1991-169e wpdoca\pelico 0
900 30
ORDINANCE NO ~/-/lam 9
AN ORDINANCE
OF CONTRACTS
PHILADELPHIA
EXPENDITURE
DATE
ACCEPTING COMPETITIVE BIDS AND PROVIDING FOR THE AWARD
FOR THE PURCHASE OF EMPLOYEE GROUP HEALTH INSURANCE TO
AMERICAN LIFE INSURANCE COMPANY, PROVIDING FOR THE
OF FUNDS THEREFORE, AND PROVIDING FOR AN EFFECTIVE
WHEREAS, the City has solicited, received and tabulated
competitive bids for the purchase of employee group health
insurance in accordance with the procedures of state law, and
WHEREAS, the City Manager, his designee, and the City's
professional insurance consultant, have received and recommended
that the bid described below is the lowest responsible bid for the
purchase of such insurance as described in the bid invitation, bid
proposals and specifications therein, and
WHEREAS, the City Council has provided in the City Budget for
the appropriation of funds to be used for the purchase of the
insurance policies approved and accepted herein, NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS
SECTION I That the bid of Philadelphia American Life Insu-
rance Company for the purchase of employee group health insurance,
as described in the plans and specifications on file in the Office
of the City's Purchasing Agent filed according to the bid number
assigned thereto, and in accordance with the policy and amendment
attached hereto as Exhibit A, and the prices enumerated in Exhibit
B, is hereby accepted and approved as being the lowest responsible
bid
SECTION II That the City Council hereby authorizes the ex-
penditure of funds in the manner and amount as specified in the
agreement
SECTION III That this ordinance shall become effective
immediately upon its passage and appr val
PASSED AND APPROVED this the day of , 1991
ATTORNEY
BY 1~~~~.41LJL.L-
PAGE 2
ATTEST
JENNIFER WALTERS, CITY SECRETARY
t Philadelphia American Life Insurance CompanU
HOME OFFICE eONEIN DEPENDENCE NO ALL PHILADELPHIA PENNS)L\ANIA QI1h
ADMINISTRATI\ E OFFICE* P U BOX 2461 nOL~TON TE\A~ 3'
(herein galled the Company)
Contractholder [%Y7 CcmpanD
Contract Number C13345
Contract Date arch 1 1980
Contract Annnersary Ctarch Q
Premium Due Date CFirst of each ^tont9
Consideration tor this Contract is the Contractholder s application and premium payment The Companv
shall pay benenta according to the provisions of this Contrac
This Contract takes etf~, on the Contract Date
This Cunt a,t is ;oyerned oy the laws of the State of C-Irnstate7
Executed By
a j Q
secretarv
14,
President
GROLP ACCIDENT AND HEALTH CONTRACT
Non Participating -Mtn Contributory
TABLE OF CONTENTS
PROVISION
DEFINITIONS
EFFECTIVE DATE OF A PERSON S COVERAGE
TERMINATION OF THE INSLRED PERSON S COVERAGE
EFFECTIVE DATE OF DEPENDENT S COV ERAGE
TERMINATION OF DEPENDENT S COVERAGE
TERMINATION OF THIS CONTRACT
COMPREHENSIVE MAJOR MEDICAL BENEFITS
COST CONTAINMENT BENEFITS
EXCEPTIONS
PROVISION FOR COORDINATION OF BENEFITS WITH MEDICARE
PROVISION FOR COORDINATION OF BENEFITS LNDER THIS
CONTRACT WITH OTHER BENEFITS
EXTENSION OF BENEFITS
CONVERSION PRIVILEGE
GENERAL CONTRACT PROVISIONS
PREMILM
APPLICATION
PAGE NLMBER
64662 11/84
DEFINITIONS
ACTIVELY AT WORK means that on the date the Persons coverage is to take effect he is not absent from
ill time work at his regular work station due to an injury or a Sickness This definition is applicable only to a
g:ouc written on an Employer/Emplovee basis
ACTIVE MEMBER/PARTICIPANT means the Person is a member in good standing with the Contract
,older This definition applies only to a group written on a Member/ Participant basis
AMBULATORY SLRGICAL CENTER' mean a facility which (t) may or may not be a part of a
Hospital (2) meets the tollowtng requirements (a) it is in compliance with the licensing or other legal re
_lirements in the state where it is located (b) it is primarily engaged in providing facilities for the perfor
ance of surgery on its premises (c) it has a licensed medical staff including Phvstcians and Registered
Nurses (d) it has a permanent operating room recoverv room and equipment for emergencv care (e) it has
an arrangement with a Hospital for immediate acceptance of patients who require Hospital care tollowmg
-eatment to such center and (f) it does not provide services or other accommodations for patients to siav
o%ernight
BIRTHING CENTER means a facility which (1) has been licensed by the state in which it is located (2) has
