Exhibit 10.35
CORPORATE HEALTH INSURANCE COMPANY
(A Minneapolis, Minnesota Domiciled Company)
Principal Executive Offices
980 Jolly Road
Blue Bell, Pennsylvania 19422
COMPREHENSIVE MAJOR MEDICAL
GROUP HEALTH INSURANCE POLICY
Providing Health Insurance With Optional Prescription Coverage
NON-PARTICIPATING
This Comprehensive Major Medical Group Health Insurance Policy (the "Policy") is
a legal contract between Corporate Health insurance Company ("CHI" or the
"Company") and the policyholder indicated on the Schedule of Benefits (the
"Policyholder"), which is set forth in the Summary of Benefits distributed to
each eligible employee of the Policyholder and incorporated herein by reference.
In consideration of a signed application and payment of the required premiums.
the Company agrees to provide insurance for eligible employees of the
Policyholder and their eligible dependents while such persons are covered under
this Policy and are insured for the applicable coverage. Benefits are subject to
the terms, conditions. exclusions and limitations of this Policy. Certain
identified benefits are subject to pre-certification requirements. which if not
followed will result in reduced benefits.
This Policy takes effect 12:01 a.m. Eastern Standard Time on the Effective Date
at the Policyholder's address.
Corporate Health Insurance Company has caused its President and Secretary to
execute and witness this Policy
/s/ /s/
Secretary President
TABLE OF CONTENTS
I. General Information 1
II. Eligibility 2
III. Enrollment Changes 5
IV. Policy Benefits and Payments 6
V. Pre-Certification 8
VI. Covered Medical Services 9
VII. General Exclusions 19
VIII. General Provisions 22
IX. Continuation of Coverage 26
X. Coordination of Benefits 30
XI. Medicare 33
XII. Subrogation 34
XIII. Policyholder/Employer Provisions 35
XIV. Pre-Existing Conditions Limitation 37
XV. Definitions 38
I. GENERAL INFORMATION
1. POLICY NUMBER: PA 18927I-Custom
2. POLICYHOLDER NUMBER: PA 18927I
3. NAME AND ADDRESS OF POLICYHOLDER:
STV Group
11 Robinson Street
Pottstown, PA 19464
4. EMPLOYER IDENTIFICATION NUMBER (E.I.N.) ASSIGNED
BY INTERNAL REVENUE SERVICE: 23-1698231
5. TYPE OF POLICY: Group Health Insurance Policy - Custom Plan
6. THE NAME, BUSINESS ADDRESS AND TELEPHONE NUMBER OF THE COMPANY:
CORPORATE HEALTH INSURANCE COMPANY
980 Jolly Road
P.O. Box 1109
Blue Bell, Pennsylvania 19422
1-800-204-2300
7. POLICY EFFECTIVE DATE: July 1, 1996
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II. ELIGIBILITY
1. Covered Persons
This Policy will cover the following Covered Persons:
(i) all Eligible Employees of the Policyholder and its subsidiaries and
affiliates specifically identified in writing by the Policyholder to
the Company; and
(ii) their Eligible Dependents.
2. Eligibility Date
The "Eligibility Date" for each Covered Person will be:
(i) if the Covered Person is an Eligible Employee, the later of the date
of hire by the Policyholder (or, if applicable, the date on which the
waiting period imposed by the Policyholder ends) and the Effective
Date of this Policy; or
(ii) if the Covered Person is an Eligible Dependent, the later of the date
of hire (or, if applicable, the date on which the waiting period
imposed by the Policyholder ends) of the Eligible Employee to whom
such Covered Person is a Dependent and the Effective Date of this
Policy.
3. When Coverage Begins
(a) If an Eligible Employee enrolls on or before the Effective Date of
this Policy, coverage will begin under this Policy on the Effective
Date for such Eligible Employee and any Eligible Dependents of such
Employee identified as Covered Persons in the Policy Enrollment Form.
(b) If an Eligible Employee enrolls after the Effective Date of this
Policy, coverage will begin on the first day of the calendar month
after the Eligible Employee enrolls under this Policy.
(c) An Eligible Employee will be deemed to have enrolled under this Policy
when the Eligible Employee has completed, signed and delivered a
Policy Enrollment Form, identifying any Eligible Dependents as Covered
Persons, to the Company and such Policy Enrollment Form has been
accepted by the Company at its sole discretion.
(d) Should the Eligible Employee not be working full-time on the day he or
she would ordinarily become covered under this Policy, the coverage
for such Employee and any Eligible Dependents will be delayed until he
or she returns to full-time work.
(e) Limitation: Each Eligible Employee will have 31 days from his or her
Eligibility Date to enroll for coverage. No Evidence of Good Health
will be required for any Eligible Employee enrolling within such 31
days. All Eligible Employees enrolling after such 31 days will be
required to submit Evidence of Good Health for his or herself and for
each Eligible Dependent. If such Employee fails to provide Evidence of
Good Health satisfactory to the Company, the Company may reject the
Employee's enrollment application for insurance under this Policy.
Coverage under this Policy for enrollees after such 31 days who
provides satisfactory Evidence of Good Health will begin no earlier
than the first day of the calendar month after CHI's approval of
Evidence of Good Health.
(f) For purpose of this Article only, each Eligible Employee who enrolls
under this Policy during any designated open enrollment period of the
Policyholder shall be deemed and treated as a new employee of the
Policyholder.
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4. Return to Work After Voluntary Termination of Employment
If an Eligible Employee returns to active full-time employment with the
Policyholder at any time following voluntary termination of employment with
the Policyholder, the waiting period described herein for new Employees
will apply, unless the Eligible Employee returns within 12 months after the
date of the voluntary termination.
5. Dependent Coverage
(a) A Covered Employee's spouse and a Covered Person's dependent children
can also be covered under the Policy pursuant to the terms hereof.
(b) The Covered Employee's spouse is eligible for dependent coverage
unless:
(i) The Covered Employee and his or her spouse are legally separated
or divorced or have obtained an annulment;
(ii) Both the Covered Employee and his or her spouse are employees of
the Policyholder. The Covered Employee and his or her spouse may
choose to be covered as individual employees of the Policyholder,
or one may cover the other as a Dependent, but both of them may
not cover the other as a Dependent;
(iii) Such spouse is in active Military Service;
(iv) Such spouse is of the same sex; or
(v) Such spouse is not a legal spouse, under the laws of the
Commonwealth of Pennsylvania.
(c) The Covered Person's natural or legally adopted child is eligible from
birth so long as the child is:
(i) Less than age 23, or if a full-time student, less than age 23;
(ii) Not married; and
(iii) Not on active duty in any of the armed forces.
(d) Child/children under legal guardianship (including foster children) or
children under court order will be included under this Policy under
the same conditions and restrictions applicable to a Covered Person's
natural or legally adopted children.
(e) The Covered Employee's spouse and child/rep meeting the requirements
described above are referred to in this Policy as "Eligible
Dependents."
6. Enrolling the Eligible Employee's Eligible Dependents
(a) The Eligible Employee can enroll for family coverage at the same time
he or she becomes eligible for his or her individual coverage.
(b) If the Eligible Employee has no Dependents when the Eligible Employee
first enrolls but later gains one, the Eligible Employee may enroll
for family coverage within 31 days of the date the Eligible Employee
gains the Dependent. This includes Dependents gained by marriage,
birth adoption, legal guardianship or court order. During the first 31
days after the birth of a child, the child will be
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automatically covered for all eligible benefits. For coverage of a
child beyond the first 31 days after birth and for coverage of a
spouse during and beyond the first 31 days after marriage, enrollment
must be made and the first premium charge for that Dependent must be
paid within that 31 day period.
(c) Note: Except for newborn child's coverage during the first 31 days
after birth. if the Eligible Employee does not enroll his or her
Dependents within 31 days after the Dependent becomes eligible.
satisfactory Evidence of Good Health for each Dependent will be
required. If satisfactory Evidence of Good Health is not provided for
such Dependent, the Company may reject the enrollment application for
insurance of such Dependent under this Policy. Coverage for such
Dependent providing satisfactory Evidence of Good Health will then
begin no earlier than the first day of the calendar month following
CHI's approval of the Evidence of Good Health. However, no Evidence of
Good Health will be required for any Dependent who enrolls within such
31 days.
(d) If a Dependent, except a child covered at birth, is confined for
medical care or treatment in any institution or at home when coverage
would normally start, the Dependent will not be covered until given a
final release by a Physician from all such confinement.
7. When Dependent Coverage Stops
Except as otherwise specifically provided in this Policy, coverage for
Dependents shall end when the dependent relationship with the Eligible
Employee ends or when coverage for the Eligible Employee of whom such
person is a Dependent ends. When coverage for a Dependent ends, the
Dependent will have an opportunity to obtain continuation of medical
coverage as provided by the Consolidated Omnibus Budget Reconciliation Act
(COBRA). For more information on COBRA and the right to continued medical
coverage, see Section 1 of Article IX of this Policy.
8. Extension of Coverage for Dependents
(a) Under certain circumstances described below, coverage could continue
for an Eligible Dependent after the time coverage would normally stop
under this Policy.
(b) A child who is otherwise eligible hereunder and is physically or
mentally incapable of self-support upon attaining the limiting age may
be continued under the coverage provided hereunder so long as he or
she remains incapacitated and unmarried at that time, subject to the
coverage of the Covered Employee to whom such child is dependent is
continuing in effect.
(c) To be eligible for the continued coverage described in this Section of
a Dependent child beyond the time coverage would normally end, proof
of his or her incapacity must be submitted to CHI within 31 days after
such Dependent's attainment of the limiting age. Proof of the
incapacity will be required from time to time to keep this coverage in
effect. Each time CHI asks for proof that a Covered Dependent is
incapacitated, CHI may require the Covered Dependent to have a
Physician's examination at the Covered Person's expense. CHI may
specify the Physician.
(d) The continued coverage of a dependent child under this Section shall
terminate on the earliest of the following dates:
(i) the date such child is no longer incapacitated according to the
Policy;
(ii) the date proof of the child's incapacity is not provided when
asked; or
(iii)the date his or her Dependent's coverage terminates pursuant to
Article II, Section 7 or Article XIII of this Policy.
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III. ENROLLMENT CHANGES
Enrollment and benefit coverage under this Policy may be changed only upon a
change in family status of the Covered Employee.
A "change of family status" occurs when:
1. A Covered Employee gets married or divorced;
2. A Covered Employee's child is born or legally adopted;
3. A Covered Employee's spouse or child dies; or
4. A Covered Employee's spouse has a loss of group insurance
coverage.
Unless otherwise permitted under Article II, a Covered Employee may change his
or her benefit coverage or enroll new Dependents only if Evidence of Good Health
has been submitted and approved by CHI for each individual involved.
