Certificate of Coverage
Table of Contents
BCR 101 04/03
This Certificate of Coverage is issued by UNICARE Life & Health
Insurance Company ("the Insurer").
In this Plan, the "Insurer" means UNICARE. The "Eligible
Participant" is the person who meets the eligibility criteria of this
Certificate. The term "Insured Person," means the Eligible
Participant and any Insured Dependents.
The benefits of this Plan are provided only for those services that the
Insurer determines are Medically Necessary and for which the Insured
Person has benefits. The fact that a Physician prescribes or orders a
service does not, by itself, mean that the service is Medically Necessary
or that the service is a Covered Expense. The Eligible Participant may
consult this Certificate of Coverage or telephone the Insurer at the
number shown on his/her identification card if he/she has any questions
about whether services are covered.
This Certificate of Coverage contains many important terms (such as
"Medically Necessary" and "Covered Expense") that are
defined in Part III and capitalized throughout the Certificate of
Coverage. Before reading through this Certificate of Coverage, consult
Part III for the meanings of these words as they pertain to this
Certificate of Coverage.
The Insurer has issued a Policy to the Group or Trust identified on the
Eligible Participant's identification card. The benefits and services
listed in this Certificate of Coverage will be provided for Insured
Persons for a covered Illness, Injury, or condition, subject to all of the
terms and conditions of the Group's Policy.
Choice of Hospital and Physician: Nothing
contained in this Plan restricts or interferes with the Eligible
Participant's right to select the Hospital or Physician of the Eligible
Participant's choice. Also, nothing in this Plan restricts the Eligible
Participant's right to receive, at his/her expense, any treatment not
covered in this Plan.
Use of Administrator: The Insurer may use a
third party administrator to perform certain of the Insurer's duties on
the Insurer's behalf. The Group or Trust and the Insured Participant will
be notified of the use of an administrator.
Benefit Overview Matrix
Following is a very brief description of the benefit schedule of the Plan.
This should be used only as a quick reference tool. The Declaration
of Coverage and the entire Certificate of Coverage sets forth, in
detail, the rights and obligations of both the Insured Person and the
Insurer. It is, therefore, important that THE ENTIRE
CERTIFICATE OF COVERAGE BE READ CAREFULLY!
The benefits outlined in the following table show the payment percentages
for Covered Expenses AFTER the Insured Person
has satisfied any Deductible and prior to satisfaction of his/her
Out-of-Pocket. Covered Expenses are based on Reasonable Charges which may
be less than actual billed charges. Providers can bill the Insured Person
for amounts exceeding Covered Expenses.
Deductible: The Insured Person's Deductible is
stated in the Declaration of Coverage per
Insured Person per Trip Coverage Period.
After the Deductible is satisfied, benefits are paid for
Covered Expenses as follows:
Benefit per Insured Person per policy period
stated in your Declaration of Coverage.
Insured Person per policy period
||As stated in your
Declaration of Coverage.
anesthesia, radiation therapy, in-hospital doctor visits,
diagnostic X-ray and lab
|b. Office Visits:
including X-rays and lab work billed by the attending physician.
|a. Surgery, X-rays,
In-hospital doctor visits
(non Medical Evacuation)
||100% up to $1000 Maximum
|Benefits for claims
resulting from downhill (alpine) skiing and scuba diving
(certification by the Professional Association of Diving
Instructors (PADI) or the National Association of Underwater
Instructors (NAUI) or diving under the supervision of a
certified instructor required)
||Up to $10,000 Maximum
|Outside the U.S.
Outpatient prescription drugs
||50% of Covered
required due to an Injury
||100% of Covered
Expenses up to $200 Maximum per Trip Period and
$200 Maximum per tooth
|Dental Care for
Relief of Pain
||100% of Covered
Expenses up to $100 Maximum per Trip Period and $100 Maximum
||Principal Sum up
to $25,000 Maximum
||Up to $25,000
||Up to $500,000
Maximum per Trip Period for all Evacuations
||Up to $1,500
Maximum per Trip Period for the cost of one (1) economy round
trip air fare ticket to the place of the Hospital Confinement
BCR 134 04/03
II. Who is eligible for
Eligible Participants and their Eligible Dependents are the
only people qualified to be covered by the Group or Trust's Policy. The
following section describes who qualifies as an Eligible Participant or
Eligible Dependent, as well as information on when and who to enroll and
when coverage begins and ends.
Who is Eligible to Enroll Under This Plan? An
- Is a member of a Group or a member or employee of a participant in a
Trust covered under the Policy.
- Has submitted an enrollment form, if applicable, and the premium to
- Is a bona fide member in good-standing of a membership Group or
An Eligible Dependent means a person who is the Eligible Participant's:
The term "primary care" means that the Insured Participant
provides food, clothing and shelter on a regular and continuous basis
during the time that the District of Columbia public schools are in
- unmarried natural child, stepchild or legally adopted child who has
not yet reached age 19;
- own or spouse's own unmarried child, of any age, enrolled prior to
age 19, who is incapable of self support due to continuing mental
retardation or physical disability and who is chiefly dependent on the
Eligible Participant. The Insurer requires written proof from a
Physician of such disability and dependency within 31 days of the
child's 19th birthday and annually thereafter;
- unmarried child, from their 19th to their 22nd
birthday who is a full-time student attending an accredited college,
university, vocational or technical school, and who is fully dependent
upon the Eligible Participant for support. The Insurer may require
proof of student status, but not more than once a Period of Insurance;
- For a person who becomes an Eligible Dependent (as described below)
after the date the Eligible Participant's coverage begins, coverage
for the Eligible Dependent will become effective in accordance with
the following provisions:
- Newborn Children: Coverage will be automatic for the
first 31 days following the birth of an Insured Participant's
Newborn Child. To continue coverage beyond 31 days, the Newborn
child must be enrolled within 31 days of birth.
- Adopted Children: An Insured Participant's adopted child
is automatically covered for Illness or Injury for 31 days from
either date of placement of the child in the home, or the date of
the final decree of adoption, whichever is earlier. To continue
coverage beyond 31 days, as Insured Participant must enroll the
adopted child within 31 days either from the date of placement or
the final decree of adoption.
- Court Ordered Coverage for a Dependent: If a court has
ordered an Insured Participant to provide coverage for an Eligible
Dependent who is a spouse or minor child, coverage will be
automatic for the first 31 days following the date on which the
court order is issued. To continue coverage beyond 31 days, and
Insured Participant must enroll the Eligible Dependent within that
31 day period;
- grandchild, niece or nephew who otherwise qualifies as a dependent
child, if: (a) the child is under the primary care of the Insured
Participant; and (b) the legal guardian of the child, if other than
the Insured Participant, is not covered by an accident or sickness
A person may not be an Insured Dependent for
more than one Insured Participant.
Additional Requirements for an Eligible Participant and
Eligible Dependents: An Eligible Participant or an Eligible Dependent must
meet all of the following requirements:
Enrollment Form and Effective Date
- Is a resident of the U.S.
- Is under Age 75
- Is traveling outside the U.S.
- Is scheduled to spend at least 24 hours away from his/her Home.
The Coverage for an Eligible Participant and his or her Eligible
Dependents will become effective if the Eligible Participant submits a
properly completed application to the Insurer, is approved for coverage by
the Insurer, and the Group or Trust and/or the Eligible Participant pays
the Insurer the premium. The Effective Date of the Coverage under the Plan
is indicated as follows:
Period of Insurance: Each Eligible Participant's
and his/her Eligible Dependent's Period of Insurance starts on the latest
of the following:
Trip Coverage Start Date: The Insured Person's
coverage under the Policy for a trip during the Period of Insurance starts
for a scheduled trip to a Foreign Country, when the Insured Person boards
a conveyance at the start of the trip.