a enty tour hour nursing services by Registered Nurses and certified nurse midwives and (3) has at least one Ph%si
, an on duty at all times Such a facilin must be operated for the purpose of providing (1) care for patients during
ncomplicated pregnancy delivery and immediate postpartum periods (2) care tor infants born to thecenter" ho
a:e either normal or who have abnormalities which do not impair function or threaten life and (3) care for
oostetncal patients and infants born in the center who require emergency and immediate life support measures to
.utam life pending transfer to a Hospital
CALENDAR YEAR means the Januarv Ist of anv vear through the December 31st of that same vear
CO INSLRANCE means the proportional sharing of payment of Insured Expenses (expressed as percen
ages in the Schedule) by the Insured Person and the Companv after satisfaction of the Deductible it ap
=,icable The percentage shown in the Schedule is what the Company will oav
CONVALESCENT FACILITY means an institution licensed by the state in which it is located that pro
des the tollowtng supplies and services (1) room and board (2) nursing vare under the supervision of a
Registered Nurse (but not private duty nursing) (3) phvstcal occupational or speech therapy (if not provided
by the facility s staff an arrangement must be made by the facilitv for the others providing the service) (a)
medical social services (3) drugs, biologicals supplies appliances and equipment ordinarily furnished for
Lie in such facility (6) diagnostic therapeutic and emergency services provided by a Hospital with which the
facility has an agreement for the transfer of patients and the exchange of clinical records and (7) other ser
vices Necessary to the health and care of patients that are generally provided by such facility
COSMETIC SURGERY" means any procedure or part of a procedure which is not Necessarv for the
restoration of function of a part of the body
COVERAGE" meats the benefits for which a Covered Person is eligible under this Contract as made bet
seen the Company and Contractholder
COVERED DEPENDENT" means the Insured Person s Dependent who is covered under this Contract
COVERED PERSON' means the Insured Person and/or his Covered Dependents who are entitled to
benefits under this Contract
CUSTODIAL CARE ' means any care involving supportive services which can be learned and performed by
the average nonmedical person It includes but is not limited to care provided primarily to maintain a good
level of person hygiene and nutrition to guarantee adherence to a schedule of prescribed medications and/or
reatments or to provide assistance with changes in bed and with the activities of daily living (t a dressing
grooming and eating) or to protect the patient
r"" I I Mae*
o~vi
DEFINITIONS (Continued)
DEDUCTIBLE means the dollar amount as shown in the Schedule which the Insured Person must pav
before the Company will begin to pay benefits Only Insured Expenses are used to satisfy the Deductible This
dollar amount will not be reimbursed by the Company
DEPENDENT ' means the Insured Person s (1) lawful spouse or (2) child from the moment of birth up to
age 19 who has never been married and who is (a) a natural child (b) a legally adopted child (c) a stepchild
who lives with the Insured Person or (d) any other child (i) of whom the Insured Person has legal custody by
court decree (u) who permanently resides in the insured Person s household and (u) who depends primarily
upon the Insured Person for support and maintenance
Coverage will be extended beyond age 19 through age 23 if such child (1) has the same legal residence as
the Insured Person, (2) is primarily dependent upon the Insured Person for maintenance and support and (3)
is a regular full time student at an accredited secondary school college or university
Coverage will be extended for a Covered Dependent child beyond any limiting age if he is and continues to
be (1) incapable of self supporting employment by reason of mental retardation or physical handicap (2) in
sured under this Contract on the day immediately preceding his 19th birthday and (3) chiefly dependent on
the insured Person for support and maintenance
Proof of such incapacity and dependency must be furnished by the Insured Person (1) within 31 days of the
child s attainment of the limiting age, (2) subsequently as may be required by the Company and (3) not more