Furthermore, if a Dependent of a Covered Employee, other than a newborn child,
is confined in a Hospital, Skilled Nursing Facility, at home or any other
institution on the date coverage would become effective, then such coverage will
be postponed until the day after the Dependent is no longer so confined and a
final release from such confinement is provided by the Physician.
IV. POLICY BENEFITS AND PAYMENTS
If, as a result of an illness or injury, a Covered Person incurs eligible
medical expenses which exceed the Deductible Amount set forth in the Schedule of
Benefits during a calendar year, the Company will pay for such excess in
accordance with the co-payment and co-insurance provisions of the Schedule of
Benefits, subject to all other terms and conditions set forth in this Policy.
1. Deductible Amount
The Deductible Amount is the specified amount of eligible expenses which a
Covered Person or a Family Unit (as the case may be) is required to pay before
CHI pays any benefits under this Policy. Covered expenses which are used in
satisfying the Deductible Amount must be incurred and applied to such deductible
within the applicable calendar year.
The Deductible Amount applies to each Covered Person, subject to any family
Deductible Amount set forth in the Schedule of Benefits, if applicable. The
Deductible Amount must be satisfied once each calendar year, except for:
(a) the Common Accident Provision: if the Deductible Amount applies to
accident expenses and if two or more members of one family incur
covered expenses because of disabilities resulting from injuries
sustained in any one accident, the Deductible Amount will be applied
only once with respect to all covered expenses incurred as a result of
the accident; and
(b) the Carryover Provision: if any part or all of the Deductible Amount
has been satisfied during the last three months of such calendar year,
the Deductible Amount for the next calendar year will be reduced by
the amount applied.
The Deductible Amount is not applicable to certain eligible medical expenses
noted in the Schedule of Benefits, for which you or your family member need to
pay any Deductible Amount prior to being paid benefits under the Policy.
2. Co-Payment and Co-Insurance
After the applicable Deductible Amount has been paid by the Covered Person or
the Family Unit (as the case may be), the eligible expenses for Covered Medical
Services will be paid by CHI and the Covered Persons in accordance with the
co-payment and co-insurance provisions set forth in the Schedule of Benefits.
Certain Covered Medical Services will be subject to co-insurance provisions,
which require the payment obligations in excess of the Deductible Amount to be
shared between CHI and the Covered Person in accordance with percentages of
Reasonable and Customary Charges set forth in the Schedule of Benefits. Certain
other Covered Medical Services will be subject to co-payment provisions, which
require an initial sum specified in the Schedule of Benefits to be paid by the
Covered Person and the balance of Reasonable and Customary Charges to be paid by
CHI.
Certain Covered Medical Services specified in the Schedule of Benefits may not
be subject to co-insurance or co-payment requirements.
3. Out-of-Pocket Maximum
During any calendar year, the Covered Person or the Family Unit (as the case may
be) will not be required to pay an aggregate amount in excess of the
out-of-pocket maximum amount specified in the Schedule of Benefits (the
"Out-of-Pocket Amount"). If during any calendar year the Covered Person or the
Family Unit (as the case may be) has paid pursuant to the above co-insurance or
co-payment provision an aggregate amount greater than the Out-of-Pocket Amount,
CHI will pay for 100% of the balance of the eligible expenses, up to the amount
of the maximum benefit amounts set forth in the Schedule of Benefits.
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The co-insurance and co-payments paid by the Covered Person or the Family Unit
will be included in the Out-of-Pocket Amount. However, the Deductible Amount
paid by the Covered Person or the Family Unit will not be included in the
Out-of-Pocket Amount.
4. Maximum Benefits
The benefits payable under this Policy for all eligible medical expenses
incurred by any Covered Person shall not exceed the applicable maximum benefits
specified in the Schedule of Benefits. Such maximum benefits may be in the form
of a maximum amount payable during lifetime or a specified period or in the form
of a maximum number of days or visits for which benefits are payable under the
Policy. Different Covered Medical Services may be subject to one or more
different maximum benefits.
5. Restoration and Reinstatement
If a Covered Person has received his or her maximum benefits under the Policy,
then on the first day of each calendar year $1,000 shall be reinstated, but in
no event shall the reinstated amount exceed the applicable maximum benefits set
forth in the Schedule of Benefits. However, any Covered Person who wishes
immediate reinstatement of the full Policy maximum shall again be entitled to
receive full benefits by submitting Evidence of Good Health at his or her own
expense. The new maximum benefits will take effect on the first day of the month
following CHI's approval at its sole discretion of Evidence of Good Health. This
restoration and reinstatement provision will not apply to certain Covered
Medical Services, as specified in the Schedule of Benefits.
6. Re-Entry Into Policy
Any person who was formerly covered under the Policy, either as an Eligible
Employee or as a Dependent, and who again becomes covered hereunder within a
one-year period from the termination date of his or her previous coverage,
either as an employee or as a Dependent, shall not have his or her full maximum
benefits restored solely by reason of the fact that s/he has become covered for
a second or subsequent time. The maximum benefits with respect to such person,
as set forth in the Schedule of Benefits, shall be reduced by any benefits
previously paid under this Policy.
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V. PRE-CERTIFICATION
When a Physician recommends that a Covered Person be hospitalized or receive
certain other medical services or supplies specified in the Schedule of
Benefits, there are certain procedures that must be followed.
The Covered Person, a member of his or her family, a hospital staff member, or
the attending Physician, must notify CHI to pre-certify the admission or
treatment, as the case may be, prior to receiving any of the services or
supplies that require pre-certification pursuant to the Schedule of Benefits or
this Policy.
The Company will reduce the benefits payable under this Policy by the percentage
set forth in the Schedule of Benefits if the procedures for pre-certification
set forth herein are not followed. Each Covered Person will be responsible to
pay the unpaid balance of the benefits.
To obtain pre-certification, call CHI at 1-800-509-3400. This call must be made:
1. Prior to any planned admission into Hospital and prior to receiving
such other eligible services or supplies that require
pre-certification according to the Schedule of Benefits or this
Policy;
2. Within 24 hours after the time of an emergency admission or as soon
thereafter as reasonably possible; and
3. As soon as the attending Physician confirms that a Covered Person is
pregnant and again within 24 hours of the birth or as soon thereafter
as reasonably possible.
When calling CHI, the caller must provide:
1. The Covered Person's name and the Covered Person's social security
number;
2. The treating Physician's name, address and phone number;
3. The name of the Hospital or treatment facility and the anticipated
admission or treatment date; and
4. The Policyholder's name and Policyholder Policy Number.
There is no requirement to call in advance before seeking treatment for an
emergency.
Case Management
Certain medical conditions for which a claim is made under the Policy may be
referred to Case Management (CM).
Only those conditions for which Covered Medical Expenses are expected to exceed
a certain dollar amount, and for which there is a potential lower cost treatment
alternative, will be referred to CM.
CM is a program which provides a case-by-case analysis and medical treatment
plan suggestions that address the need of catastrophically ill or injured
individuals. It concentrates on severe injuries and illnesses, such as spinal
cord injuries or head trauma, when early intervention and individual case
management will prove effective to a patient's recovery.
The decision to refer any case to CM will remain with CHI, who will rely on the
criteria established by the CM service provider to determine which claims are
recommended for CM, except that no alternative treatment will be provided to the
Covered Person under CM without prior consent of the Covered Person and the
attending Physician.
In certain instances a recommendation to use alternative treatment not normally
covered by the Policy may be made when such treatment endorses quality care,
Medical Necessity and cost effectiveness. Under these circumstances, any such
alternative treatment will be covered by the Policy.
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VI. COVERED MEDICAL SERVICES
Subject to the terms, conditions, exclusions and limitations set forth in the
Schedule of Benefits (including the co-payment, co-insurance and maximum benefit
amounts set forth therein) and in this Policy, the Company will pay and provide
to each Covered Person the benefits described below.
This Policy does not cover charges in excess of Reasonable and Customary Charges
(as defined herein) and does not provide benefits for services or supplies other
than those Medically Necessary (as defined herein). Therefore, the term
"charges" used below shall refer only to Reasonable and Customary Charges for
Medically Necessary services or supplies. The coverage under this Policy is also
subject to other exclusions set forth in Article VII of this Policy.
Acupuncture
The charges for the administration of acupuncture when provided for pain
management in lieu of anesthesia.
Alcoholism and Drug Addiction Treatment
For alcoholism and drug addiction treatment, please refer to "Substance Abuse
Treatment" below.
Ambulance Transportation
The charges for ambulance service. Coverage is limited to transportation to and
from the nearest facility that can give necessary care and treatment.
Ambulatory Surgery
The charges for services and supplies furnished in connection with performance
of a surgical procedure at an Ambulatory Surgical Facility or the outpatient
department of a Hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the case may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Limitations/Exceptions
Coverage is limited to charges for the following:
1. Services and supplies furnished by the Ambulatory Surgical Facility or
Hospital on the date of the procedure;
2. Services of the operating Physician for performing the procedure and
for: a. Related pre- and post-operative care; and b. The administering
of an anesthetic; and
3. Services of any other Physician for the administering of a general
anesthetic.
This Policy does not cover Ambulatory Surgery charges incurred:
(a) For the services of a Physician who renders technical assistance to
the operating Physician, unless required in connection with the
procedure; or
(b) While the Covered Person is confined as a full-time Inpatient in a
Hospital.
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Anesthesia
The charges for the administration of anesthetics by a Physician (other than the
surgeon, assistant surgeon or the attending Physician) or registered nurse
anesthetist (R.N.A.).
Assistant Surgeon
The charges for the professional services of a legally qualified Physician to
render technical assistance to the operating surgeon when Medically Necessary in
connection with a surgical procedure performed. However, no benefits are payable
for surgical assistance rendered in hospitals where it is routinely available as
a service provided by a hospital intern, resident or house officer. The
assistant surgeon's charges are determined by using the surgeon's Reasonable and
Customary Charges.
Birthing Center
The charges for services and supplies furnished by a Birthing Center for:
1. Prenatal care;
2. Delivery of a child or children; and
3. Post-partum care rendered within twenty-four (24) hours after the
delivery.
Also included are charges for the services shown below if received in connection
with the above services and supplies furnished by the Birthing Center:
1. Charges by the operating Physician or certified nurse midwife for:
a. Performing an obstetrical procedure;
b. Related pre- and post-operative care; and
c. Administering an anesthetic.
2. Charges by any other Physician for the administering of a general
anesthetic.
Limitations/Exclusions
This Policy does not cover Birthing Center charges incurred:
1. For the services of a Physician or certified nurse midwife who renders
technical assistance to the operating Physician; or
2. For which pregnancy-related expenses are not covered under this
Policy.