- The Policy Effective Date;
- 12:00:01am on the date or the postmark of the enrollment received by
- 12:00:01 am on the date designated by the Eligible Participant in
the enrollment form, if that date is after the Insurer receives the
- 12:00:01 am on the date designated by the Group or Trust of which
the Eligible Participant is a member.
An Insured Person is eligible for benefits during his/her Period
of Insurance ONLY during the Trip Coverage Period.
All applications, if applicable, must be approved by the Insurer for
coverage to go into effect.
In no event will an Eligible Dependent's coverage become effective prior
to the Insured Participant's Effective Date of Coverage.
How Period of Insurance Coverage Ends
The Insured Person's coverage ends without notice from the Insurer on the
Trip Coverage End Date: The Insured Person's
coverage under the Plan for a trip during the Period of Insurance ends as
- the end of the last period for which premium payment has been made
to the Insurer;
- the date the Policy terminates;
- the date the Maximum Trip Coverage Period Benefit of the Plan has
- the date of fraud or misrepresentation of a material fact by the
Insured Participant, except as indicated in the Time Limit on Certain
In no event will coverage for a trip extend past the Maximum Trip Coverage
Period stated below, subject to 3 immediately above and as stated in the
- For a scheduled trip to a Foreign Country, when the Insured Person
alights from a conveyance at the completion of the trip.
- On the Period of Insurance Termination Date. However, if the Insured
Person has not canceled his/her coverage, then coverage for a trip
will extend past the Period of Insurance Termination Date if the
Insured Person's return is delayed by unforeseeable circumstances
beyond his/her control. In this event, coverage will terminate as
stated immediately above or, if earlier, 11:59 p.m. on the seventh day
following the Period of Insurance Termination Date.
- If the Insured Person is covered under the Medical Evacuation
Benefit, upon the Insured Person's evacuation to his/her Home Area.
Maximum Trip Coverage Period:Coverage for any
one trip may not exceed 180 days.
Group and Insurer
The coverage of all Insured Persons shall terminate if the Policy is
terminated. If the Insurer terminates the Policy then the Insurer will
notify the Group of cancellation. In addition, the Policy may be
terminated by the Group on any premium due date. It is the Group's
responsibility to notify all Insured Participants in either situation.
The Policy may be terminated by the Insurer:
Extension of Benefits
- for non-payment of premium;
- on the date of fraud or intentional misrepresentation of a material
fact by the Group, except as indicated in the Time Limit on Certain
- on any premium due date for any of the following reasons. The
Insurer must give the Group written notice of cancellation at least 30
days in advance if termination is due to:
- failure to maintain the required minimum premium contribution;
- failure to provide required information or documentation related
to the Primary Plan or Other Plan upon request.
- on any premium due date if the Insurer is also canceling all
short-term plans in the state. The Insurer must give the Group written
notice of cancellation:
- at least 180 days in advance; and
- again at least 30 days in advance.
No benefits are payable for medical treatment benefits after the Insured
Person's insurance terminates. However, if the Insured Person is in a
Hospital on the date the insurance terminates, the Insurer will continue
to pay the medical treatment benefits until the earlier of the date the
confinement ends or 31 days after the date the insurance terminates.
BCR 121 04/03
The following definitions contain the meanings of key terms
used in this Plan. Throughout this Plan, the terms defined appear with the
first letter of each word in capital letters.
Accidental Injury means an accidental bodily
Injury sustained by an Insured Person which is the direct cause of a loss
independent of disease, bodily infirmity, or any other cause.
Age means the Insured Person's attained age.
Ambulatory Surgical Center is a freestanding
outpatient surgical facility. It must be licensed as an outpatient clinic
according to state and local laws and must meet all requirements of an
outpatient clinic providing surgical services. It also must meet
accreditation standards of the Joint Commission on Accreditation of Health
Care Organizations or the Accreditation Association of Ambulatory Health
Certificate of Coverage is the document issued
to each Eligible Participant outlining the benefits under the Group
Coinsurance is the percentage of Covered
Expenses the Insured Person is responsible for paying (after the
applicable Deductible is satisfied). Coinsurance does not include
charges for services that are not Covered Services or charges in excess of
Covered Expenses. These charges are the Insured Person's responsibility
and are not included in the Coinsurance calculation.
Complications of Pregnancy are conditions,
requiring hospital confinement (when the pregnancy is not terminated),
whose diagnoses are distinct from the pregnancy, but are adversely
affected by the pregnancy, including, but not limited to acute nephritis,
nephrosis, cardiac decompression, missed abortion, pre-eclampsia,
intrauterine fetal growth retardation, and similar medical and surgical
conditions of comparable severity. Complications of Pregnancy also include
termination of ectopic pregnancy, and spontaneous termination of
pregnancy, occurring during a period of gestation in which a viable birth
is not possible. Complications of Pregnancy do not include elective
abortion, elective cesarean section, false labor, occasional spotting,
morning sickness, physician- prescribed rest during the period of
pregnancy, hyperemesis gravidarium, and similar conditions associated with
the management of a difficult pregnancy not constituting a distinct
complication of pregnancy.
Continuing Hospital Confinement means
consecutive days of in-hospital service received as an inpatient, or
successive confinements for the same diagnosis, when discharge from and
readmission to the Hospital occurs within 24 hours.
Cosmetic and Reconstructive Surgery. Cosmetic Surgery
is performed to change the appearance of otherwise normal looking
characteristics or features of the patient's body. A physical feature or
characteristic is normal looking when the average person would consider
that feature or characteristic to be within the range of usual variations
of normal human appearance. Reconstructive Surgery
is surgery to correct the appearance of abnormal looking features or
characteristics of the body caused by birth defects, Injury, tumors, or
infection. A feature or characteristic of the body is abnormal looking
when an average person would consider it to be outside the range of
general variations of normal human appearance. Note: Cosmetic
Surgery does not become Reconstructive Surgery because of psychological or
Coverage Period Maximum Benefit is the maximum
amount of benefits available to each Insured Person during the person's
Coverage Period (Period of Insurance and/or Trip Coverage Period). All
benefits furnished are subject to these maximum amounts.
Covered Expenses are the expenses incurred for
Covered Services. Covered Expenses for Covered Services
will not exceed Reasonable Charges. In addition, Covered Expenses may be
limited by other specific maximums described in this Plan under section IV.
How this Plan Works and section V. Benefits: What this
Plan Pays. Covered Expenses are subject to applicable
Deductibles, penalties and other benefit limits. An expense is
incurred on the date the Insured Person receives the service or supply.
Covered Services are Medically Necessary
services or supplies that are listed in the benefit sections of this Plan
and for which the Insured Person is entitled to receive benefits.
Custodial Care is care provided primarily to
meet the Insured Person's personal needs. This includes help in walking,
bathing or dressing. It also includes preparing food or special diets,
feeding, administration of medicine that is usually self-administered or
any other care that does not require continuing services of a medical
Deductible means the amount of Covered Expenses
the Insured Person must pay for Covered Services before benefits are
available to him/her under this Plan. The Period of Insurance
Deductible is the amount of Covered Expenses the Eligible
Participant must pay for each Insured Person before any benefits are
available regardless of provider type.
Dental Prostheses are dentures, crowns, caps,
bridges, clasps, habit appliances and partials.
Effective Date of the Policy is the date that
the Group or Trust Policy became active with the Insurer.
Effective Date of Coverage is the date on which
coverage under this Plan begins for the Insured Participant and any
Eligible Dependent (See 'Eligibility Rules' in
Section II of this Plan).
Eligible Participant (See 'Eligibility Rules' in
Section II of this Plan).
Emergency (See Medical Emergency).