'frequently than once a year after the two year period following the child s attainment of the limiting age
FAMILY UNIT means the Insured Person and his Covered Dependents
HOSPITAL means only an institution which meets all of the following requirements (1) maintains perma
nent and full time facilities for bed care of resident patients (2) has a licensed Physician in regular full time at
tendance (3) continuously provides 24 hour a day nursing service by Registered Nurses (4) is primarily
engaged in providing diagnostic and therapeutic facilities for medical and surgical care of injured and sick
persons on a basis other than as a rest home nursing home convalescent home a place for the aged a place
for alcoholics or drug addicts (5) is operating lawfully in the jurisdiction where it is located and (6) is ac
credited as a Hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation
of Hospitals
IMMEDIATE FAMILY MEMBER means any of the following persons who are related by blood or mar
riage to the Insured Person or his Covered Dependent (1) spouse (2) father (3) mother (4) son (5)
daughter (6) brother or (7) sister
INJURY means an accidental bodily wound or damage due to external forces
INSURED EXPENSE ' means a medical expense incurred by a Covered Person which is (1) recommended
and approved by a Physician (2) Necessary to the treatment of an Injury or a Sickness (not applicable to the
Medical Check Up Benefit) and (3) not in excess of the Usual and Prevailing charges for the services per
formed or the materials furnished Only the Usual and Prevailing portion of the initial expense is considered
to be an insured Expense
INSURED PERSON means the Contractholder s employee member or participant who is entitled to
benefits under this Contract
MEDICAL CHECK UP means a medical examination and medical tests performed to (1) identify a
Sickness before symptoms develop or (2) determine the risk of the development of a Sickness
NECESSARY' means medically required recognized and professionally accepted nationally as the usual
customary and effective means of treating a condition as determined by the Company
OUT OF POCKET EXPENSES ' means those Insured Expenses which the Insured Person has incurred
which will not be reimbursed by the Company
PERSON means any employee member or participant who is eligible to elect coverage under this Con
tract
' PHYSICIAN ' means a practitioner of the healing arts who is operating pursuant to the authority of his
respective license, in connection with a service covered by the terms of this Contract and who is not an Im
mediate Family Member Such Physician's services are recognized if required to be covered by the laws of the
state governing this Contract
PRE EXISTING CONDITION" means any Injury or Sickness for which a Covered Person has received
treatment or a diagnosis within one year prior to being eligible for coverage under this Contract
64664 page 2
11/84
DEFINITIONS (Continued)
PROSTHESIS means any device by which performance of natural bodily tunctton is aided or augmented
provided that it meets all of the following requirements (1) its use must be for the sole and specific purpose of
treating the Injury or Sickness present and must not be of general use in aiding the health or comfort or
preventive medical needs of the average person (2) it must be of such Necessary type that the same results
annot be obtained through other means not requiring the Prosthesis (3) in the case of >pecial wearing ap
parel it must not be obtainable in the absence of a Physician s recommendation and/or pres~npnon and (i)
it must not be excluded elsewhere in this Contract The Company reserves the right to determine Anether the
purchase or rental will be applicable
REHABILITATION means those procedures performed for the purpose of restoring tie tunctton of mo
non vision or speech lost as a result of Injury surgery or debilitating Sicxness
SCHEDLLE means item 9 of the Application
SICKNESS means a condition marked by pronounced deviation from the normal healthy state
SLBSTANCE ABLSE means (I) alcoholism or (2) dependence on addiction to or abuse of (a) alcohol
(b) chemicals or (cl drugs
TOTAL DISABILITY means with respect to (1) the Insured Person that he is (a) not engaged in any gain
rul occupation and (b) completely unable due to Sickness or injury or both to engage in any and every