Blood and Blood Plasma
The charges for blood and blood plasma, and blood plasma expanders when not
replaced on behalf of the Covered Person.
Cardiac Rehabilitation Services
The charges for cardiac rehabilitation therapy rendered by a licensed therapist,
when prescribed by and provided under the supervision of the attending
Physician.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400 prior to
receiving services. The Company will reduce the benefits under this Policy by
the percentage or dollars (as the case may be) set forth in the Schedule of
Benefits if the procedures for pre-certification are not followed.
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Chemotherapy
The charges for the treatment of malignant disease by chemical or biological
antineoplastic agents for cancer chemotherapy and cancer hormone treatments and
for services which have been approved by the United States Food and Drug
Administration for general use in treatment of cancer, whether performed in a
Physician's office, as an Inpatient or Out-Patient at a Hospital, or in any
other medically appropriate treatment setting.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the case may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Chiropractic Care
The charges for detection and correction by manual means of structural imbalance
or subluxation resulting from or related to distortion, misalignment or
subluxation of or in the vertical column.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the case may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Consultation
The charges for consultation services by a Professional Provider, provided that
the consultation services are given to the Covered Person at the request of the
attending Physician while confined as an Inpatient in a Hospital, a Skilled
Nursing Facility or a Substance Abuse Treatment Facility.
Consultation consists of an examination of the Covered Person and a review of
his or her x-ray and laboratory examinations and medical history, but not staff
consultations required by hospital rules and regulations.
Diagnostic Services
The charges for Diagnostic Services.
Durable Medical Equipment
The charges for rental or initial purchase (or necessary repair) of Durable
Medical Equipment prescribed by a Physician for the treatment of an Illness or
Injury. It does not include any changes made to the Covered Person's home,
automobile, or personal property, such as air conditioning or remodeling. Rental
coverage is limited to the purchase price of the Durable Medical Equipment.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400 prior to
leasing or purchasing any equipment in excess of $1,500. The Company will reduce
the benefits under this Policy by the percentage or dollars (as the case may be)
set forth in the Schedule of Benefits if the procedures for pre-certification
are not followed.
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Emergency Services
The charges for Emergency Services received within 48 hours after the onset of a
Medical Emergency. Surgery (e.g., suturing, burn care fracture care, etc.)
payment will be made as a surgical benefit.
After being admitted into a facility for Emergence Services, CHI must be
notified at 1-800-509-3400 within 24 hours of the admission or as soon as
reasonably possible. The Company will reduce the benefits under this Policy by
the percentage or dollars (as the case may be) set forth in the Schedule of
Benefits if the procedures for such notification are not followed.
Hemodialysis
The charges for hemodialysis treatment.
Home Health Services
The charges for Home Health Services provided by a licensed Home Health Agency
pursuant to a Home Health Plan.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400, and CHI
must approve the Home Health Plan, prior receiving Home Health Services. The
Company will reduce the benefits under this Policy by the percentage or dollars
(as the case may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
Coverage is limited to one visit per day. Each period of up to four (4) hours or
less will be considered one visit, and each visit by a Home Health Agency is
counted as one visit.
Hospice Care
The charges for Hospice Services if the attending Physician certifies that the
Covered Person is a Terminally Ill Person and recommends admission into a
Hospice Care Program.
To qualify for payment under the Policy, Hospice Services must be:
1. Provided while the Terminally Ill Person is a Covered Person;
2. Provided within six (6) months of the Terminally Ill Person's entry or
re-entry (after a remission period) in the Hospice Care Program; and
3. Furnished or arranged by a Hospice.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 1-800-509-3400, and CHI
must approve the Hospice Care Program, prior receiving Hospice Services. The
Company will reduce the benefits under this Policy by the percentage or dollars
(as the case may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
Coverage is limited to one or more of the following charges:
1. For the confinement of a Terminally Ill Person as an Inpatient in a
Hospice facility;
2. For Home Health Services furnished to the Terminally Ill Person in the
person's home;
3. For social services furnished to the Terminally Ill Person or to the
Family Unit by a Social Worker;
4. For palliative care (medication/treatment directed toward relief); or
5. For respite care.
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Hospital
The charges for Out-Patient services and supplies, and the following Inpatient
charges when a Covered Person is confined in a Hospital:
1. Room and board and general nursing care charges for semi-private
accommodations (designated as such by the Hospital) or, if the Covered
Person utilizes private accommodations because the Covered Person's
medical condition requires isolation for his or her health and the
attending Physician orders such private accommodations, charges for
private accommodations; and
2. Charges for all other hospital services and supplies, including
special meals and dietary services, medicines, laboratory tests, use
of operating rooms and special equipment anesthetics and x-rays,
provided and billed by hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to hospital admission as an Inpatient. The Company will
reduce the benefits under this Policy by the percentage or dollars (as the case
may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
The Policy does not cover hospital charges for any day that the Covered Person
does not receive any medical treatment after being admitted to a Hospital.
Immunization for Children
The charges for child immunization, up to the minimum benefits mandated by the
Pennsylvania Department of Health.
Coverage will be provided for those child immunizations, including the
immunizing agents, which as determined by the Department of Health, conform to
the standards of the U. S. Department of Health and Human Services. These
benefits will be exempt from Deductible Amounts and other dollar limits.
Infertility Services
The charges for services to diagnose infertility. Services to treat infertility
are not covered by this Policy.
Inpatient Physician Services
The charges for medical treatment given by the attending Physician to a Covered
Person while confined as an Inpatient in a Hospital or Skilled Nursing Facility.
Limitations/Exclusions Inpatient Physician services coverage does not include
charges for:
1. Surgical services;
2. Diagnostic Services;
3. Maternity services;
4. Any therapy;
5. For psychiatric treatment; or
6. Treatment rendered to a Covered Person who has exceeded the maximum
number of days of confinement or the maximum benefit amount for
Inpatient Physician services, as set forth in the Schedule of
Benefits.
13
Mammography
The charges for female Covered Person's expenses for mammography services, up to
one routine mammography every calendar year if the Covered Person is age 40 or
older. In addition, any mammography recommended by a Physician.
Maternity-Related Care
The charges for female Covered Person's expenses incurred as a result of
pregnancy, miscarriages and Medically Necessary and elective abortions. Life
threatening abortions will be covered as any other surgery.
The Covered Person, a member of his or her family, a hospital staff member' put
preferably the attending Physician, must notify CHI at 1-800-509-3400 as soon as
pregnancy is confirmed and within 24 hours after birth of a child or as soon
thereafter as reasonably possible.
Mental or Nervous Disorders
For coverage of mental or nervous disorder, please refer to "Psychiatric
Treatment" below.
Newborn Baby Care
The charges for care of newborn children, including Hospital charges for nursery
room and board and miscellaneous expenses.
Occupational Therapy
The charges for occupational therapy rendered by a licensed therapist for
Illnesses and Injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to treatment. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Limitations/Exclusions
Coverage is limited only to treatment for up to such number of days per incident
of Illness or Injury set forth in the Schedule of Benefits, beginning with the
first day of treatment.
Office Visits
The charges for diagnosis or treatment of any Injury or Illness at a Physician's
office.
Organ Transplants
The charges for services which are directly and specifically related to organ
transplants when performed at a Hospital. Where the Covered Person is the
recipient, coverage hereunder includes the hospitalization of donors, and for
those hospital services directly and specifically related to the transplantation
of the organ to the Covered Person, to the extent that the Covered Person
(recipient) would be entitled to such benefits and the donor is not otherwise
insured or covered by another health care plan.
The purchase price of the organ is not covered under this Policy. Coverage under
this Policy is limited to organ transplants meeting the following requirements:
14
1. The attending Physician certifies that the organ transplant is
Medically Necessary;
2. The covered Person must be the recipient; and
3. The transplant is accepted by the general medical community at the
time of the procedure as appropriate treatment for the specific
conditions of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to treatment. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Oxygen
The charges for oxygen and the rental equipment for its administration when
prescribed by the attending Physician.
Papanicolaou Smear (Pap Smear)
The charges for a female Covered Person's expenses for a routine pap smear in
accordance with the recommendations of the American College of Obstetricians and
Gynecologists.
Physical Therapy
The charges for physical therapy rendered by a licensed therapist for Illnesses
and Injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Preventive Care
The charges for an annual gynecological examination including a pelvic
examination and clinical breast examination by a Physician.
The charges for immunizations (other than immunization for children covered
elsewhere in this Policy) and physical examinations (other than papanicolaou
smears and mammography covered elsewhere in this Policy) by a Physician, subject
to the limitations set forth in the Schedule of Benefits.
Private Duty Nursing
The charges for private duty professional nursing services from a L.P.N. or R.N.
for a Covered Person's non-hospitalized acute-illness or injury
Private duty nursing care furnished for Custodial Care is not covered.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
15
Psychiatric Treatment
The charges for the following Inpatient and Out-Patient services for a Covered
Person for the treatment of a Mental Illness.
Inpatient: The hospital services and supplies provided to a Covered Person for
the treatment of a Mental Illness while confined as an Inpatient at a Hospital
or a Psychiatric Hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to admission. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the ease may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Out-Patient: The following Out-Patient services for the treatment of a Mental
Illness rendered by a licensed psychiatrist, psychologist, psychotherapist or
psychiatric Social Worker at a Mental Health Treatment Facility:
1. Oral and written diagnostic tests;
2. Consultation visits;
3. Diagnostic visits;
4. Physician's personal treatment visits; and
5. Group therapy.
Radiation Therapy
The charges for the treatment of any Illness or Injury by x-ray (but not dental
x-rays, unless directly related to a Covered Medical Service), gamma ray,
accelerated particles, mesons, neutrons, radium or radioactive isotopes,
including the cost of radioactive materials.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the ease may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Reconstructive/Corrective Surgery
The charges for reconstructive surgery if such surgery is required to:
1. To restore normal functions of a body part (other than a tooth or
structure that supports the teeth) which is malformed as a result of a
birth defect or as a direct result of Illness or Injury or surgery
performed to treat an Illness; or
2. Repair an Injury which occurs while the person is covered under this
Policy. Surgery must be performed in the calendar year of the accident
which causes the Injury or in the next calendar year.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving surgery. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the ease may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Reconstructive surgery coverage does not include Cosmetic Surgery.
16
Respiratory Therapy
The charges for respiratory therapy rendered by a licensed therapist for
Illnesses and injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Skilled Nursing Facility
The charges listed below when a Covered Person is confined as an Inpatient in a
Skilled Nursing Facility while recovering from an Illness or Injury. Coverage is
limited to services and supplies furnished while the Covered Person is under
continuous care of his or her Physician, requires 24-hour nursing care and the
confinement in a Skilled Nursing Facility is required by his or her Physician:
1. Room and board and general nursing care charges for semi-private
accommodations (designated as such by the Hospital) or, if the Covered
Person utilizes private accommodations because the Covered Person's
medical condition requires isolation for his or her health and the
attending Physician orders such private accommodations, charges for
private accommodations; and
2. Charges for all other skilled nursing services and supplies, including
special meals and dietary services and medicines.