Experimental / Investigational Procedures. Any
medical, surgical and/or other procedures, services, products, drugs or
devices (including implants) are considered experimental or
"Reliable evidence" means only: the published reports and
articles in authoritative medical and scientific literature; written
protocol or protocols by the treating facility or other facilities
studying substantially the same drug, device or medical treatment or
procedure; or the medical informed consent used by the treating facility
or other facilities studying substantially the same drug, device or
medical treatment or procedure.
- Its use is mainly limited to laboratory and/or research;
- It has not been given approval for marketing by the United States
Food & Drug Administration at the time it is furnished and such
approval is required by law;
- Reliable evidence shows it is the subject of ongoing phase I, II or
III clinical trials or under study to determine its maximum tolerated
dose, its toxicity, its safety, its efficacy or its efficacy as
compared with the state or means of treatment or diagnosis;
- Reliable evidence shows that the consensus of the opinion among
experts is that further studies or clinical trials are necessary to
determine its maximum tolerated dose, its toxicity, its safety, its
efficacy or its efficacy as compared with the stated means of
treatment of diagnosis;
- Reliable evidence shows that it is not generally approved or used by
Physicians in the medical community; or
- It does not have final approval from the appropriate governmental
Foreign Country is a country
other than the Insured Person's Home Country.
Foreign Country Provider is any institutional or
professional provider of medical or psychiatric treatment or care who
practices in a country outside the U.A. A Foreign Country Provider may
also be a supplier of medical equipment, drugs or medications. HTH
provides Insured Persons with access to a database of Foreign Country
Full Time Student is a student enrolled at an
accredited college, university or trade school participating in the
Federally Guaranteed Student Loan Program. The student must be currently
attending classes, carrying at least 12 units per term.
Group or Trust to the business entity to which
the Insurer has issued the Policy.
Group Health Benefit Plan means a group, blanket
or franchise insurance policy; a certificate issued under a group policy;
a group hospital service contract; or a group subscriber contract or
evidence of coverage issued by a health maintenance organization that
provides benefits for health care services. The term does not include:
- accident-only, credit or disability insurance coverages;
- specified disease coverage or other limited benefit policies;
- coverage of Medicare services under a federal contract;
- Medicare Supplement and Medicare Select policies regulated in
accordance with federal law;
- long-term care, dental care or vision care coverages;
- coverage provided by a single service health maintenance
- insurance coverage issued as a supplement to liability insurance;
- insurance coverage arising out of a workers' compensation system or
similar statutory system;
- automobile medical payment insurance coverage;
- jointly managed trusts authorized under 29 U.S.C. Section 141 et
seq. that contain a plan of benefits for employees that is negotiated
in a collective bargaining agreement governing wages, hours and
working conditions of the employees that is authorized under 29 U.S.C.
- hospital confinement indemnity coverage; or
- reinsurance contracts issued on a stop-loss, quota share or similar
Home Country means the Insured
Person's country of domicile named on the enrollment form or the roster,
as applicable. However, the Home Country of an Eligible Dependent who is a
child is the same as that of the Eligible Participant.
Hospital is a facility which provides diagnosis,
treatment and care of persons who need acute inpatient hospital care under
the supervision of Physicians. It must:
- be licensed as a hospital and operated pursuant to law;
- be primarily engaged in providing or operating (either on its
premises or in facilities available to the hospital on a contractual,
prearranged basis and under the supervision of a staff of one or more
Physicians) medical, diagnostic and major surgery facilities for the
medical care and treatment of sick or injured persons on an inpatient
basis for which a charge is made;
- provide 24-hour nursing service by or under the supervision of a
registered graduate professional nurse (R.N.);
- be an institution which maintains and operates a minimum of five
- have X-ray and laboratory facilities either on the premises or
available on a contractual, prearranged basis; and
- maintain permanent medical history records.
This definition excludes
convalescent homes, convalescent facilities, rest facilities, nursing
facilities or homes or facilities primarily for the aged and those
primarily affording custodial care or educational care.
HTH means Highway to Health (d/b/a HTH
Worldwide). This is the entity that provides the Insured Person with
access to online databases of travel, health and security information and
online information about Physicians and other medical providers.
HTH International Healthcare Community consists
of Physicians, dentists, mental health professionals, other allied health
professionals, hospitals, health systems and medical practices in
countries throughout the world, all dedicated to providing high quality
medical care to international travelers, employees and students. The
providers are accessed through the HTH online database or through the HTH
Illness is a sickness, disease or condition of
an Insured Person which first manifests itself after the Insured Person's
Injury (See Accidental Injury).
Insurance Coverage Area is the primary
geographical region in which coverage is provided to the Insured Person.
Insured Dependents are members of the Eligible
Participant's family who are eligible and have been accepted by the
Insurer under this Plan.
Insured Participant is the Eligible Participant
whose enrollment form has been accepted by the Insurer for coverage under
Insured Person means both the Insured
Participant and all Insured Dependents who are covered under this Plan.
Insurer means the UNICARE Life & Health
Insurance Company. UNICARE is a nationally licensed and regulated
insurance company. Insurer also includes a third party
administrator with which the Insurer has contracted to perform certain of
its duties on its behalf. The Group or Trust and the Insured Participant
will be notified of the use of an administrator.
Investigative Procedures (See
Medical Emergency means a sudden onset of a
medical condition manifesting itself by acute symptoms of sufficient
severity including, without limitation, sudden and unexpected severe pain
for which the absence of immediate medical attention could reasonably
- Permanently placing the Insured Person's health in jeopardy,
- Causing other serious medical consequences;
- Causing serious impairment to bodily functions; or
- Causing serious and permanent dysfunction of any bodily organ or
part. Previously diagnosed chronic conditions in which subacute
symptoms have existed over a period of time shall not be included in
this definition of a Medical Emergency unless symptoms suddenly become
so severe that immediate medical aid is required.
Medically Necessary services or
supplies are those that the Insurer determines to be all
of the following:
- Appropriate and necessary for the symptoms, diagnosis or treatment
of the medical condition.
- Provided for the diagnosis or direct care and treatment of the
- Within standards of good medical practice within the organized
- Not primarily for the patient's, the Physician's or another
- The most appropriate supply or level of service that can safely be
provided. For Hospital stays, this means acute care as an inpatient is
necessary due to the kind of services the Insured Person is receiving
or the severity of the Insured Person's condition and that safe and
adequate care cannot be received as an outpatient or in a less
intensified medical setting.
Newborn is a recently born infant
within 31 days of birth.
Office Visit means a visit by the Insured
Person, who is the patient, to the office of a Physician during which one
or more of only the following three specific services are provided:
- History (gathering of information on an Illness or Injury).
- Medical Decision Making (the Physician's diagnosis and plan of
treatment). This does not include other services (e.g. X-rays or lab
services) even if performed on the same day.
Other Plan is an insurance plan
other than this Plan that provides medical, repatriation of remains and/or
medical evacuation benefits for the Insured Person.
Out-of-Pocket Maximum is the amount of
Coinsurance each Insured Person incurs for Covered Expenses in a Period of
Insurance. The Out-of-Pocket Maximum does not include any
amounts in excess of Covered Expenses, the Deductible, any penalties or
any amounts in excess of other benefit limits of this Plan.
Period of Insurance Maximum Benefit is the
maximum amount of benefits available to each Insured Person during the
person's Period of Coverage. All benefits furnished are subject to this
Physical and/or Occupational Therapy/Medicine is
the therapeutic use of physical agents other than drugs. It comprises the
use of physical, chemical and other properties of heat, light, water,
electricity, massage, exercise, spinal manipulation and radiation.
Physician means a physician licensed to practice
medicine or any other practitioner who is licensed and recognized as a
provider of health care services in the state and/or country the Insured
Person resides or is treated and provides services covered by this Plan
that are within the scope of his/her licensure.
