SUMMARY Inpatient Hospital Confinement Low Plan High Plan Lump Sum Hospital One benefit per insured person, per Policy year $175 $275 Daily Hospital Days 1 through 15 $100 $150 Days 16 through 180 ~ Per insured person, per day Surgery* (One surgical procedure per insured person, per day) Surgery Covered surgeries Bone Gynecologic Miscellaneous** Brain Heart Pancreas Breast Larynx Skin Digestive Liver Spine Ear/Nose Lungs Thyroid Eye Lymphatic Urinary ~ Payable only for insured person related to an illness ~ Examinations covered under invasive diagnostic procedure are not payable under this benefit * Refer to the Schedule of Benefits for specific payment amount ** Miscellaneous surgeries are defined in the Schedule of Benefits Physician-Office Visit $150 $250 $25 - $500 $50 - $1,000 Office Visits Includes wellness or illness visits $20 $30 ~ Per insured person, per Policy year 2 visits 3 visits ~ Per family, per Policy year 4 visits 6 visits Major Diagnostic Exam (One diagnostic exam per insured person, per Policy year) Diagnostic Exam Types of Exams CT Scan EEG Myelogram Arteriogram MRI Angiogram Thallium Stress Test ~ Payable only for insured person related to an illness Hospital Rehabilitation Unit (Paid in lieu of hospital confinement benefit) Rehabilitation ~ Not to exceed 15 days per illness ~ Not to exceed 30 days per Policy year Emergency Ambulance (One trip per insured person, per illness) $100 $175 $25 $50 Ground or Water $50 $100 Air $500 $1,000 Form CH-26112-IP (06/09) GA ~ Choice of two plan options ~ Premiums do not increase with age ~ Waiver of Premium refer to Other Important Information section 2 CH PLUS GA 311
HospitalFit Plus Hospitalization Protection Package An unexpected hospital stay can quickly impact your life and your budget, adding a financial burden when you can least afford one. Our hospitalization protection plan can help you with the expenses related to hospital care. ~ Pays a lump sum benefit directly to you ~ No Deductible and No Copay ~ Fully portable plan that moves with you BENEFIT SUMMARY Inpatient Hospital Confinement (Per insured person; not to exceed 365 days per illness or injury) Low Plan High Plan Daily Hospital Days 1 through 7 $200 $400 Days 8 through 365 $75 $150 ~ Confinements separated by less than 30 days are considered the same confinement Outpatient Surgery Facility (Per insured person, per illnes or injury) Outpatient Surgery* With anesthesia $175 $350 * Paid in lieu of hospital confinement benefit Without anesthesia $50 $100 Invasive Diagnostic Exam (One diagnostic procedure per insured person, per day) Invasive Diagnostic Exam ~ Five diagnostic exams per Policy year ~ Inpatient hospital or outpatient surgery facility Surgery* (One surgical procedure per insured person, per day) Surgery Covered surgeries Bone Gynecologic Miscellaneous** Brain Heart Pancreas Breast Larynx Skin Digestive Liver Spine Ear/Nose Lungs Thyroid Eye Lymphatic Urinary ~ Payable only for covered illness or injury ~ Examinations covered under invasive diagnostic procedure are not payable under this benefit * Refer to the Schedule of Benefits for specific payment amount ** Miscellaneous surgeries are defined in the Schedule of Benefits Hospital Rehabilitation Unit (Paid in lieu of hospital confinement benefit, not to exceed 30 days per Policy year) Rehabilitation Emergency Ambulance (One trip per illness or injury) Not to exceed 15 days per illness or injury per insured person, per hospitalization $125 $250 $25 - $500 $50 - $1,000 $75 $150 Ground or Water $175 $350 Air $1,750 $3,500 Form CH-26111-IP (06/09) GA ~ Choice of two plan options ~ Premiums do not increase with age ~ Waiver of Premium refer to Other Important Information section CH PLUS GA 311 3
Plan Terms for all Packages Ambulance A ground, water or air vehicle which is licensed as required by law, as an ambulance, and is equipped to transport sick or injured people. Confined/Confinement An insured person s medically necessary admission to and subsequent continued stay in a hospital for which a daily charge for room and board is made for each day of confinement with no discharge or interruption in such hospital stay. Covered Dependent An eligible dependent, as shown on the Policy schedule and listed as a covered dependent, whose coverage has become effective under the Policy and has not terminated. Hospital An institution operated pursuant to its license for the care and treatment of sick and injured persons for which a charge is made that the insured person is legally obligated to pay. The institution must: Maintain on its premises organized facilities for medical, diagnostic and surgical care for sick and injured persons on an inpatient basis Maintain a staff of one or more duly licensed physicians Provide 24-hour nursing care by or under the supervision of a registered graduate professional nurse (R.N.) and Is accredited as a hospital by the joint commission on accreditation of hospitals. The term "hospital" does not include: A hospice unit, including any bed