EXHIBIT 10.30
- ----------------------------------------------------------------------------
EXECUTIVE MEDICAL BENEFITS
Covered Payment will be made for 100% of the Covered Expenses incurred
Services and by a Covered Person while covered under this Plan.
Supplies
Covered Expenses are the actual cost to you for services and
supplies given for Medical Care.
4
"Medical Care" means the diagnosis, care, mitigation,
treatment or prevention of disease, or treatment affecting
any structure or function of the body due to defect, illness, or
accidental injury or care during and following pregnancy
including treatment of any condition caused by the pregnancy.
Medical Care includes prescription drugs, dental and
vision care.
The Covered Expense must be an allowable tax deductible item
as defined under Section 213(d) of the Internal Revenue Code
of 1954 and as may be amended from time to time.
Payment will be made if the Covered Expenses are more than the
benefits payable under both of the following:
- The Base Plan whether or not the person is covered under
the Base Plan.
- Benefits paid for Medical Care under any Workers
Compensation Act or similar law.
"Base Plan" means the Unova, Inc. Welfare Benefit Plan
(Contract No. 186522) or any other medical, surgical or
hospital plan; Health Maintenance Organization or prescription
drug, dental or vision plan(s) which the Employer (or any
designated subsidiary of the Employer) contributes to or
otherwise sponsors.
Benefits are payable for pregnancy on the same basis as
sickness under this Plan. Pregnancy benefits are payable for
at least:
- 48 hours of inpatient care for the mother and newborn child
following a normal vaginal delivery.
- 96 hours of inpatient care for the mother and newborn child
following a cesarean section.
The hospital or other provider is not required to get
authorization from the Company for the time periods stated
above.
Hearing aid services, including full cost of hearing aids and
exams to prescribe and fit them.
Medical Expense Benefits will be determined on the same basis
for the following routine exams as benefits due to a sickness.
1. Cancer screening; Such services will include pap smears
which are ordered or provided by a doctor of medicine (M.D.)
in accordance with generally accepted medical standards.
2. A mammographic exam for a Covered Person who: resides in
Delaware; or is principally employed in Delaware, as
follows:
A periodic exam in accordance with the following schedule;
or as declared appropriate by the Delaware State Board of
Health.
a. A base line mammogram for a Covered Person who is at
least age 35.
b. One mammogram every two Calendar Years for a Covered
Person who is age 40 to 49, inclusive; provided such
mammogram occurs no sooner than two Calendar Years
after the Covered Person's base line exam as per a
above.
c. One mammogram per Calendar Year for a Covered Person
who is 50 years of age or older.
5
Upon the recommendation of a Covered Person's physician, any
mammogram received by a Covered Person who has
been determined by that physician to be at risk for breast
cancer.
3. A prostate antigen test for a Covered Person
age 50 or older who is:
(i) a resident of Delaware; or
(ii) principally employed in Delaware.
provided the test is ordered by a doctor of
medicine (M.D.) in accordance with generally accepted
medical standards.
4. Services and supplies received for the routine
care of a newborn Dependent child while such child is confined
as an inpatient in a Hospital
5. Routine health examinations
Any Copayments, Deductibles and any percentage
penalties for not obtaining services from a Network Provider
under the other Employer sponsored group plan are not payable
under this Plan.
MAXIMUM BENEFIT
There is a Unlimited Maximum Benefit per
family for the Executive Medical Benefits. The Unlimited
Maximum Benefit is shown in the Schedule of Benefits. It
applies to you and all of your Dependents each Calendar Year.
NOT COVERED
Expenses for the following are not covered
under Executive Medical Benefits:
- Injury or Sickness caused by war or
international armed conflict, except in
the case of an innocent bystander taking
no active part in the war or
international armed conflict.
- Services of a person who is a member of your
immediate family (your spouse, child, brother, sister,
parent or grandparent; your spouse's child, brother,
sister, parent or grandparent).
- Services of a person who resides in your
home.
- Expenses not directly involved with
Medical Care (as defined in Section 213(d) of the Internal
Revenue Code).
- Any service or supply that is not
allowable as a tax deduction under the Internal Revenue
Code.
- injury which happens during work at any
job for pay or profit.
- Expenses incurred before you or your
Dependent becomes covered.
- Expenses for long term care.
- Cosmetic or reconstructive surgery or
treatment. (This is surgery or treatment primarily to change
appearance.) It does not matter whether or not it is for
psychological or emotional reasons. However, the following
will be covered if it is for:
- Reconstructive surgery in connection
with surgical treatment of injury or Sickness.
- Correction of deformities caused by
Sickness.
6
- Correction of damage caused by accidental injury
sustained by you or a Dependent while the injured person
is covered.
- Correction of birth defects which are outside the normal
range of human variation.
- Custodial Care. This is care made up of services and
supplies that meets one of the following conditions:
- Care furnished mainly to train or assist in personal
hygiene or other activities of daily living, rather
than to provide medical treatment.
- Care that can safely and adequately be provided by
persons who do not have the technical skills of a covered
health care professional.
- Care that meets one of these conditions is custodial
care regardless of any of the following:
- Who recommends, provides or directs the care.
- Where the care is provided
- Whether or not the patient or another caregiver can be
or is being trained to care for himself or herself.
- Education, training and bed and board while confined in
an institution which is mainly a school or other
institution for training, a place of rest, a place for
the aged or a nursing home.
- Expenses and associated expenses incurred for services
and supplies for Experimental, Investigational or Unproven
Services, except for services which are otherwise
Experimental, Investigational, or Unproven that are
deemed to be, in the Company's judgment, covered
transplant services. The fact that an Experimental,
Investigational or Unproven Service, is the only available
treatment for a particular condition will not result in
coverage if the procedure is considered to be
Experimental, Investigational or Unproven for the
treatment of that particular condition.
- Services and supplies which the Covered
Person is not legally required to pay.
- Services or supplies which are not Medically Necessary,
including any confinement or treatment given in connection
with a service or supply which is not Medically Necessary.
- Treatment for infertility, including but not limited to
in-vitro fertilization (IVF), gamete intrafallopian tube
transfers (GIFT), and artificial insemination.
7