Skilled Nursing Facility care coverage does not include Custodial Care.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to admission. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Speech Therapy
The charges for speech therapy rendered by a qualified speech therapist to
restore or rehabilitate any speech loss or impairment caused by Injury or
Illness, a previous speech therapeutic process, or as a result of surgery for an
Injury or Illness.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending physician, must obtain pre-certification by CHI at
1-800-509-3400 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Substance Abuse Treatment (including Alcoholism and Drug Addiction)
The charges for the following Inpatient and Out-Patient services to treat
Substance Abuse or Dependency, subject to the limitations set forth below and
any additional limitations set forth in the Schedule of Benefits:
1. Out-Patient Care: Covered Medical Services include the following
Out-Patient services in a Substance Abuse Treatment Facility for
treatment for medical conditions resulting from the Substance Abuse or
Dependency: (1) Physician, psychologist, nurse, certified addictions
counselor and trained staff services; (2) rehabilitation therapy and
counseling; (3) family counseling and intervention; (4) psychiatric,
psychological and medical laboratory tests; and (5) drugs, medicines,
equipment use and supplies.
17
Each Covered Person is eligible for thirty (30) Out-Patient full
visits per calendar year. Each Covered Person is also eligible for
thirty (30) additional Out-Patient full visits or equivalent partial
visits per calendar year at a Substance Abuse Treatment Facility,
which may be exchanged on a two-for-one basis for up to fifteen (15)
non-hospital, residential alcohol or drug treatment days described in
Paragraph 3 below. Treatment for Substance Abuse or Dependency shall
be provided according to an individualized treatment plan, subject to
a lifetime limit of one hundred and twenty (120) Out-Patient full
visits or equivalent partial visits.
2. Inpatient Detoxification: Covered Medical Services include the
following Inpatient services at a Hospital or a Substance Abuse
Treatment Facility for detoxification and treatment for medical
conditions resulting from the Substance Abuse or Dependency: (1)
lodging and dietary services; (2) Physician, psychologist, nurse,
certified addictions counselor and trained staff services; (3)
diagnostic x-ray; (4) psychiatric, psychological and medical
laboratory testing; (5) drugs, medicines, equipment use and supplies.
Each Covered Person is eligible for seven (7) Inpatient days of per
calendar year, subject to a lifetime limit of four (4) separate such
admissions. Inpatient rehabilitation beyond detoxification in the
Hospital is not covered hereunder.
3. Inpatient Rehabilitation: Covered Medical Services include the
following Non-Hospital Substance Abuse Residential Facility care: (l)
lodging and dietary services; (2) Physician, psychologist, nurse,
certified addictions counselor and trained staff services; (3)
rehabilitation therapy and counseling; (4) family counseling and
intervention; (5) psychiatric, psychological and medical laboratory
tests; and (6) drugs, . medicines, equipment use and supplies.
Each Covered Person is eligible for thirty (30) days per calendar year
for such residential treatment in a Non-Hospital Substance Abuse
Residential Facility, subject to a lifetime limit of ninety (90) days
of such services.
4. Court-ordered chemical dependency admissions are covered but only to
the extent of the covered benefits described above.
In the case of Paragraph 2 or 3 above, the Covered Person, a member of his or
her family, a hospital staff member, but preferably the attending Physician,
must submit to CHI prior to treatment a certificate from a Physician that the
Covered Person is suffering from Substance Abuse or Dependency and needs
treatment.
Voluntary Sterilization
The charges for male or female voluntary sterilization procedures. The Policy
will not cover reversal procedures.
18
VII. GENERAL EXCLUSIONS
This Policy Does Not Cover Charges, Expenses or Costs:
1. For services or supplies not Medically Necessary for the diagnosis or
treatment of an Illness or Injury.
2. Which exceeds the Reasonable and Customary Charges or exceeds the
maximum benefit amounts set forth in the Schedule of Benefits.
3. Caused by war (declared or undeclared) or any act of war.
4. Suffered while on full-time active duty in the armed forces of any
country or international authority.
5. Incurred in connection with any injury or illness which is compensable
under any workers' compensation or occupational disease act or law or
the federal Longshoreman's and Harbor Worker's Compensation Act.
6. For services received in a veteran's administration hospital, a public
health service hospital, or any facility operated by the U.S.
government or any of its agencies, except to the extent that there is
an unconditional requirement to pay those charges.
7. For medical and dental care received by retirees from armed forces or
their dependents pursuant to and covered by programs established under
federal law.
8. For the treatment of or care for mental retardation, defects and
deficiency, except that this exclusion does not apply to Mental
Illnesses specifically covered in Article VI.
9. For dental services related to the care, filling, removal or
replacement of teeth and treatment of injuries to or diseases of the
teeth and gums, including but not limited to apicoectomy (dental root
resection), orthodontics, root canal treatment, soft tissue
impactions, alveolectomy, augmentation and vestibuloplasty treatment
of periodontal disease, and dental implants, except for accidental
injuries to sound natural teeth.
10. For optical services: The Policy does not cover charges for
examinations to determine the need for (or change of) eyeglasses or
lenses of any type except initial replacements for loss of the natural
lens, eye surgery such as radial keratotomy when the primary purpose
is to correct myopia (nearsightedness), hyperopia (farsightedness) or
astigmatism (blurring), or exams for the correction of vision and
radial keratotomy eye surgery to improve visual acuity.
11. For services rendered by the Covered Person or his or her Close
Relative.
12. For medical services or supplies not prescribed or rendered by a
Physician.
13. Directly related to attempted suicide or an intentionally
self-inflicted injury (whether sane or insane).
14. For provision or replacement of the following items: arch supports;
elastic hose; birth control devices including, but not limited, to
IUDs, diaphragms and condoms; false teeth; braces; traction apparatus;
canes; cervical collars; walkers; corrective shoes; wheelchairs;
corsets; crutches; wigs or cranial prosthesis; diapers; special
appliances, supplies or equipment. This exclusion does not apply to
Durable Medical Equipment specifically covered by Article VI.
15. For Custodial Care.
16. For Cosmetic Surgery except reconstructive surgery specifically
covered by Article VI
19
17. Resulting from the commission of or attempt to commit a felony by the
Covered Person.
18. For personal convenience items or services such as telephones, barber
services, meals, formulas, radio and television rentals, homemaker
services and other like items and services.
19. Applied toward satisfaction of the Deductible Amount or the co-payment
or co-insurance amount payable by the Covered Person.
20. For blood, blood plasma and blood products that are replaced on behalf
of the Covered Person.
21. For actual or attempted impregnation or fertilization which involves
either a Covered Person or a surrogate as a donor or a recipient.
22. For examinations, adjustment of, or purchase of a hearing aid.
23. For career and pastoral counseling.
24. For services or supplies of an Educational, Experimental or
Investigative nature. This exclusion includes, but is not limited to:
- All phases of clinical trials;
- All treatment protocols based upon or similar to those used in
clinical trials;
- Drugs approved by the Federal Food and Drug Administration
under its Treatment Investigatory New Drug regulation or
equivalent;
- Federally approved drugs used for treatment indications not
generally recognized by the medical community.
25. For the reversal of any sterilization procedure or any related care.
26. For sex transformations or other transsexual surgery or related
services not necessitated by an Injury or Illness covered by this
Policy.
27. For services rendered for academic reasons.
28. For orthoptic therapy (vision exercises).
29. For weight reduction programs and gastric stapling for treatment of
obesity.
30. Infertility services, including but not limited to, In-Vitro
fertilization procedures, Gamete Intrafallopian Transfer (GIFT),
Zygote Intrafallopian transfer (ZIFT ) and other similar or related
services; and infertility injectables or other infertility-related
supplies.
31. For bereavement counseling services, except as specifically provided
for under the Hospice Services in Article VI.
32. For treatment of temporomandibular joint dysfunction with/intra oral
devices or any other method to alter vertical dimension.
33. For hypnosis not used as an integral part of a Covered Medical Service
covered under Article VI
34. For telephone consultations, failure to keep a scheduled visit, or
completion of a claim form.
35. For any services or supplies not specifically described herein.
20
36. For services or supplies covered by any automobile insurance policy up
to the amount of coverage limitation under such policy.
37. For prescription drugs.
The Company shall determine whether a service or supply is covered under this
Policy or excluded from coverage under this Policy.
21
VIII. GENERAL PROVISIONS
1. Notice of Claim
Written notice of claim must be furnished to the Company within 90 days after
Covered Medical Services have been rendered to the Covered Person. A notice of
claim form may be obtained from CHI or the Policyholder. However, in case of a
claim for which the Policy provides any periodic payment contingent upon
continued provision of Covered Medical Services, this notice may be furnished
within 90 days after termination of each period for which the Company is liable.
Failure to furnish the notice of claim within the time required will not
invalidate nor reduce any claim if it is not reasonably possible to give the
notice of claim within 90 days, provided the notice of claim is furnished as
soon as reasonably possible. However, except in the absence of legal capacity of
the claimant, the notice of claim may not be furnished later than one year from
the date when the notice of claim was originally required.
2. Time for Payment of Claim
Benefits payable under the Policy will be paid promptly upon receipt by CHI of
satisfactory notice of claim, unless the Policy provides for periodic payment.
Where the Policy provides for periodic payments, the benefits will accrue and be
paid monthly, subject to satisfactory notice of claim.
3. Payment of Claims
All or any portion of any indemnities provided by the Policy on account of
hospital, nursing, medical or surgical services may, at the Company's option, be
paid directly to the hospital or other persons rendering such services; but it
is not required that the service be rendered by a particular hospital or person.
Any payment made by the Company in good faith pursuant to this provision will
fully discharge the Company's obligation to the extent of the payment. The
Covered Person may request that payments not be made pursuant to this provision.
The request must be made in writing and must be given to the Company not later
than the time of filing notice of claim. Payment made prior to receipt of the
Covered Person's written request at the Company's principal executive office
will be deemed to be payment made in good faith.
The Covered Person shall be responsible for the payment of all charges for any
service or supply in excess of the Reasonable and Customary Charges or otherwise
not covered by this Policy.
4. Review and Appeal Procedures
Reviews of Pre-Certification Denials
If a Covered Person is denied coverage for a procedure during the
pre-certification process described in Article V, the Covered Person will be
advised of the reason(s) for the denial and of his or her right to a prompt
review by a person who did not participate in the denial decision.