designated as a hospice or a swing bed, a convalescent home, a rest or nursing facility; an extended care facility, a skilled nursing facility or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders; care for the aged, or care for persons addicted to drugs or alcohol and Any military or veteran's hospital, soldier's home or any hospital contracted for or operated by the federal government or any agencies thereof for the treatment of members or former members of the armed forces, unless the insured person is legally required to pay for services. Injury Bodily harm caused by an accident resulting in unforeseen trauma requiring immediate medical attention or within 72 hours, and is not contributed to (directly or indirectly, for HospitalFit Plus only) by a sickness. Insured Person You or a covered dependent under the Policy. Invasive Diagnostic Exam (HospitalFit Plus only) An arthroscopy, bronchoscopy, colonoscopy, cystoscopy, gastroscopy, laryngoscopy, sigmoidoscopy, esophagoscopy, laparoscopy, or mediastinoscopy procedure that is performed on an insured person as a result of an illness or injury in a hospital or outpatient surgery facility. Policy Year Each consecutive 12-month period beginning with your effective date of coverage. Pre-Existing A medical condition not excluded by name or specific description for which Medical advice, consultation, or treatment was recommended by or received from a physician within the 12-month period before the effective date of coverage or Symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 12-month period before the effective date of coverage. Sickness An illness or disease. Surgery The performance of generally accepted operative and cutting procedures, including surgical diagnostic procedures, specialized instrumentation, endoscopic examinations, and other invasive procedures while an insured person is under local or general anesthesia The correction of fractures and dislocations and Any of the procedures designated by current procedural terminology codes as surgery. 4 CH PLUS GA 311
Other Important Information Coverage Begins Once your application is approved, the effective date of coverage for you and your eligible dependents listed on the application and accepted by us will be the Policy date shown on the Policy schedule. Waiver of Premium We will waive all monthly premiums due for the Policy during your extended hospital confinement. The waiver of premium begins after you have been hospital confined for a period of at least 30 consecutive days. Premiums will resume under this Policy when you are no longer receiving a hospital confinement benefit under this Policy. Once premiums are resumed under the Policy, any new hospital confinements will be subject to a 30 day continued confinement without discharge, before premiums will be waived. Health Savings Account Eligibility In the event that you qualify for a Health Savings Account (HSA), and you are or will be making contributions to your Account, please note that the purchase of the PersonalFit Plus or HospitalFit Plus Plans may cause you to lose your eligibility for the tax advantages of contributing to an HSA. Therefore, we recommend that you consult your tax advisor if you are considering purchasing this plan and you are or will be making contribution to an HSA account. Claim Submission You must notify the company in order for your claim to be considered. Refer to your policy materials for the claim form and additional instructions. Termination of Coverage Your coverage will terminate and no benefits will be payable under the Policy: At the end of the month for which premium has been paid, subject to the grace period On the next Policy anniversary date following your reaching age 65 At the end of the month following the date of our receipt of your written request of termination If the insured person performs an act or practice that constitutes fraud or intentional misrepresentation of material fact in applying for or procuring coverage, subject to the Time Limit on Certain Defenses provision appearing under the General Provisions section of the Policy On the date we elect to discontinue this plan or type of coverage. We will give you at least 90 written days notice before the date coverage will be discontinued. You will be offered an option to purchase any other coverage that we offer without regard to health status On the date we elect to discontinue all coverage in your state. We will give you and the proper state authority at least 180 days written notice before the date coverage will be discontinued On the date an insured person is no longer a permanent resident of the United States. Any unearned premium which has been paid by you will be refunded on a pro rata basis. Your covered dependent s coverage will terminate under the Policy: On the date your coverage terminates At the end of the month following the date such dependent ceases to be an eligible dependent At the end of the month following the date of our receipt of your written request of termination