Plan is the set of benefits described in the
Certificate of Coverage and in the amendments to the Certificate (if any).
This Plan is subject to the terms and conditions of the Policy the Insurer
has issued to the Group or Trust. If changes are made to the Policy or
this Plan, an amendment or revised Certificate of Coverage will be issued
to the Group or Trust for distribution to each Insured Participant
affected by the change.
Policy is the Group insurance policy the Insurer
has issued to the Group or Trust.
Pre-existing Condition means a medical condition
for which medical advice, diagnosis, care or treatment was recommended or
received during the six (6) months immediately preceding the Insured
Person's Effective Date of Coverage.
Primary Plan is a Group Health Benefit Plan, an
individual health benefit plan or a governmental health plan designed to
be the first payer of claims for an Insured Person prior to the
responsibility of this Plan.
Reasonable Charge, as determined by the Insurer,
is the amount the Insurer will consider a Covered Expense with respect to
charges made by a Physician, facility or other supplier for Covered
Services. In determining whether a charge is Reasonable, the Insurer will
consider all of the following factors:
- The actual charge.
- Specialty training, work value factors, practice costs,
regional/geographic factors and inflation factors.
- The amount charged for the same or comparable services or supplies
in the same region or in other parts of the country.
- Consideration of new procedures, services or supplies in comparison
to commonly used procedures, services or supplies.
- The Average Wholesale Price for Pharmaceuticals.
Reconstructive Surgery (See
Cosmetic and Reconstructive Surgery).
Special Care Units are special areas of a
Hospital that have highly skilled personnel and special equipment for
acute conditions that require constant treatment and observation.
Totally Disabled or Total Disability means:
The patient must be under the care of a Physician.
- As applied to an Insured Participant, any period of time during the
Insured Participant's lifetime in which he/she is unable to perform
substantially all the duties required by his/her usual occupation,
provided the disability commences within twelve (12) months from the
date the disabling condition occurred; and
- As applied to a Dependent, not being able to perform the normal
activities of a like person of the same Age and sex.
Trip Coverage Period Maximum Benefit
is the maximum amount of benefits available to each Insured Person during
the person's Trip Coverage Period. All benefits furnished are subject to
this maximum amount.
U.S. means the United States of America.
BCR 111 04/03
IV. How this Plan Works
The Insured Person's Plan pays a portion of his/her Covered Expenses
after he/she meets his/her Deductible for each Period of Insurance. This
section describes the Deductible and discusses steps to take to ensure
that he/she receives the highest level of benefits available under this
Plan. See Definitions (Section III) for a definition of
Covered Expenses and Covered Services.
The benefits described in the following sections are provided for
Covered Expenses incurred by the Insured Person while covered under this
Plan. An expense is incurred on the date the Insured Person receives the
service or supply for which the charge is made. These benefits are subject
to all provisions of this Plan, which may limit benefits or result in
benefits not being payable.
Either the Insured Person or the provider of service must claim
benefits by sending the Insurer properly completed claim forms itemizing
the services or supplies received and the charges.
This Benefits section shows the maximum Covered Expense for each type of
No benefits are payable unless the Insured Person's coverage is in
force at the time services are rendered, and the payment of benefits is
subject to all the terms, conditions, limitations and exclusions of this
Hospitals, Physicians, and Other Providers
The amount that will be treated as a Covered Expense for services
provided by a Provider will not exceed the lesser of actual billed charges
or a Reasonable Charge as determined by the Insurer.
Exception: If Medicare is the primary payer, Covered
Expense does not include any charge:
The Insured Person will always be responsible for any expense incurred
which is not covered under this Plan.
- By a Hospital in excess of the approved amount as determined by
- By a Physician or other provider, in excess of the lesser of the
maximum Covered Expense stated above; or
- For providers who accept Medicare assignment, the approved
amount as determined by Medicare; or
- For providers who do not accept Medicare assignment, the
limiting charge as determined by Medicare.
Deductibles are prescribed amounts of Covered Expenses the Insured Person
must pay before benefits are available. The Period of Insurance Deductible
applies to all Covered Expenses. Only Covered Expenses are applied to the
Deductible. Any expenses the Insured Person incurs in addition to Covered
Expenses are never applied to any Deductible.
Deductibles will be credited on the Insurer's files in the order in
which the Insured Person's claims are processed, not necessarily in the
order in which he/she receives the service or supply.
If the Insured Person submits a claim for services which have a maximum
payment limit and his/her Period of Insurance Deductible is not satisfied,
the Insurer will only apply the allowed per visit, per day, or per event
amount (whichever applies) toward any applicable Deductible.
Period of Insurance Deductible
The Insured Person's Period of Insurance Deductible is the amount as
stated in the Declaration of Coverage for each Insured
Person per Period of Insurance. This Deductible is the amount of Covered
Expenses the Insured Participant and other Insured Persons must pay for any
Covered Services incurred for services received.
The Out-of-Pocket Maximum is the amount of Coinsurance each Insured Person
incurs for Covered Expenses in a Period of Insurance. The Out-of-Pocket
Maximum does not include any amounts in excess of Covered
Expenses, Period of Insurance Deductible, amounts applied to any
penalties, or any amounts in excess of other benefit limits of this Plan.
Once an Insured Person incurs $0 Out-of-Pocket in a Period of
Insurance, he/she will no longer have to pay any Coinsurance for the
remainder of the Period of Insurance.
After the Insured Person satisfies any required Deductible,
payment of Covered Expenses is provided as defined below:
Regardless of the Insured Person's Out-of-Pocket Maximum, the Insurer
- For Ambulance Service (non Medical Evacuation), 100% up to $1,000;
- For claims resulting from downhill (alpine) skiing and scuba diving
(certification by the Professional Association of Diving Instructors (PADI)
or the National Association of Underwater Instructors (NAUI) or diving
under the supervision of a certified instructor required), the Trip
Period Maximum or $10,000, whichever is less;
- For Outpatient prescription drugs outside the U.S., 50% of
Reasonable Charges for Covered Expenses;
- For Dental Care required due to an Injury, 100% of Covered Expenses
up to $200 maximum per Trip Period and $200 maximum per tooth;
- For Dental Care for Relief of Pain, 100% of Covered Expenses up to
$100 maximum per Trip Period and $100 maximum per tooth.
For all other Covered Expenses
First Level Payment.
Until an Insured Person satisfies his/her Out-of-Pocket Maximum for the
Period of Insurance, the Insurer pays:
- 100% of the Reasonable Charge for Covered Expense for Office Visits.
- 100% of the Reasonable Charge for the Covered Expense for all other
Covered Services. The Insured Person pays 0% of the Covered Expense,
plus any amount in excess of the Covered Expense and in excess of the
Reasonable Charge for the Covered Expense.
Period of Insurance Maximum Benefits
The combined total of all medical benefits paid to the Eligible
Participant or any Insured Dependent is limited to the maximum amount
stated in the Declaration of Coverage during each Insured
Person's Period of Insurance, so long as the Participant or the Dependent
remains insured under this Plan.
Trip Coverage Period Maximum Benefits
The combined total of all medical benefits paid to the Eligible
Participant or any Insured Dependent is limited to the maximum amount
stated in the Declaration of Coverage during each Trip
Coverage Period for each Insured Person, so long as the Participant or the
Dependent remains insured under this Plan and so long as the cumulative
amount of paid benefits for all Trip Coverage Periods within the Period of
Insurance does not exceed the Period of Insurance Maximum.
Please note any additional limits on the maximum amount of Covered
Expenses in the discussions of each specific benefit
BCR 362 04/03
What this Plan Pays
Before this Plan pays for any benefits, the Insured Person
must satisfy his/her Period of Insurance Deductible, which is stated in
the Declaration of Coverage. After the Insured Person
satisfies the Deductible, the Insurer will begin paying for Covered
Services as described in this section.