If a review is requested, in addition to reviewing the reasons for the denial,
CHI may discuss the case with the treating Physician in an effort to agree on
care that would be covered under the Policy.
If the review does not result in a satisfactory resolution, the Covered Person
will receive a written notice explaining the reason(s) for the denial.
Appeals of Denied Claims or Other Denials
If a Covered Person is denied coverage for a claim or denied coverage for a
procedure during pre-certification process, the Covered Person will be advised
in writing of the reason(s) for the denial. This notice will set forth
22
the reasons for such denial. If the Covered Person wishes to appeal this
decision, the Covered Person may write to the address which appears on the
notice (to the attention of the person who signed the letter, if any).
The Covered Person may appeal a denial of benefits within 30 days of the date of
the rejection by sending a letter stating why the Covered Person thinks the
claim should not have been denied, including a copy of the denial letter and
with any additional claim. The Policyholder number, claim number, if any, and
the date of service for which benefits were denied must be included will become
final and incontestable.
Upon receipt of the letter and any additional information the Covered Person
provides, the Covered Person's records will be reviewed; and the results of this
review will be sent to the Covered Person promptly. In unusual cases, as when
review of the claim or denial of coverage requires examination by medical
personnel, including consulting physicians, the review may be extended.
5. Choice of Physician
Each Covered Person has free choice of any Physician, Hospital or other
provider.
6. Time Limit on Certain Defenses
No claim for loss incurred after one year from commencement of the individual
Covered Person's insurance will be reduced or denied on the grounds that the
disease or physical condition existed prior to the commencement of the Covered
Person's insurance.
7. Contract
The entire contract between the Company and the Policyholder consists of the
Policy, the Summary of Benefits and the applications of the Policyholder and
each Covered Employee. All statement contained in the applications will, in the
absence of fraud, be deemed representations and not warranties. No statement
made by an applicant for insurance will be used to void the insurance or reduce
the benefits, unless contained in a written application and signed by the
applicant. No agent has the authority to make or modify the Policy, or to extend
the time for payment of premiums, or to waive any of the Company's rights or
requirements.,
No modification of the Policy will be valid unless evidenced by an endorsement
or amendment of the Policy, signed by an executive officer of the Company and
delivered to the Policyholder.
8. Incontestability
The validity of a Covered Person's insurance will not be contested, except for
non-payment of premium, after his or her insurance under the Policy has been
continuously in force for one year during his or her lifetime. No statement made
by a Covered Employee relating to his or her insurability or that of his or her
Dependents will be used in defense to a claim under the Policy unless: (a) it is
contained in a written application signed by the Covered Employee; and (b) a
copy of the application has been furnished to the Covered Employee or to his or
her beneficiary.
9. Misstatements of Age
If the age of any Covered Person has been misstated, an equitable adjustment
will be made in the premiums or, at the Company's discretion, the amount of
insurance payable. Any premium adjustment will be based on the premium that
would have been charged for the same coverage on a Covered Person of the same
age and similar circumstances.
23
10. Physical Examination and Autopsy
The Company, at its own expense, will have the right and opportunity to examine
a Covered Person, when and as often as may reasonably be required during the
pendency of a claim under the Policy and to make an autopsy in case of death,
where it is not forbidden by law.
11. Legal Action
No action at law or in equity may be brought to recover on the Policy unless and
until the expiration of 60 days after notice of claim has been furnished to CHI
in accordance with the requirements of this Policy. No such action may be
brought after the expiration of three (3) years after the time notice of claim
is required to be furnished.
12. Conformity With State Statutes
Any provision of the Policy which, on its Effective Date, is in conflict with
the statutes of the state in which it is issued, is hereby amended to conform to
the minimum requirements of those statutes.
13. Assignment
No assignment of the Policy, or any part of it, will be binding on the Company
unless approved in writing by the President or Executive Vice President of the
Company. The Company does not assume any responsibility for the validity of any
assignment.
14. Rights of Employees
This Policy does not provide any benefit not specifically described herein. This
Policy does not constitute a contract of employment and does not affect the
right of the employer to discharge any Employee.
15. Facility of Payment
If, in the opinion of the Company, a Covered Person is not competent to execute
a valid release for payment of any benefit to which he is entitled under this
Policy, the Company may, but shall not be required to, make payment to such
individual(s) or institution(s) as have assumed the care and support of such
Covered Person. In the event the Covered Person dies before payment is made to
him of all benefits to which he is entitled under the Policy, the Company may,
but shall not be required to, make payment to such individual(s) or
institution(s) as may be, in the opinion of the Company, equitably entitled
thereto, including without limitation, individual(s) or institution(s) to which
the Covered Person may have assigned such benefits prior to his death. Any
payment made in accordance with the foregoing provisions shall fully discharge
the Company to the extent of such payments.
16. Right to Receive and Release Information
For the purpose of determining the applicability of and implementing the terms
of the provisions of the Policy, the Company may release to, or obtain from, any
other plan or policy administrator, insurance company, or other organization or
individual any information, concerning any individual, which the Company
consider to be necessary for those purposes. Any individual claiming benefits
under this Policy will furnish the information that may be necessary to
implement the provisions.
17. Deductible Amounts
For each Covered Medical Expense, the individual Deductible Amount stated in the
Schedule of Benefits must be incurred with respect to a Covered Person before
benefits become payable. If, during a calendar year, such deductibles are equal
to the family Deductible Amount shown in the Schedule of Benefits, no further
deductible amount shall apply with respect to any remaining expenses incurred by
members of that Family Unit during the remainder of that calendar year.
24
18. Incorporation of Summary of Benefits
The Summary of Benefits is hereby incorporated in and made a part of this
Policy.
25
IX. CONTINUATION OF COVERAGE
1. Consolidated Omnibus Budget Reconciliation Act of 1985, As Amended ("COBRA")
Upon timely notice from the Employer, CHI will make available continuation
coverage, as required by COBRA, for all Covered Persons determined to be
qualified beneficiaries, as defined in Subsection 162(k)(7)(B) of the Internal
Revenue Code, as amended from time to time, and Subsection 607(3) of the
Employee Retirement Income Security Act (ERISA), as amended from time to time.
The Employer shall retain full responsibility for notifying Covered Persons of
their rights to continuation coverage and administering the exercise of
continuation rights, as required by COBRA. CHI shall have no obligation to
ensure that any notices received from the Employer comply with the requirements
of COBRA. For purposes of COBRA, CHI is not the plan administrator.
A. Each Covered Employee has a right to continue coverage if:
1. Employment with the Employer ends for a reason other than gross
misconduct; or
2. Work hours are reduced which result in a loss of coverage.
B. Each Covered Dependent has a right to continue coverage if:
1. The Covered Employee's employment with the Employer ends for a
reason other that gross misconduct;
2. The Covered Employee's work hours are reduced;
3. The Covered Employee dies;
4. In the case of the Covered Employee's spouse, when such spouse
ceases to be an Eligible Dependent as a result of divorce or
legal separation;
5. The Covered Employee becomes entitled to Medicare; or
6. In the case of a Dependent child, when such child no longer
satisfies the eligibility requirements for coverage as an
Eligible Dependent under this Agreement.
Similar rights may apply to certain retirees and their dependents if the
employer commences certain bankruptcy proceedings and these individuals lose
coverage.
Under COBRA, the Covered Employee or a family member has the responsibility to
inform the Employer of a divorce, legal separation, or a child losing dependent
status under the Employer's health plan within 60 days of the later of the date
of the event or the date on which coverage would end under the plan because of
the event. The Employer has the responsibility to notify the Employer of the
Covered Employee's death, termination of employment, reduction in hours or
Medicare entitlement.
When the Employer is notified that one of these events has happened, the
Employer will in turn notify the qualified beneficiary within 14 days of the
notification that he/she has the right to choose continuation coverage. The
qualified beneficiary has at least 60 days from such notification or the
qualifying event, whichever date is later, to inform the Employer of his or her
decision to elect continued coverage. The qualified beneficiary will then have
45 days after notifying the Employer of his or her decision to pay the
retroactive premium.
In the case of the Covered Employee's termination of employment or reduction in
work hours, the coverage may be continued for up to 18 months. The 18 months of
coverage may be extended to 36 months if one of the other events described in
Part B above occurs to a dependent within the initial 18 months of coverage. The
qualifying
26
events listed in Part B, other than B(1) and B(2), will entitle the dependents
for up to 36 months of continuation coverage. The 18 months may also be extended
to 29 months if an individual is determined to have been disabled for Social
Security disability purposes at the time of the initial qualifying event and the
Employer is notified of the disability of the Social Security Administrator
determination within 60 days of its disability determination. The affected
individual must also notify the Employer within 30 days of any final
determination that the individual is no longer disabled.
However, coverage will cease earlier if one of the following events occurs:
1. The Employer ceases to provide any group health insurance to any
of its employees;
2. The qualified beneficiary fails to make timely payments of any
premium required;
3. The qualified beneficiary is covered under another group health
plan that does not contain any exclusion or limitation with
respect to any preexisting condition that the qualified
beneficiary may have;
4. The qualified beneficiary is entitled to benefits under Medicare;
or
5. The qualified beneficiary extended coverage for up to 29 months
due to a disability and there has been a final determination that
the qualified beneficiary is no longer disabled.
27
2. Employee Conversion Option
When a Covered Employee's coverage under this Policy terminates for reasons
other than failure to make the required premium contributions, the benefits may
be converted to an individual policy (the "Converted Policy") issued by the
Company.
This conversion privilege is available:
(a) to an Eligible Employee if s/he has been continuously insured under
this Policy for at last three (3) months immediately prior to the
termination;
(b) to an Eligible Dependent spouse if the coverage terminates because of
his or her spouse/Employee's death, or because of divorce or annulment
of marriage; and
(c) to an Eligible Dependent child if the coverage terminates because of
the Eligible Dependent's age or because of the death of his or her
parent/Covered Employee.
The conversion privilege is not available to any Covered Person if:
(i) if the Covered Person is, or is eligible to be, within 31 days of
termination of coverage under this Policy, covered for similar
benefits by: (1) another group plan, medical service subscriber
contract, medical practice or other prepayment plan, or (2) any
governmental program;
(ii) if issuing the Converted Policy to the Covered Person would result in
over-insurance, as determined by CHI; or
(iii) if coverage under the Policy terminated because any required premium
contribution was not paid when due.
Application and payment of the first premium under the Converted Policy must be
made to the Company within 31 days immediately following termination of coverage
under this Policy.
If continuation of coverage as described above is elected, this conversion
option will apply at the end of the maximum continuation period under this
Policy.