The covered dependent performs an act or practice which constitutes fraud or intentional misrepresentation of material fact in applying for or procuring coverage subject to the Time Limit on Certain Defenses provision appearing under the General Provisions section of the Policy. Any unearned premium which has been paid by you will be refunded on a pro rata basis. The attainment of the limiting age for an eligible dependent will not cause coverage to terminate while that person is and continues to be: Incapable of self-sustaining employment by reason of mental retardation or physical handicap, as determined by the Department of Human Resources, and Chiefly dependent on you for support and maintenance. For the purpose of this provision chiefly dependent means the eligible dependent receives the majority of his or her financial support from you. We require that you provide written proof that the dependent child is a disabled and dependent person within 31 days of the child's attainment of the limiting age. Thereafter, we may require such written proof not more frequently than annually after the two-year period following the child s attainment of the limiting age. In the absence of such proof, we may terminate the coverage of such person after the attainment of the limiting age. CH PLUS GA 311 5
THE CHESAPEAKE LIFE INSURANCE COMPANY A Stock Company (Hereinafter called: the Company, We, Our or Us) Home Office: Oklahoma City, Oklahoma Administrative Office: P.O. Box 982010 North Richland Hills, Texas 76182-8010 Customer Service: 1-800-733-1110 SICKNESS-ONLY SCHEDULED INDEMNITY POLICY OUTLINE OF COVERAGE FOR FORM CH-26112-IP (06/09) GA 1. READ YOUR POLICY CAREFULLY! This Outline of Coverage provides a very brief description of some of the important features of Your Policy. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both You and Us. It is, therefore, important that You READ YOUR POLICY CAREFULLY. THIS IS NOT A MEDICARE SUPPLEMENT POLICY. 2. SICKNESS-ONLY SCHEDULED INDEMNITY COVERAGE This coverage is designed to provide You or Your Covered Dependents with coverage for certain losses resulting from a Sickness occurring after Your coverage has become effective and while coverage is in force under the Policy. The Policy does not provide benefits for loss from Injury. 3. BENEFITS. The Policy provides the lump sum indemnity Benefit Amount shown in the Policy Schedule for the following benefits. All benefits are subject to the Benefit Amount shown in the Policy Schedule, any benefit limitations shown in the Policy Schedule, the Exclusions and Limitations listed below, and all other provisions of the Policy. INPATIENT HOSPITAL CONFINEMENT BENEFIT SURGERY BENEFIT: Bone Brain Breast Digestive Ear/Nose Eye Gynecologic Heart Larynx Liver Lungs Lymphatic Miscellaneous Pancreas Skin Spine Thyroid Urinary PHYSICIAN OFFICE VISIT BENEFIT MAJOR DIAGNOSTIC EXAM BENEFIT HOSPITAL REHABILITATION UNIT BENEFIT EMERGENCY GROUND/WATER AMBULANCE BENEFIT EMERGENCY AIR AMBULANCE BENEFIT CH-26112-IP (06/09) OC GA 6 CH PLUS GA 311
4. EXCLUSIONS AND LIMITATIONS. We will not provide any benefits for loss caused by, resulting from or in connection with: 1. An Injury; 2. Any care not Medically Necessary or benefits which are not specifically provided for in the this Policy; 3. Any act of war, declared or undeclared; 4. Active military duty in the service or any country; 5. Participation in a riot, civil commotion or insurrection; 6. Suicide, attempted suicide, or any intentionally self-inflicted injury, while sane or insane; 7. Mental or nervous disorders; 8. Having Cosmetic Surgery or other elective procedures that are not Medically Necessary; 9. Intoxicants or Narcotics: any loss sustained or contracted in consequence of the Insured Person being intoxicated or under the influence of any narcotic, unless administered on the advice of a Physician; 10. Any loss to which a contributing cause was the Insured Person's commission of or attempt to commit a felony, or to which a contributing cause was the Insured Person's being engaged in an illegal occupation; 11. Normal pregnancy, except for Complications of Pregnancy while Hospital Confined; and 12. Hospital Confinement for routine or normal newborn child care. Pre-Existing Condition Limitation We will not provide benefits for any loss resulting from a Pre-Existing Condition, as defined, unless the loss is incurred at least 6 months after the Effective Date of Coverage for an Insured Person. 5. RENEWAL CONDITIONS. The Policy is guaranteed renewable to the next Policy anniversary date following Your reaching age 65, at Your option, subject to the Company s right to discontinue or terminate the coverage as provided in the TERMINATION OF COVERAGE section of the Policy. Any change in rates will be effective on the next following premium due date. Please read the Premium Changes provision of the Policy carefully. The Company reserves the right to change the applicable table of premium rates on a Class Basis. 6. PREMIUMS. We reserve the right to change the table of premiums, on a Class Basis, becoming due under the Policy at any Policy anniversary; provided, We have given You written notice of at least 60 days prior to the effective date of the new rates. Such change will be on a Class Basis. CH-26112-IP (06/09) OC GA CH PLUS GA 311 7