The benefits described in this section will be paid for Covered
Expenses incurred on the date the Insured Person receives the service or
supply for which the charge is made. These benefits are subject to all
terms, conditions, exclusions, and limitations of this Plan. All services
are paid at percentages and amounts indicated below or in the Declaration
of Coverage and the Benefit Overview Matrix, and are subject to
limits outlined in Section IV, How the Plan Works.
Following is a general description of the supplies and services for
which the Insured Person's Plan will pay benefits, if such supplies and
services are Medically Necessary:
Services and Supplies Provided by a Hospital
For any eligible condition other than for Mental, Emotional or Functional
Nervous Conditions or Disorders, Alcoholism or Drug Abuse, the Insurer
will pay indicated benefits on Covered Expenses for:
- Inpatient services and supplies provided by the Hospital except
private room charges above the prevailing two-bed room rate of the
- Outpatient services and supplies including those in connection with
outpatient surgery performed at an Ambulatory Surgical Center.
Payment of Inpatient Covered Expenses are subject to these conditions:
Note: No benefits will be provided for personal items, such as TV, radio,
guest trays, etc.
- Services must be those which are regularly provided and billed by
- Services are provided only for the number of days required to treat
the Insured Person's Illness or Injury
Professional and Other Services: The Insurer will pay
Covered Expenses for:
Note: Medical equipment and supplies must meet all
of the above guidelines in order to be eligible for benefits under this
Plan. The fact that a Physician prescribes or orders equipment or supplies
does not necessarily qualify the equipment or supply for payment. The
Insurer determines whether the item meets these conditions. Rental charges
that exceed the reasonable purchase price of the equipment are not
- Services of a Physician.
- Services of an anesthesiologist or an anesthetist.
- Outpatient diagnostic radiology and laboratory services.
- Radiation therapy and hemodialysis treatment.
- Surgical implants.
- Artificial limbs or eyes.
- The first pair of contact lenses or the first pair of eyeglasses
when required as a result of a covered eye surgery.
- Self-administered, injectable drugs
- Syringes when dispensed with self-administered injectable drugs
- Blood transfusions, including blood processing and the cost of
unreplaced blood and blood products.
- Services for the detection and prevention of osteoporosis for
- Rental or purchase of medical equipment and/or supplies that are all
of the following:
- ordered by a Physician;
- of no further use when medical need ends;
- usable only by the patient;
- not primarily for the Insured Person's comfort or hygiene;
- not for environmental control;
- not for exercise; and
- manufactured specifically for medical use.
The following ambulance services are covered under this Plan:
- Base charge, mileage and non-reusable supplies of a licensed
ambulance company for ground or air service for transportation to and
from a Hospital.
- Monitoring, electrocardiograms (EKGs or ECGs), cardiac
defibrillation, cardiopulmonary resuscitation (CPR) and administration
of oxygen and intravenous (IV) solutions in connection with ambulance
service. An appropriate licensed person must render the services.
Dental Care for An Accidental Injury
Benefits are payable for dental care for an Accidental Injury to natural
teeth that occurs while the Insured Person is covered under this Plan,
subject to the following:
In addition, the Plan provides benefits for up to three days of Inpatient
Hospital services when a Hospital stay is ordered by a Physician and a
Dentist for dental treatment required due to an unrelated medical
condition. The Insurer determines whether the dental treatment could have
been safely provided in another setting. Hospital stays for the purpose of
administering general anesthesia are not considered Medically Necessary.
- services must be received during the six months following the date
- no benefits are available to replace or to repair existing Dental
Prostheses even if damaged in an eligible Accidental Injury; and
- damage to natural teeth due to chewing or biting is not considered
an Accidental Injury under this Plan.
Dental Care for Relief of Pain
Benefits are payable for dental care for Relief of Pain to the teeth that
occurs while the Insured Person is covered under this Plan. Services must
be received while covered during the Trip Coverage Period.
Complications of Pregnancy
Complications of Pregnancy are covered under this Plan as any other
medical condition. Benefits for complications of pregnancy shall be
provided for all Insured Persons.
Treatment received from Foreign Country Providers
Benefits for services and supplies received from Foreign Country Providers
are covered. The Insured Person may seek the assistance of HTH in locating
Benefits for Claims resulting from downhill skiing and scuba
The Insurer will pay Covered Expenses for claims resulting from downhill
(alpine) skiing. It will also pay Covered Expenses resulting from scuba
diving provided that the diver is certified by the Professional
Association of Diving Instructors (PADI) or the National Association of an
Underwater Instructors (NAUI), or provided that he/she is diving under the
supervision of a certified instructor. These Covered Expenses are Limited
to Trip Period Maximum or $10,000 whichever is less.
Accidental Death And Dismemberment Benefit
The Insurer will pay the benefit stated below if a Insured Person sustains
an Injury resulting in any of the losses stated below within 365 days
after the date the Injury is sustained:
|Loss of life
||100% of the Principal Sum
|Loss of one hand
||50% of the Principal Sum
|Loss of one foot
||50% of the Principal Sum
|Loss of sight in one eye
||50% of the Principal Sum
Loss of one hand or loss of one foot means the actual severance through
or above the wrist or ankle joints. Loss of the sight of one eye means the
entire and irrecoverable loss of sight in that eye.
If more than one of the losses stated above is due to the same Accident,
the Insurer will pay 100% of the Principal Sum. In no event will the
Insurer pay more than the Principal Sum for loss to the Insured Person due
to any one Accident.
The Principal Sum is stated in Benefit Overview Matrix.
There is no coverage for loss of life or dismemberment for or arising from
an Accident in the Insured Person's Home Country.
Repatriation Of Remains Benefit
If an Injury or a Sickness results in the Insured Person's loss of life
outside the U.S., the Insurer will pay the Reasonable Expense incurred for
cremation or for preparation of the body for burial in, and for
transportation of the body to, the Home Area up to the maximum stated for
this benefit in the Benefit Overview Matrix. Payment of this benefit is
subject to the Limitations and Conditions on Eligibility for Benefits.
No benefit is payable if the death occurs after the Period of Insurance
Termination Date. However, if the Insured Person is Hospital Confined on
the Termination Date, eligibility for this benefit continues until the
earlier of the date the Insured Person's Confinement ends or 31 days after
the Termination Date. The Insurer will not pay any claims under
this provision unless the expense has been approved by the Insurer before
the body is prepared for transportation.
Medical Evacuation Benefit
If a Insured Person sustains an Injury or suffers a sudden Sickness while
traveling outside the U.S., the Insurer will pay the Medically Necessary
expenses incurred, up to the lifetime Maximum Limit for all medical
evacuations shown in the Benefit Overview Matrix, for a medical evacuation
to the nearest Hospital, appropriate medical facility or back to the
Insured Person's home area. Transportation must be by the most direct and
economical route. However, before the Insurer makes any payment, it
requires written certification by the attending Physician that the
evacuation is Medically Necessary. No benefits are payable under any other
provision of the Policy for expense incurred by the Insured Person on and
after the date of the evacuation to the Insured Person's home area.
Evacuation of the Insured Person to his or her home area terminates
further insurance under the Policy for the trip. The Insurer will pay
Reasonable Charges for escort services if the Insured Person is a minor or
if the Insured Person is disabled during a trip an escort is recommended
in writing by the attending Physician and approved by the Insurer. Any
expenses for medical evacuation require the Insurer's prior approval.
With respect to this provision only, the following is in lieu of the
Policy's Extension of Benefits provision: No benefits are payable for
Covered Expenses incurred after the date the Insured Persons insurance
under the Policy terminates. However, if on the date of termination the
Insured Person is Hospital Confined, then coverage under this benefit
provision continues until the earlier of the date the Hospital Confinement
ends or the end of the 31st day after the date of termination.