The Converted Policy will be issued as follows:
(A) The Covered Policy will in the form CHI has them available for
conversion which is most similar to the coverage being converted. The
coverage under the Converted Policy may be different from the coverage
provided under this Policy;
(B) The Converted Policy may exclude any condition for which the Covered
Person was not covered under this Policy, provided a 12-month period
has not elapsed from the original Effective Date of this Policy; and
(C) The premium payable for the Converted Policy will be based on the
CHI's rate then applicable to the class of risk to which the Covered
Person belongs, the age of the Covered Person, and the form and amount
of . coverage provided, on the effective date of the Converted Policy.
If the Covered Employee and one or more of his Dependents were covered by the
Policy, the Converted Policy must cover all previously insured Covered Persons
who are eligible for conversion coverage. The Company may, at its option, issue
a separate Covered Policy to cover any Dependent.
28
3. Extension of Benefits Upon Termination of Policy
Except as set forth below, if the Covered Person is an Inpatient on the day
coverage under this Policy terminates, the benefits of coverage under this
Policy shall be provided until the earlier of:
A. the date on which the maximum amount of benefits under this Policy has
been paid; or
B. the date on which the Inpatient stay ends; or
C. the 90th day after the date of termination.
If this Policy is terminated because the Employer participates in or obtains
medical coverage under a health benefit plan or arrangement made available by
another organization, the liability of CHI shall cease as of the date of such
termination, and no benefits will be provided for any services or supplies
provided after such date.
29
X. COORDINATION OF BENEFITS
All benefits provided under this Policy are subject to this Article, and will
not be increased by virtue of this Article.
1. Definitions
In addition to the Definitions set forth in Article XV of this Policy, the
following definitions only apply to this Article:
a. "Plan" means any plan providing benefits or services for or by reason
of medical or dental care or treatment, which benefits or services are
provided by:
(1) group, blanket or franchise insurance coverage;
(2) service plan contracts, group practice, individual practice and
other prepayment coverage;
(3) any coverage under labor-management trusteed plans, union welfare
plans, employer organization plans, or employee benefit
organization plans; or
(4) any coverage under governmental programs, and any coverage
required or provided by any statute.
The term "Plan" shall exclude any school accident-type coverages or
group or group-type hospital indemnity benefits of $100 per day or
less.
b. "Dependent" means, for any Plan, any person who qualifies as a
Dependent under that Plan.
c. "Allowable Benefits" means the eligible charges for Covered Medical
Services under this Policy.
d. "Benefits Paid or Payable" means the amounts actually paid for Covered
Medical Services.
2. Effect on Benefits
a. This Article shall apply in determining the benefits of this Policy
if, for Covered Medical Services received, the sum of the Benefits
Payable under this Policy and the Benefits Payable under other Plans
would exceed the Allowable Benefits.
b. Except as provided in Subsection c. of this Section 2, the Benefits
Payable under this Policy for Covered Medical Services will be reduced
so that the sum of the reduced benefits and the Benefits Payable for
Covered Medical Services under other Plans does not exceed the total
of Allowable Benefits.
c. If (1) the other Plan contains a provision coordinating its benefits
with those of this Policy and its rules require the benefits of this
Policy to be determined first, and (2) the rules set forth in
Subsection e. of this Section 2 require the benefits of this Policy to
be determined first, then the benefits of the other Plan will be
ignored in determining the benefits under this Policy.
d. If the other Plan does not include a coordination of benefits
provision, such Plan will be primary.
e. If the other Plan does include a coordination of benefits provision:
(1) The Plan covering the patient other than as a Dependent will be
primary.
(2) Where both Plans cover the patient as a dependent child, the Plan
covering the patient as a dependent child of a parent whose date
of birth, excluding year of birth, occurs earlier in a calendar
year shall be the primary Plan. But, if both parents have the
same birthday, the
30
Plan which covered the parent longer will be the primary Plan. If
the parents are separated or divorced, the following will apply:
(a) The Plan which covers the child as a Dependent of the parent
with custody will be the primary Plan.
(b) If the parent with custody has remarried, the Plan which
covers the child as a Dependent of the stepparent with
custody will determine its benefits before the Plan covering
the child as a Dependent of the parent without custody.
(c) Where there is a court decree which establishes financial
responsibility for the health care expenses of the dependent
child, the Plan which covers the child as a Dependent of the
parent with such financial responsibility will be the
primary Plan as long as the Plan of that parent has actual
knowledge of the court decree.
(d) If the specific terms of the court decree state that the
parents shall share joint custody, without stating that one
of the parents is responsible for the health care expenses
of the child, the plans covering the child shall follow the
order of benefit determination rules outlined in the first
paragraph of 2. e. 2).
In the event CHI is coordinating with a Plan that uses the
male/female rule regarding dependent children, the introductory
paragraph of this clause (2) shall be replaced with to the
following introductory paragraph:
Where both Plans cover the patient as a dependent child, the
Plan covering the patient as a dependent child of a male
will be the primary Plan, except that if the parents are
separated or divorced, the following will apply:
(3) Where the determination cannot be made in accordance with clause
(1) or (2) above, the Plan which has covered the patient for the
longer period of time will be the primary Plan; provided that,
(a) the benefits of a plan covering the person as an employee
other than a laid-off or retired employee or as the
Dependent of such person shall be determined before the
benefits of a plan covering the person as a laid-off or
retired employee as a Dependent of such person; and
(b) if either Plan does not have a provision regarding laid-off
or retired employees, and, as a result, the benefits of each
plan are determined after the other, then the provisions of
clause (3)(a) above shall not apply.
f. Services provided under any governmental program for which any
periodic payment of rate is made by the Covered Person shall always be
the primary Plan, except when prohibited by law, or when the Covered
Person has elected Medicare secondary.
3. Facility of Payment
Whenever payments should have been made under this Policy in accordance with
this Article, but the payments have been made under any other Plan, CHI has the
right to pay to any organization that has made such payment any amount it
determines to be warranted to satisfy the intent of this Article. Amounts so
paid shall be deemed to be Benefits Paid under this Policy and to the extent of
the payments for Covered Medical Services, CHI shall be fully discharged from
liability under this Policy.
31
4. Right of Recovery
a. Whenever payments have been made by CHI for Covered Medical Services
in excess of the maximum amount of payment necessary at that time to
satisfy the intent of this Article, irrespective of to whom paid, CHI
shall have the right to recover the excess from among the following,
as CHI shall determine: any person to or for whom such payments were
made, any insurance company, or any other organization.
b. The Covered Employee, personally and on behalf of his or her Covered
Dependents shall, upon request, execute and deliver such documents as
may be required and do whatever else is reasonably necessary to secure
CHI's rights to recover the excess payments.
5. CHI shall not be required to determine the existence of any Plan or amount
of Benefits Payable under any Plan except this Policy, and the payment of
benefits under this Policy shall be affected by the Benefits Payable under
any and all other Plans only to the extent that CHI is furnished with
information relative to such other Plans by the Employer or Covered Person
or any other insurance company or organization or person.
6. When the benefits are reduced under the primary Plan because a Covered
Person does not comply with the Plan articles, or does not maximize
benefits available under the primary Plan, the amount of such reduction
will not be considered an Allowable Benefit. Examples of such provisions
are those related to second surgical opinions and pre-certification of
admissions and services.
7. CHI may, without the consent or notice to any person, release to or obtain
from any other insurance company, or other organization or person, any
information, with respect to any Covered Person which CHI deems necessary
to determine the applicability of, and implement the terms of, this
Article, or any similar provision of any other Plan. Any person claiming
benefits under this Policy will furnish to CHI any information necessary to
implement this Article.
32
XI. MEDICARE
When a Covered Person is eligible for Medicare, that person must sign and
deliver an election card to the Company, stating whom that Covered Person wants
to be his primary insurer. If the Covered Person elects Medicare as his primary
source of coverage and belongs to a group covered by the Policy covering twenty
(20) persons or more, all Policy benefits otherwise payable to that Covered
Person shall discontinue. If belonging to a covered group of less than twenty
(20) persons, all Policy benefits otherwise payable with respect to the Covered
Person will be reduced by any service or supply provided, or any benefits paid
or payable, under Part A and Part B of Medicare.
For the purposes of this Article, benefits will be paid on the basis that the
Covered Person is covered by both Part A and Part B of Medicare. If the Covered
Person should not receive benefits under either Part A or Part B because of:
(a) failure to enroll when required;
(b) failure to pay any premiums that may be required for full coverage of
the person under Medicare; or
(c) failure to file any written request or claim required for payment of
Medicare benefits;
the Company will make determination of the total benefits that would have been
payable under Medicare in the absence of this failure.
"Part A" means the "Hospital Insurance Benefits for the Aged" portion of
Medicare.
"Part B" means the "Supplementary Medical Insurance for the Aged" portion
of Medicare.
33
XII. SUBROGATION
In the event of any payment under the Policy, the Company will, to the extent of
the payment under the Policy, be subrogated to all the rights of recovery of the
Covered Person arising out of the acts or omissions of any person or
organization. The Covered Person hereby agrees to reimburse the Company for any
benefits paid hereunder, out of any moneys recovered from any person or
organization as the result of judgment, settlement or otherwise. After any
benefits under this Policy are paid by the Company, the Covered Person also
agrees to execute and deliver all necessary instruments and to furnish such
information and such reasonable assistance as may be required to facilitate
enforcement of its rights hereunder. In the event the Company recovers an amount
greater than the benefit paid, the excess, will be paid to the Covered Person.
The Covered Person shall do nothing after loss to prejudice these rights. This
Article will not apply, however, to a recovery obtained by any Covered Person
from any insurance company on a policy under which the Covered Person is
entitled to indemnity. as a named insured person or an insured Dependent of a
named person. For purposes of this Article only, "Covered Person" will include
anyone receiving payment under the Policy, either directly or indirectly.
This Article does not pertain to medical malpractice insurance pursuant to
Pennsylvania Law, Chapter 4, Article V1, Section 602 (40 P.S. Section 1301.602),
and is limited for Pennsylvania No-Fault Insurance pursuant to Pennsylvania Law
Chapter 4, Article VI(J), Section III(4) (40 P.S. Section 1009. 111), as now
constituted or later amended.
The Subrogation rights under this Article shall be enforced only to the extent
and at those times permitted by law and shall not be enforceable to the extent
prohibited by any Pennsylvania statute or regulation.
34
XIII. POLICYHOLDER/EMPLOYER PROVISIONS
Premiums
1. The premiums for this Policy shall be based upon the administrative
requirements of CHI and the cost of Covered Medical Services and shall be
payable in advance according to the mode of payment agreed upon. At the end
of the first calendar year or at any time thereafter, the premiums for this
Policy may be readjusted by CHI based upon the experience under the Policy.