THE CHESAPEAKE LIFE INSURANCE COMPANY A Stock Company (Hereinafter called: the Company, We, Our or Us) Home Office: Oklahoma City, Oklahoma Administrative Office: P.O. Box 982010 North Richland Hills, Texas 76182-8010 Customer Service: 1-800-733-1110 HOSPITAL AND SURGICAL INDEMNITY POLICY OUTLINE OF COVERAGE FOR FORM CH-26111-IP (06/09) GA 1. READ YOUR POLICY CAREFULLY! This Outline of Coverage provides a very brief description of some of the important features of Your Policy. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both You and Us. It is, therefore, important that You READ YOUR POLICY CAREFULLY. THIS IS NOT A MEDICARE SUPPLEMENT POLICY. 2. HOSPITAL AND SURGICAL INDEMNITY COVERAGE This coverage is designed to provide You or Your Covered Dependents with coverage for hospital and surgical expenses incurred as a result of a covered Sickness or Injury. 3. BENEFITS. The Policy provides the lump sum indemnity Benefit Amount shown in the Policy Schedule for the following benefits. All benefits are subject to the Benefit Amount shown in the Policy Schedule, any benefit limitations shown in the Policy Schedule, the Exclusions and Limitations listed below, and all other provisions of the Policy. INPATIENT HOSPITAL CONFINEMENT BENEFIT OUTPATIENT SURGERY FACILITY BENEFIT INVASIVE DIAGNOSTIC EXAM BENEFIT SURGERY BENEFIT: Bone Brain Breast Digestive Ear/Nose Eye Gynecologic Heart Larynx Liver Lungs Lymphatic Miscellaneous Pancreas Skin Spine Thyroid Urinary HOSPITAL REHABILITATION UNIT BENEFIT EMERGENCY GROUND/WATER AMBULANCE BENEFIT EMERGENCY AIR AMBULANCE BENEFIT CH-26111-IP (06/09) OC GA 8 CH PLUS GA 311
4. EXCLUSIONS AND LIMITATIONS. We will not provide any benefits for loss caused by, resulting from or in connection with: 1. Any care not Medically Necessary or benefits which are not specifically provided for in the Policy; 2. Any act of war, declared or undeclared; 3. Active military duty in the service or any country; 4. Participation in a riot, civil commotion or insurrection; 5. Suicide, attempted suicide, or any intentionally self-inflicted injury, while sane or insane; 6. Mental or nervous disorders; 7. Having Cosmetic Surgery or other elective procedures that are not Medically Necessary; 8. Operating any motorized passenger vehicle (such as a taxi) for wage, compensation or profit; 9. Intoxicants or Narcotics: any loss sustained or contracted in consequence of the Insured Person being intoxicated or under the influence of any narcotic, unless administered on the advice of a Physician; 10. Any loss to which a contributing cause was the Insured Person's commission of or attempt to commit a felony, or to which a contributing cause was the Insured Person's being engaged in an illegal occupation; 11. Normal pregnancy, except for Complications of Pregnancy while Hospital Confined; 12. Hospital Confinement for routine or normal newborn child care; 13. Mountaineering using ropes and/or other equipment, parachuting, hang gliding, racing any type of vehicle in an organized event, sky diving, scuba diving below 50 feet, motorized racing, para-sailing, experimental aviation, ultra-light flying, base jumping, bungee jumping, heli-skiing, heli-snowboarding or officiating or coaching such hazardous sport or activity; and 14. Travel in or descent from any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a commercial airline (other than a charter airline) certified by the U.S. Federal Aviation Administration (FAA), on a regularly scheduled passenger trip. Pre-Existing Condition Limitation We will not provide benefits for any loss resulting from a Pre-Existing Condition, as defined, unless the loss is incurred at least 6 months after the Effective Date of Coverage for an Insured Person. 5. RENEWAL CONDITIONS. The Policy is guaranteed renewable to the next Policy anniversary date following Your reaching age 65, at Your option, subject to the Company s right to discontinue or terminate the coverage as provided in the TERMINATION OF COVERAGE section of the Policy. Any change in rates will be effective on the next following premium due date. Please read the Premium Changes provision of the Policy carefully. The Company reserves the right to change the applicable table of premium rates on a Class Basis. 6. PREMIUMS. We reserve the right to change the table of premiums, on a Class Basis, becoming due under the Policy at any Policy anniversary; provided, We have given You written notice of at least 60 days prior to the effective date of the new rates. Such change will be on a Class Basis. CH-26111-IP (06/09) OC GA CH PLUS GA 311 9
The Chesapeake Life Insurance Company www.chesapeakeplus.com 1-800-815-8535 2011 The Chesapeake Life Insurance Company CH PLUS GA 311_311