Bedside Visit Benefit
If the Insured Person is Hospital Confined due to an Injury or Sickness
for more than 7 days while traveling outside the U.S., the Insurer will
pay up to a maximum benefit of $1,500 for the cost of one economy round
trip air fare ticket to the place of the Hospital Confinement for one
person designated by the Insured Person. With respect to any one trip,
this benefit is payable only once for that trip, regardless of the number
of Insured Persons on that trip. No more than one visit may be made during
any 12 month period. No benefits are payable under this provision prior to
the end of the 7-day Hospital Confinement. No benefits are payable
unless the trip is approved in advance by the Insurer.
BCR 364 04/03
Exclusions and Limitations: What the Plan does not pay for
The Plan does not provide benefits for:
- Any amounts in excess of maximum amounts of Covered Expenses
stated in this Plan.
- Services not specifically listed in this Plan as
- Services or supplies that are not Medically Necessary
as defined by the Insurer.
- Services or supplies that the Insurer considers to be Experimental
- Services received before the Effective Date of
coverage or during an inpatient stay that began before that Effective
Date of Coverage.
- Services received after coverage ends unless an
extension of benefits applies as specifically stated under Extension
of Benefits in the 'Who is Eligible for Coverage' section of this
- Services for which the Insured Person has no legal
obligation to pay or for which no charge would be made if
he/she did not have a health policy or insurance coverage.
- Services for any condition for which benefits are recovered
or can be recovered, either by adjudication, settlement or
otherwise, under any workers' compensation, employer's liability law
or occupational disease law, even if the Insured Person does not claim
- Treatment or medical services required while traveling
against the advice of a Physician, while on a waiting list
for a specific treatment, or when traveling for the purpose of
obtaining medical treatment.
- Services related to pregnancy or maternity care
other than for complications of pregnancy that may arise during a Trip
- Conditions caused by or contributed by (a) An act of war;
(b) The inadvertent release of nuclear energy when government funds
are available for treatment of Illness or Injury arising from such
release of nuclear energy; (c) An Insured Person participating in the military
service of any country; (d) An Insured Person participating
in an insurrection, rebellion, or riot; (e) Services
received for any condition caused by an Insured Person's commission
of, or attempt to commit a felony or to which a contributing
cause was the Insured Person being engaged in an illegal occupation;
(f) An Insured Person, age 19 or older, being under the influence of alcohol
or intoxicants or of illegal narcotics or non-prescribed
controlled substances unless administered on the advice of a
- Any services provided by a local, state or federal government
agency except when payment under this Plan is expressly
required by federal or state law.
- Professional services received or supplies purchased from the
Insured Person, a person who lives in the Insured Person's home or who
is related to the Insured Person by blood, marriage
or adoption, or the Insured Person's employer.
- Inpatient or outpatient services of a private duty nurse.
- Inpatient room and board charges in connection with a Hospital
stay primarily for environmental change, physical therapy or treatment
of chronic pain; Custodial Care or rest cures; services
provided by a rest home, a home for the aged, a nursing home or any
similar facility service.
- Inpatient room and board charges in connection with a Hospital stay
primarily for diagnostic tests which could have been
performed safely on an outpatient basis.
- Treatment of Mental, Emotional of Functional Nervous
Conditions or Disorders.
- Treatment of drug, alcohol, or other substance addiction or
- Dental services, dentures, bridges, crowns, caps or
other Dental Prostheses, extraction of teeth or treatment to the teeth
or gums, except as specifically stated under Dental Care for
Accidental Injury in the Benefits section of this
- Dental and orthodontic services for temporomandibular joint
- Orthodontic Services, braces and other orthodontic
- Dental Implants: Dental materials implanted into or
on bone or soft tissue or any associated procedure as part of the
implantation or removal of dental implants.
- Hearing aids.
- Routine hearing tests.
- Optometric services, eye exercises including
orthoptics, eyeglasses, contact lenses, routine eye exams, and routine
eye refractions, except as specifically stated in this Plan.
- An eye surgery solely for the purpose of correcting
refractive defects of the eye, such as near-sightedness (myopia),
astigmatism and/or farsightedness (presbyopia).
- Outpatient speech therapy.
- Any drugs, medications, or other substances except
as specifically stated in this Plan. This includes, but is not limited
to, items dispensed by a Physician.
- Any intentionally self-inflicted Injury or Illness.
This exclusion does not apply to the Medical Evacuation, Repatriation
of Remains and Bedside Visit Benefits.
- Cosmetic Surgery or other services for
beautification, including any medical complications that are generally
predictable and associated with such services by the organized medical
community. This exclusion does not apply to Reconstructive Surgery to
restore a bodily function or to correct a deformity caused by Injury
or congenital defect of a newborn child, or to Medically Necessary
reconstructive surgery performed to restore symmetry incident to a
- Procedures or treatments to change characteristics of the body to
those of the opposite sex. This includes any medical, surgical or
psychiatric treatment or study related to sex change.
- Treatment of sexual dysfunction or inadequacy.
- All services related to the evaluation or treatment of fertility
and/or infertility, including, but not limited to, all tests,
consultations, examinations, medications, invasive, medical,
laboratory or surgical procedures including sterilization reversals
and In vitro fertilization
- All contraceptive services and supplies, including
but not limited to, all consultations, examinations, evaluations,
medications, medical, laboratory, devices, or surgical procedures.
- Cryopreservation of sperm or eggs.
- Orthopedic shoes (except when joined to braces) or
shoe inserts, including orthotics.
- Services primarily for weight reduction or
treatment of obesity including morbid obesity, or any care which
involves weight reduction as a main method of treatment.
- Routine physical exams or tests that do not
directly treat an actual Illness, Injury or condition, including those
required by employment or government authority.
- Charges by a provider for telephone consultations.
- Items which are furnished primarily for the Eligible Participant's personal
comfort or convenience (air purifiers, air conditioners,
humidifiers, exercise equipment, treadmills, spas, elevators and
supplies for hygiene or beautification, etc.).
- Educational services except as specifically
provided or arranged by the Insurer.
- Nutritional counseling or food supplements.
- Durable medical equipment not specifically listed
as Covered Services in this Plan. Excluded durable medical equipment
includes, but is not limited to: orthopedic shoes or shoe inserts; air
purifiers, air conditioners, humidifiers; exercise equipment,
treadmills; spas; elevators; supplies for comfort, hygiene or
beautification; disposable sheaths and supplies; correction appliances
or support appliances and supplies such as stockings.
- All infusion therapy together with any associated
supplies, drugs or professional services are excluded.
- Growth Hormone Treatment.
- Routine foot care including the cutting or removal
of corns or calluses; the trimming of nails, routine hygienic care;
and any service rendered in the absence of localized Illness, Injury
or symptoms involving the feet.
- Charges for which the Insurer are unable to determine the
Insurer's liability because the Eligible Participant or an
Insured Person failed, within 60 days, or as soon as reasonably
possible to: (a) authorize the Insurer to receive all the medical
records and information the Insurer requested; or (b) provide the
Insurer with information the Insurer requested regarding the
circumstances of the claim or other insurance coverage.
- Charges for the services of a standby Physician.
- Charges for animal to human organ transplants.
- Under the medical treatment benefits, for loss due to or arising
from a motor vehicle Accident if the Insured Person operated the
vehicle without a proper license in the jurisdiction where the
- Medical treatment services or supplies or Confinement in a Hospital
owned or operated by a national government or its
agencies. (This exclusion does not apply to charges the law requires
the Insured Person to pay.)
- Claims arising from loss due to riding in any aircraft
except one licensed for the transportation of passengers.