2. The Employer is solely responsible for the payment of premiums with respect
to its Covered Employees and their Covered Dependents. Payment shall be
made directly to CHI.
3. The first premium will be the sum of the individual premiums determined by
applying the premium rates, shown in the initial schedule of premium rates,
to the amount of insurance then in force at the respective ages of the
Covered Persons insured on the Effective Date of the Policy. The premium
for each successive month will be the sum of the individual premiums
determined by applying the premium rates then in effect to the amount of
insurance then in force at the respective ages of the Covered Persons
insured on the premium due date.
4. The premium rates will be guaranteed for the first twelve (12) months
following the issuance of the Policy. CHI reserves the right to change,
after such guaranteed period, the premium rates by written notice to the
Policyholder at least thirty (30) days prior to the date of the change.
5. Any change in premium rates necessitated by an amendment of the Policy will
be effective on the effective date of the amendment. If the effective date
of the amendment is any day other than the premium due date, then a pro
rata premium adjustment will be made to the applicable month.
6. There will be no premium adjustment for Covered Person who may be added or
terminated between premium due dates. If notice of a Covered Person's
termination received by CHI more than thirty (30) days after their
termination, any unearned premium will be credited only from the first
premium due date prior to the receipt of such notice. This provision will
not extend the Covered Person's insurance beyond the termination date.
Grace Period
If the Policyholder has not previously given written notice to CHI that the
Policy is to be discontinued, the grace period of thirty one (31) days will be
granted to the Policyholder for payment of every premium after the first
premium. During the grace period, the Policy will continue in force, unless
prior to the date payment was due the Policyholder gave timely written notice to
CHI that the Agreement is to be canceled. If the premiums are not paid within
the grace period, the Policy will be discontinued, but the Policyholder will
still be liable to CHI for all unpaid premiums, including the premiums for the
grace period. If during the grace period CHI receives written notice from the
Policyholder that the Policy is to be discontinued, the Policy will be
discontinued on the date notice is received, but the Policyholder will still be
liable to CHI for the payment of all premiums then unpaid, together with a pro
rata premium for the period commencing with the date on which the last premium
became due and ending with the date of receipt of written notice by CHI.
Term of Policy and Right to Terminate
This Policy is issued for an indefinite term, commencing on the Effective Date
shown on the face page. The Policy continues in force, so long as premiums are
paid when due, until terminated in accordance with the terms of this Policy.
The Policyholder may terminate the Policy by giving written notice to CHI.
Termination by the Policyholder will be effective on the latter of: (a) the day
specified in the notice; or (b) the day the notice is received by CHI. CHI
35
may terminate any or all insurance under the Policy, as of any premium due date,
by giving written notice to the Policyholder at least thirty (30) days prior to
that date.
Notice
Written notice to the Policyholder will be deemed to be effective on the date it
is placed in the United States mail, postage prepaid and properly addressed to
the principal place of business of the Policyholder. Notice will be deemed to be
properly addressed if it reflects the last address provided to CHI by the
Policyholder.
Individual Certificates
CHI will issue a Summary of Benefits, describing the insurance protection to
which each Covered Person is entitled and to whom payable. Copies of the Summary
of Benefits will be issued to the Policyholder for delivery to each Covered
Employee.
Registry
The Policyholder shall furnish CHI with:
(a) the names of all individuals initially eligible for insurance or who
later become eligible for insurance under the Policy, even if they do
not become insured;
(b) the names of all Covered Persons who become insured or whose insurance
terminates, together with the respective date; and
(c) any information required to initiate, maintain or terminate coverage
on each Eligible Person.
CHI will have the right, at reasonable times, to inspect all books and records
of the Policyholder which relate to the insurance under the Policy.
36
XIV. PRE-EXISTING CONDITIONS LIMITATION
No payment will be made to any Covered Person under this Policy for any charge
relating to any condition which was precluded by the group policy (if any) that
this Policy replaced, which existed prior to the date the individual became
covered under this Policy and for which the individual received medical advice
or treatment within 90 days immediately preceding the date coverage under this
Policy commenced, unless the charge is incurred:
1. More than six (6) consecutive months after the Covered Person has been
covered under this Policy during which time no medical advice or
treatment was received; or
2. If the Covered Person is a Covered Employee, collectively more than
twelve (12) consecutive months after the Covered Employee has been
actively employed with the Employer and has been covered under this
Policy and/or another group health insurance policy issued to the
Employer; or
3. If the Covered Person is a Covered Dependent, collectively more than
twelve (12) consecutive months after the Covered Dependent has been
covered under this Policy and/or another group health insurance policy
issued to the Employer.
This Article applies only to Employees and Dependents who become covered under
this Policy after the Effective Date of this Policy.
37
XV. DEFINITIONS
For the purposes of this Policy, unless the context clearly indicates otherwise,
the following words and phrases have the following meanings. The following words
and phrases are not intended to imply that coverage for them is provided under
this Policy.
Ambulatory Surgical Facility - A specialized facility licensed, where required,
to render surgical procedures on an Out-Patient basis, which has an
organized staff of Physicians, has been approved by the Joint Commission on
Accreditation of Health Care Organizations, the Accreditation Association
for Ambulatory Healthcare, Inc., or CHI, and which:
1. has permanent facilities and equipment for the primary purpose of
performing surgical procedures on an Out-Patient basis;
2. provides treatment by or under the supervision of Physicians and
nursing services whenever the patient is in the facility;
3. does not provide Inpatient accommodations;
4. provides the full-time services of one or more RNs for patient care in
the operating rooms and in the post-anesthesia recovery room; and
5. provides at least one operating room and at least one post-anesthesia
recovery room; is equipped to perform diagnostic x-ray and laboratory
examinations; and has available trained personnel and necessary
equipment to handle foreseeable emergencies;
6. maintains a written agreement with at least one Hospital in the area
for immediate acceptance of patients who develop complications or
require post-operative confinement; and
7. is not, other than incidentally, a facility used as an office or
clinic for the private practice of a Professional Provider.
Birthing Center - A free-standing facility licensed, where required, to provide
maternity care, which:
1. Is organized and staffed to provide prenatal care, delivery and
immediate post-partum care;
2. Is directed by at least one Physician who is a specialist in
obstetrics and gynecology;
3. Has a Physician or certified nurse midwife present at all births and
during the immediate post-partum period;
4. Has at least two (2) beds or two (2) birthing rooms for use by
patients while in labor and during delivery;
5. Has the capacity to administer a local anesthetic and to perform minor
surgery. This includes episiotomy and repair of perineal tear;
6. Accepts only patients with low risk pregnancies; and
7. Has a written agreement with a Hospital in the area for emergency
transfer of a patient or a child.
38
Close Relative - The Covered Person, his or her spouse, a child, brother,
sister, or parent of the Covered Person or his or her spouse.
Company - Corporate Health Insurance Company, a Minnesota corporation, and its
successor, if any.
Co-payment - The flat, fixed-dollar amount which shall be payable by a Covered
Person pursuant to this Policy to a provider of services or supplies, regardless
of, but not in excess of, the charge for such services or supplies, such amount
to be set forth in the Schedule of Benefits with respect to applicable Covered
Medical Service.
Cosmetic Surgery - Any surgery not Medically Necessary, including, without
limitation, ear piercing, rhinoplasty or lipectomy, except cosmetic surgery
resulting from the complication of such Cosmetic Surgery.
Covered Dependent - Any Eligible Dependent whose coverage became effective and
has not terminated.
Covered Employee - Any Eligible Employee whose coverage became effective and has
not terminated.
Covered Person - Any Eligible Employee or Eligible Dependent whose coverage
became effective and has not terminated.
Covered Medical Services - Those services and supplies which are Medically
Necessary and are otherwise covered by this Policy and for which charges are
Reasonable and Customary.
Custodial Care - Any type of care that does not require the skills of technical
or professional personnel or are not furnished by or under the supervision of
such personnel or does not otherwise meet the requirements of post-hospital
Skilled Nursing Facility Care. Custodial Care includes, but is not limited to:
o Help in walking, getting into or out of bed, bathing, dressing, eating
and other functions of daily living of a similar nature;
o General supervision of exercise programs including carrying out of
maintenance programs of repetitive exercises that do not need the
skills of a therapist and are not skilled rehabilitation services;
o Bowel training and management;
o General safety/health precautions and preventive procedures such as
turning to prevent bedsores; and
o Providing patient recreation and/or companionship.
Deductible Amount - The amount of charges for Covered Medical Services a Covered
Person must incur and pay during the calendar year under this Policy. The
Deductible Amount will differ depending upon whether the Covered Person is
covered under an individual coverage or a family coverage. If covered under an
individual coverage, the Covered Person must pay the Deductible Amount for
"individual," as set forth in the Schedule of Benefits, before becoming entitled
to benefits under the Policy. If covered under a family coverage, the Covered
Person and his or her Family Unit must pay the Deductible Amount for "family,"
as set forth in the Schedule of Benefits, before becoming entitled to benefits
under the Policy.
Dentist - Licensed Doctor of Dental Surgery or Doctor of Dental Medicine.
Dependent - Includes a spouse or child, whether by birth or adoption, of an
Eligible Employee.
39
Detoxification - The process whereby an alcohol or drug intoxicated or alcohol
or drug dependent person is assisted, in a facility licensed by the Department
of Health, through the period of time necessary to eliminate, by metabolic or
other means. the intoxicating alcohol or drug, alcohol or drug dependent factors
or alcohol in combination with drugs, as determined by a licensed Physician,
while keeping the physiological risk to the patient at a reasonable minimum.
Diagnostic Services - the following procedures prescribed by a Professional
Provider because of specific symptoms to determine a definite condition or
disease. Diagnostic Services include, but are not limited to:
A. diagnostic radiology, consisting of x-ray, ultrasound and nuclear
medicine;
B. diagnostic pathology, consisting of laboratory and pathology tests;
C. diagnostic medical procedures, consisting of ECG, EEG, and other
diagnostic medical procedures; and
D. allergy testing consisting of percutaneous, intracutaneous and patch
tests.
Durable Medical Equipment - Equipment prescribed by the attending Physician
which is:
- Not primarily and customarily used for non-medical purposes;
- Designed for prolonged use; and
- For a specific therapeutic purpose in the treatment of an Illness
or Injury.
Durable Medical Equipment includes, but is not limited to, prosthetic appliances
and orthopedic braces.
Educational - a service or supply the primary purpose of which is to provide the
Covered Person with any of the following training in the activities of daily
living: instruction in scholastic skills such as reading and writing;
preparation for occupation; or treatment for learning disabilities.
Eligible Dependent - Any Eligible Employee's Dependent who satisfies the
eligibility requirements of Article I.
Eligible Employee - Any active employee full-time of the Policyholder who
regularly works at least 30 hours per week and otherwise satisfies the
eligibility requirements of Article I.