- Claims arising from participation in interscholastic or professional
and/or non-professional club sports or sports event
or participation in mountaineering, motor racing, speed contests,
skydiving, hang gliding, parachuting, spelunking, heliskiing, extreme
skiing or bungee-cord jumping.
- Treatment for or arising from sexually transmittable
diseases. (This exclusion does not apply to HIV, AIDS, ARC or
any derivative or variation.)
- Under the Accidental Death and Dismemberment provision,
for loss of life or dismemberment for or arising from an Accident in
- Under the Repatriation of Remains Benefit and the Medical
Evacuation Benefit provision, for repatriation of remains or
medical evacuation of the Covered Accident in the U.S.
- Treatment of Congenital Conditions.
Benefits are not available for any services received on or within 6 months
after the Eligibility Date of an Insured Person, if those services are
related to a Pre-existing Condition as defined in the Definitions
section. This exclusion does not apply to a Newborn that is enrolled
within 31 days of birth or a newly adopted child that is enrolled within
31 days from either the date of placement of the child in the home, or the
date of the final decree of adoption.
Note: Creditable Coverage does not apply to this short term
This limitation does not apply to the Medical Evacuation Benefit, the
Repatriation of Remains Benefit and to the Bedside Visit Benefit.
BCR 365 04/03
Third Party Liability
No benefits are payable for any Illness, Injury, or other condition for
which a third party may be liable or legally responsible by reason of
negligence, an intentional act, or breach of any legal obligation on the
part of such third party. Nevertheless, the Insurer will advance the
benefits of this Plan to the Insured Person subject to the following:
- The Insured Participant agrees to advise the Insurer, in writing,
within 60 days of any Insured Person's claim against the third party
and to take such action, provide such information and assistance, and
execute such paper as the Insurer may require to facilitate
enforcement of the claim. The Insured Participant and Insured Person
also agree to take no action that may prejudice the Insurer's rights
or interests under this Plan. Failure to provide notice of a claim or
to cooperate with the Insurer, or actions that prejudice the Insurer's
rights or interests, will be material breach of this Plan and will
result in the Insured Participant being personally responsible for
reimbursing the Insurer.
- The Insurer will automatically have a lien, to the extent of
benefits advanced, upon any recovery that any Insured Person receives
from the third party, the third party's insurer, or the third party's
guarantor. Recovery may be by settlement, judgment or otherwise. The
lien will be in the amount of benefits paid by the Insurer under this
Plan for the treatment of the Illness, disease, Injury or condition
for which the third party is liable.
Benefits for Medicare-Eligible Insured Persons
Insured Persons eligible for Medicare receive the full benefits of this
Plan, except for those Insured Persons listed below:
- Insured Persons who are receiving treatment for end-stage renal
disease following the first 30 months such Insured Persons are
entitled to end-stage renal disease benefits under Medicare,
regardless of group size.
- Insured Persons who are entitled to Medicare benefits as disabled
persons, unless the Insured Persons have a current employment status,
as determined by Medicare rules, through a Group of 100 or more
employees (subject to COBRA legislation).
- Insured Persons who are entitled to Medicare for any other reason,
unless the Insured Persons have a current employment status, as
determined by Medicare rules, through a Group of 20 or more employees
(subject to COBRA legislation).
In cases where exceptions 1, 2 or 3 apply, the Insurer will determine
the Insurer's payment and then subtract the amount of benefits available
from Medicare. The Insurer will pay the amount that remains after
subtracting Medicare's payment. Please note the Insurer will not pay any
benefit when Medicare's payment is equal to or more than the amount which
we would have paid in the absence of Medicare.
For example: Assume exception 1, 2 or 3 applies to the
Insured Person, and he/she is billed for $100 of Covered Expense. And
assume in the absence of Medicare, the Insurer would have paid $80. If
Medicare pays $50, the Insurer would subtract that amount from the $80 and
pay $30. However, if in this example, Medicare's payment is $80 or more,
the Insurer will not pay a benefit.
Alternate Cost Containment Provision
If it will result in less expensive treatment, the Insurer may approve
services under an alternate treatment plan. An alternate treatment plan
may include services or supplies otherwise limited or excluded by the
Plan. It must be mutually agreed to by the Insurer, the Insured Person,
and the Insured Person's Physician, Provider, or other healthcare
practitioner. The Insurer's offering an alternate treatment plan in a
particular case in no way commits the Insurer to do so in another case,
nor does it prevent the Insurer from strictly applying the express
benefits, limitations, and exclusions of the Plan at any other time or for
any other Insured Person.
Terms of the Insured Participant's Plan
- Entire Contract and Changes: The entire contract
between the Group and the Insurer is as stated in the Policy and the
entire contract between the Insured Participant and the Insurer is as
stated in the Certificate of Coverage including the endorsements,
application, and the attached papers, if any. No change in the Policy
or Certificate of Coverage shall be effective until approved by one of
the Insurer's officers. This approval must be noted on or attached to
the Certificate of Coverage. No agent may change the Policy or waive
any of its provisions.
- Payment of Premiums: Premiums are payable in
advance. Premiums must be paid monthly including any contributions the
Insured Participant must make. The Insurer may change the premium
rates from time to time. The Insurer must give the Group written
notice of any premium rate change at least 30 days prior to the
change. The Insurer may not increase premiums without first providing
written notification to the Group at least 30 days prior to the date
the increase is to take effect, with the exception of retroactive
premium rate increases related to fraud or the intentional
misrepresentation of a material fact.
- Grace Period: There is a Grace Period of 31 days
allowed for the payment of each premium after the first premium.
- Representations: All statements made by the Insured
Participant or the Group shall be considered representations and not
warranties. The Insurer must provide the Insured Participant or the
Group with a copy of any statements used to contest coverage.
- Time Limit on Certain Defenses/Misstatements on the
Application: After two years from the Effective Date of the
Policy, the Insurer will not contest the validity of the Policy. After
two years from the Insured Participant's Effective Date of Coverage,
no misstatements on the Eligible Participant's application may be used
The above does not apply to fraudulent misstatements.
- void this coverage, or
- deny any claim for loss incurred or disability that starts after
the 2 year period.
- Legal Actions: The Insured Person cannot file a
lawsuit before 60 days after the Insurer has been given written proof
of loss. No action can be brought after 3 years from the time that
proof is required to be given.
- Conformity With State Statutes: If any provision of
this Plan which, on its Effective Date, is in conflict with the
statutes of the state in which the Policyholder resides, it is amended
to conform to the minimum requirements of those statutes.
- Provision in Event of Partial Invalidity: If any
provision or any word, term, clause, or part of any provision of this
Plan shall be invalid for any reason, the same shall be ineffective,
but the remainder of this Plan and of the provision shall not be
affected and shall remain in full force and effect.
- The Claims Process
Notice of Claim: Within 20 days after an Insured
Person receives Covered Services, or as soon as reasonably possible,
he/she or someone on his/her behalf must notify the Insurer in writing
of the claim.
Within 15 days after the Insurer receive the Insured Person's written
notice of claim, the Insurer must:
- acknowledge receipt of the claim;
- begin any investigation of the claim;
- specify the information the Eligible Participant must provide to
file proof of loss. (The Insurer can request additional
information during the investigation if necessary.)
- send the Insured Person any forms the Insurer require for filing
proof of loss. If the Insurer does not send the forms within this
time period, the Insured Person can file proof of loss by giving
the Insurer a letter describing the occurrence, the nature and the
extent of the Insured Person's claim. The Insured Person must give
the Insurer this letter within the time period for filing proof of
Proof of Loss: Within 90 days after the Insured
Person receives Covered Services, he/she must send the Insurer written
proof of loss. If it is not reasonably possible to give the Insurer
written proof in the time required, the Insurer will not reduce or
deny the claim for being late if the proof is filed as soon as
reasonably possible. Unless the Insured Person is not legally capable,
the required proof must always be given to the Insurer no later than
one year from the date otherwise required.
All benefits payable under the Plan will be payable immediately upon
receipt of due written proof of such loss. Should the Insurer fail to
pay the benefits payable under the Plan, the Insurer shall have 15
workings days thereafter within which to mail the Insured Person a
letter or notice which states the reasons the Insurer may have for
failing to pay the claim, either in whole or in part, and which also
gives the Insured Person a written itemization of any documents or
other information needed to process the claim or any portions thereof
which are not being paid. When all of the listed documents or other
information needed to process the claim have been received, the
Insurer shall then have 15 working days within which to process and
either pay the claim or deny it, in whole or in part, giving the
Insured Person the reasons the Insurer may have for denying such claim
or any portion thereof.
Subject to proof of loss, all accrued benefits payable under the Plan
for loss of time will be paid not later than at the expiration of each
period of 30 days during the continuance of the period for which the
Insurer are liable and any balance remaining unpaid at the termination
of such period will be paid immediately upon receipt of such proof.
Time Payment of Claims: Benefits for a loss covered
under this Plan will be paid as soon as the Insurer receives proper
written proof of such loss. Any benefits payable to the Insured
Participant and unpaid at the Insured Participant's death will be paid
to the Insured Person's estate.
Payment of Claims: The Insurer will pay all or a
portion of any indemnities provided for health care services by a
health care services provider directly to the Insured Person, unless
the Insured Participant directs otherwise in writing by the time
proofs of loss are filed. The Insurer cannot require that the services
be rendered by a particular health care services provider.
Assignment of Claim Payments: The Insurer will
recognize any assignment made under the Plan, if:
The Insurer assumes no responsibility for the validity or effect of an
- It is duly executed on a form acceptable to the Insurer; and
- A copy is on file with the Insurer.
Payment to a Managing Conservator: Benefits paid on
behalf of a covered dependent child may be paid to a person who is not
the Insured Participant if an order issued by a court of competent
jurisdiction in this or any other state names such person the managing
conservator of the child.
To be entitled to receive benefits, a managing conservator of a child
must submit to the Insurer with the claim form, written notice that
such person is the managing conservator of the child on whose behalf
the claim is made and submit a certified copy of a court order
establishing the person as managing conservator. This will not apply
in the case of any unpaid medical bill for which a valid assignment of
benefits has been exercised or to claims submitted by the Insured
Participant where the Insured Participant has paid any portion of a
medical bill that would be covered under the terms of the Plan.
- Misstatement of Age: If the age of an Insured
Person has been misstated, an adjustment of premiums shall be made
based on the Insured Person's true age. If age is a factor in
determining eligibility or amount of insurance and there has been a
misstatement of age, the insurance coverages or amounts of benefits,
or both, shall be adjusted in accordance with the Insured Person's
true age. Any such misstatement of age shall neither continue
insurance otherwise validly terminated nor terminate insurance
otherwise validly in force.
- Right to Recovery: If the Insurer makes benefit
payments in excess of the benefits payable under the provisions of the
Plan, the Insurer has the right to recover such excess from any
persons to, or for, or with respect to whom, such payments were made.
- Plan Administrator - COBRA and ERISA: In no event
will the Insurer be plan administrator for the purpose of compliance
with the Consolidated Omnibus Budget Reconciliation Act (COBRA) or the
Employee Retirement Income Security Act (ERISA). The term "plan
administrator" refers either to the Group or to a person or
entity other than the Insurer, engaged by the Group to perform or
assist in performing administrative tasks in connection with the
Group's health plan. The Group is responsible for satisfaction of
notice, disclosure and other obligations of administrators under ERISA.
In providing notices and otherwise performing under the Continuation
(COBRA) section of this certificate (if applicable), the Group is
fulfilling statutory obligations imposed on it by federal law and,
where applicable, acting as the Eligible Participant's agent.
- Waiver of Rights: Failure by the Insurer to enforce
or require compliance with any provision herein will not waive, modify
or render such provision unenforceable at any other time, whether the
circumstances are or are not the same.
- Physical Exam and Autopsy: The Insurer has the
right to require a medical examination, at reasonable intervals, or an
autopsy, where not prohibited by law, when a claim is made. If an
examination or autopsy is required, the Insured Participant will not
have to pay for it.
- Required Information: The Group will furnish the
Insurer all information necessary to calculate the Premium and all
other information that the Insurer may require. Failure of the Group
to furnish the information will not invalidate any insurance, nor will
it continue any insurance beyond the last day of coverage. The Insurer
has the right to examine any records of the Group, any person, company
or organization which may affect the Premiums and benefits of the
The Insurer's right to examine any records that exist:
The Insurer is not responsible for any claim for damages or injuries
suffered by the Insured Person while receiving care in any Hospital,
Ambulatory Surgical Center, skilled nursing facility, or from any
Provider. Such facilities are providers act as independent contractors
and not as employees, agents or representatives of the Insurer.
- During the time the Plan is in force; or
- Until the Insurer pay the last claim.
The Insurer is entitled to receive from any provider of service
information about the Insured Person which is necessary to administer
claims on the Insured Person's behalf. This right is subject to all
applicable confidentiality requirements. By submitting an application
for coverage, the Insured Participant has authorized every provider
furnishing care to disclose all facts pertaining to the Insured
Participant's and his/her Insured Dependent's care, treatment, and
physical condition, upon the Insurer's request. The Insured
Participant agrees to assist in obtaining this information if needed.
Payments of benefits under this Plan neither regulate the amounts
charged by providers of medical care nor attempt to evaluate those
Grievance Procedures: If the Insured Person's claim is
denied in whole or in part, he/she will receive written notification of
the denial. The notification will explain the reason for the denial.
The Insured Person has the right to appeal any denial of a claim for
benefits by submitting a written request for reconsideration with the
Insurer. Requests for reconsideration must be filed within 60 days after
receipt of the written notification of denial. When the Insurer receives
the Insured Person's written request, the Insurer will review the claim
and arrive at a determination.
If the matter is still not resolved to the Insured Person's satisfaction,
he/she may request a second review of the claim by sending the Insurer a
written request for a second reconsideration. This written request must be
filed within 60 days of the Eligible Participant's receipt of the
Insurer's written notification of the result of the first review. If the
issue involves a dispute over the coverage of medical services, or the
extent of that coverage, the second review will be completed by physician
consultants who did not take part in the initial reconsideration. The
Insured Person will be informed, in writing, of the Insurer's final
The Insurer shall not take any retaliatory action, such as refusing to
renew or canceling coverage, against the Eligible Participant or the Group
because the Eligible Participant, the Group, or any person acting on the
Eligible Participant's or the Group's behalf, has filed a complaint
against the Insurer or has appealed a decision made by the Insurer.
The Insurer will meet any Notice requirements by mailing the Notice to
the Group at the billing address listed on our records. The Group will
meet any Notice requirements by mailing the Notice to:
UNICARE Life & Health Insurance Company
4553 LaTienda Drive
Thousand Oaks, CA 91362M
All complaints or disputes relating to coverage under this Plan must be
resolved in accordance with the Insurer's grievance procedures. Grievances
may be reported by telephone or in writing. All grievances received by the
Insurer that cannot be resolved by telephone conversation (when
appropriate) to the mutual satisfaction of both the Insured Person and the
Insurer will be acknowledged in writing, along with a description of how
the Insurer proposes to resolve the grievance.
The Insurer shall not take any retaliatory action, such as refusing to
renew or canceling coverage, against the Insured Participant and his/her
Insured Dependents or the Group because the Insured Participant's, the
Group's, or any person's action on the Insured Person's or the Group's
behalf, has filed a complaint against the Insurer or has appealed a
decision made by the Insurer.
BCR 173 04/03