Emergency Services - Medical services required for the initial treatment of a
Medical Emergency. These services shall not include treatment for occupational
injury for which benefits are covered under workers' compensation law or similar
occupational disease law. The condition of the Covered Person must be of
sufficient severity to warrant immediate attention.
Employer - The Policyholder.
Evidence of Good Health - A statement from an Eligible Employee or an Eligible
Dependent attesting to the "good health" of such person or his or her Eligible
Dependents. A standard form available from the Policyholder's human resources
department will be provided for this purpose. The Eligible Employee or the
Eligible Dependent is responsible for any and all related costs.
Experimental or Investigative - the use of any treatment, procedure, facility,
equipment, drug, or drug usage device or supply which the general medical
community does not accept as standard medical treatment of the condition being
treated, or any such items requiring federal or other governmental agency
approval which approval has not been granted at the time the services were
rendered.
Family Unit - A Covered Employee and his or her Covered Dependents.
40
Home Health Agency - Any organization certified as a home health agency under
the Medicare law or otherwise approved by CHI for the delivery of non-Physician
patient care in the home of a Covered Person.
Home Health Plan - A program for care and treatment of a Covered Person
established and approved in writing by such Covered Person's attending
Physician, together with such Physician's certification that the proper
treatment of the Injury or Illness would require confinement as a resident
Inpatient in a Hospital or confinement in a Skilled Nursing Facility the absence
of services and supplies provided as part of the Home Health Plan.
Home Health Services - Those items and services defined as "home health
services" in the Medicare law and set forth in 42 CFR Part 417.101 et seq.
Hospice - A facility which is licensed as such, where required, and provides
short periods of stay for a Terminally Ill Person in a home-like setting for
either direct care or respite care. This facility may be either free-standing or
affiliated with a Hospital. It must operate as an integral part of the Hospice
Care Program.
Hospice Care Program - A formal program directed by a Physician to help care for
a Terminally III Person. This may be through either
o A centrally-administrated, medically directed and nurse-coordinated
program which
- Provides a coherent system primarily of home care; and
- Is available 24 hours a day, seven (7) days a week; or
o Confinement in a Hospice.
The program must meet standards set by the National Hospice Organization and
approved by CHI. If such a program is required by a state to be licensed,
certified, or registered, it must also satisfy such requirement.
Hospice Services - Services and supplies furnished or arranged by a Hospice to a
Terminally Ill Person.
Hospital - An institution accredited as a Hospital by the Joint Commission on
Accreditation of Health Care Organizations, the Bureau of Hospitals of the
American Osteopathic Association or under Medicare Law, or as otherwise
determined by CHI as meeting reasonable standards, which:
1. is a duly licensed, where required; and
2. is primarily engaged in providing Inpatient diagnostic and surgical
and therapeutic services for the diagnosis, treatment and care of
injured or ill persons by or under the supervision of Physicians; and
3. provides 24-hour nursing service by or under the supervision of
Registered Nurses; and
4. is not a Skilled Nursing Facility, Custodial Care home, health resort,
spa or sanitarium, place for rest, place for the treatment of Mental
Illness, place for the treatment of Substance Abuse or Dependency,
Hospice, rehabilitation center, or place for the treatment of
pulmonary tuberculosis.
Illness - Sickness or disease which requires medical service or supply covered
by this Policy.
Injury - Bodily harm which results from an accident and which requires medical
service or supply covered by the Policy.
41
Inpatient - A person who is admitted to a Hospital, a Psychiatric Hospital, a
Skilled Nursing Facility or a Substance Abuse Treatment Facility and incurs room
and board charges.
L.P.N. - A full-time licensed practical nurse, other than a Close Relative, who
is recognized by the state in which care is given as qualified to perform
limited nursing functions.
Medical Emergency - a sudden, unexpected onset of a medical condition
manifesting itself by acute symptoms or a traumatic bodily injury resulting from
an accident, which is of sufficient severity that the absence of immediate
medical attention could reasonably result in:
1. Death of the Covered Person;
2. Serious harm the Covered Person's health; or
3. Serious or permanent impairment to bodily functions or any bodily
organ or part.
The non-availability of a private Physician or the fact that the Physician may
refer the Covered Person to the emergency room does not, by itself, constitute a
Medical Emergency. Medical Emergencies include, but are not limited to:
(a) uncontrolled or excessive bleeding;
(b) suspected heart attack;
(c) inability to breath;
(d) appendicitis;
(e) serious burns;
(f) poisoning;
(g) severe pain and suffering; and
(h) convulsion or unconsciousness.
Medically Necessary - Medical service or supply which is provided by a
Professional Provider for the diagnosis or the direct care and treatment of a
Covered Person's Injury or Illness and which is:
1. Appropriate for the symptoms and diagnosis or treatment of the
Covered Person's Injury or Illness; and
2. In accordance with current standards of good medical practice.
Confinement as an Inpatient in a Hospital or other facility is considered
Medically Necessary when the Covered Person needs to be confined because of the
nature of the services being delivered the Covered Person or when treatment for
his or her condition cannot be given safely and adequately if performed on an
Out-Patient basis.
Medicare - The programs health care for the aged and the disabled established by
Title XVIII of the Social Security Act, as first enacted by the Social Security
Amendment of 1965 or as later amended.
Mental Illness - An emotional, nervous or mental disorder means a neurosis,
psychoneurosis, psychopathy or psychosis and mental, emotional or nervous
disorder without demonstrable organic origin.
Mental Health Treatment Facility - A facility, licensed by the Department of
Health, for the care or treatment of person with a Mental Illness and in which
services are provided by or under the supervisions of a Physician.
Military Service - Service in any Army, Navy, Air Force, Marines, Coast Guard,
or other branch of the military.
Non-Hospital Substance Abuse Residential Care - The provision of medical,
nursing, counseling or therapeutic services to patients suffering from alcohol
or drug abuse or dependency in a residential environment, according to
individualized treatment plans.
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Out-Patient - A patient who receives diagnosis or treatment at a facility, but
does not incur room and board charges.
Physician - A person, other than a Close Relative of the Covered Person, who is
duly licensed member of a medical profession and is practicing within the scope
of his or her license.
Policy - this Comprehensive Major Medical Group Health Insurance Policy issued
by the Company to the Policyholder.
Policy Enrollment Form - A printed form approved by CHI that an Eligible
Employee must complete, execute and deliver to CHI to be eligible for coverage
under this Policy.
Policy Year - The twelve (12) month period commencing on a date agreed to
between the Policyholder and CHI or, if no such agreement exists, the twelve
(12) month period of January l through December 31 inclusive.
Pre-Certification - A certification that a Covered Person must obtain prior to
receiving any of the services or supplies that are identified by the Schedule of
Benefits or this Policy as needing a Pre-Certification, which certifies the
proposed Hospital admission and length of stay as Medically Necessary.
Prescription Drugs - Drugs and medicines which require a prescription by a
Physician to dispense and are approved by the U.S. Food and Drug Administration
for general use in treating the illness or injury for which they are prescribed.
Prescriptions Drugs include oral contraceptives and vitamins.
Professional Provider - a person or practitioner licensed, where required, and
performing services within the scope of such licensure. The Professional
Providers include:
- R.N. - optometrist
- chiropractor - physical therapist
- clinical laboratory - Physician
- Dentist - podiatrist
- nurse midwife - psychologist
Psychiatric Hospital - An institution which is primarily engaged in providing
diagnosis and therapeutic services for the Inpatient treatment of Mental
Illnesses and meets all of the following requirements:
1. Services are provided by or under the supervision of a Physician;
2. Provides continuous nursing services under the supervision of an RN.; and
3. Is not a Skilled Nursing Facility, Custodial Care home, health resort,
place for rest, place for the treatment of Substance Abuse or Dependency,
Hospice, rehabilitation center, or place for the treatment of pulmonary
tuberculosis.
R.N. - A registered nurse, other than a Close Relative, who is licensed in the
state in which care is given to perform all nursing functions.
Reasonable and Customary Charge - Any charge which, as determined by CHI, does
not exceed (i) the usual or customary fee for comparable service or supply
charged by other providers of similar services or supplies in the area where the
service or supply is provided and who have training, experience and professional
standing comparable to those of the actual provider of the service or supply or
(ii) if no comparison exists, the reasonable fee (which may differ from the
usual or customary fee) determined by CHI after considering unusual clinical
circumstances and/or the actual cost of equipment and facilities involved in the
treatment. When determining whether a charge is Reasonable and Customary, CHI
may consider the severity of the condition being treated and any complications
and unusual circumstances that may be involved.
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Schedule of Benefits - The Schedule of Benefits set forth in the Summary of
Benefits, which summarizes the benefits payable under the Policy. The terms of
the Schedule of Benefits will be individually tailored to each Policyholder.
Semi-Private - A two (2) bed room in a Hospital. If the facility has no such
rooms, the rate most commonly charged by similar institutions in the same
geographic area.
Skilled Nursing Facility - An institution or a distinct part of an institution
which is licensed, where required, or approved under state or local law, and
which is primarily engaged in providing skilled nursing care and related
services (on an Inpatient basis to patients requiring 24-hour skilled nursing
but not requiring confinement in an acute care Hospital) as a skilled nursing
facility, extended care facility, or nursing care facility approved by the Joint
Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or as a certified skilled
nursing facility under Medicare law, or as otherwise determined by CHI to meet
the reasonable standards applied by any of the aforesaid authorities.
A Skilled Nursing Facility does not include a rest home, a home for the aged, a
place for Custodial Care or educational care, or a treatment facility for
alcoholism, drug addiction, or mental illness.
Social Worker - A duly licensed or certified social worker with at least two (2)
years or three thousand (3,000) hours of post-masters clinical social work
practice in a clinical program established by the state regulatory board or
agency.
Substance Abuse or Dependency - Any use of alcohol or drugs which produces a
pattern of pathological use causing impairment in social or occupational
functioning or which produces physiological dependency evidenced by physical
tolerance or withdrawal.
Substance Abuse Treatment Facility - A Hospital or non-Hospital facility,
licensed by the Department of Health, for the care or treatment of alcohol or
drug dependent persons, except for transitional living facilities.
Terminally Ill Person - A Covered Person who life expectancy is six (6) months
or less, as certified by the attending Physician.
TotalDisability or Totally Disabled - A Covered Employee shall be considered
totally disabled if, as a result of an illness or injury, he or she is unable to
engage in any gainful occupation for which s/he is reasonably fitted by
education, training, or experience, and is not performing work of any kind for
wage or profit. A Covered Dependent will be considered totally disabled if,
because of an illness or injury, he or she is prevented from engaging in all the
normal activities of a person of like age and sex.
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