gainful occupation for which he is reasonably fitted by education training or experience or (2) a Covered
Dependent that he is unable to perform the normal activities of a healthy person of like age and sec
The impairment causing the Total Disability must be vharacterized by anatomical or physiological abnor
malmes as determined by the Company
L SLAL AND PREP AILING means that the charge is (1) LSLAL when it is the fee regularly chareed in
he absence of insurance ov a health vare provider for a given treatment service or upplies and
PREN,AILING in relation to what other health bare providers charge nationally for the same and/or similar
reatment ervice or supplies
64M 5 oaae 3 11/84
EFFECTIN E DATE OF A PER5044 5 COV ERAGE
Upon the Person s written request tor coverage his coverage will become a recti%e
(1) On a non contributory basis on the date he satisfies the eligibility requirements as spectried in the ap
placation
(2) On a ,ontnbutorv basis
(a) on the date ne atisties the eligibility requirements if such request s made on or ^etore that date
(b) on the date or his request it such request is made within 31 days after the date the Person satisnes
the eligibility requirements or
(c) on the date specified by he Compan% atter it has reviewed and round the Person s evidence or to
,urabilit% which he has oubmitted at his own expense to be satisractory if such request is made
W more than 31 days after the date he satisfies the eligibility requirements
tit) by the Person who had loss or ,overage because he had not r^ade premium payments or
tut) by the Person on re employment or on renewal of membership who had previously been re
quested to submit evidence of insurability but had not done so
If the Person is not actively at Work on the date his coverage would become etfecttye or on the date of any
)ubsequent ,hange in the amount or benetns his erfective date of coverage or oenetit ,hange snail be the date
tie returns to active rull time work at his regular work station This paragraph applies only to
Employer Employee groups
If the Person is not an 4,tiye Member/ Participant in good standing on the crate his coverage would became
°rfective or on the date or any euosequent hange in the amount of benefits its etfecttve date of ,overage or
^enetit 6hange shall be the date ne is in good ~tandtng with the Contracmoider This paragraph applies to
Member/ Participant groups
64666 page 4 11/84
TERMINATION OF THE INSURED PERSON S COVERAGE
C Employer/ Employee Buts
The Contractholder can terminate the Insured Person s coverage
(1) by giving written notice to such effect to the Company or
(2) by stopping premium payments
In the event that the actions shown above do not occur the Insured Person $ coverage shall cease upon the
earliest of
(1) his failure to make any required premium contribution
(2) his written request for termination
(3) his termination of (a) employment or (b) membership within the eligible classes except when this Con
tract provides benefits for retireees or
(4) termination of this Contract except when he has a Total Disability and has applied for and been ap
proved by the Company for the Extension of Benefits Provision
The Insured Person s employment shall be demed to have ended upon his cessation of active work This shall
not apply if the Insured Person is
(1) on an approved leave of absent a subject to the Company s receipt of a written notice from the Con
tractholder of such leave of absence
(2) temporarily laid off or
(3) unable to work due to disability
For the three items above his coverage may be continued from the date of cessation of active work for up to
90 days subject to the Contractholder's payment of premium
The Weekly Income Benefit if applicable shall be continued
(1) while the Insured Person remains disabled or
(2) until his Maximum Benefit is paid, whichever occurs first
Member/Participant Buis
The Contractholder can terminate the insured Person's coverage
(1) by giving written notice to such effect to the Company or
(2) by stopping premium payments
In the event that the actions shown above do not occur, the Insured Person's Coverage shall cease upon the
earliest of
(1) his failure to make any required premium contribution,
(2) his written request for termination,
(3) his termination of (a) membership, or (b) date the date he is no longer a member in good standing or
(4) termination of this Contract except when he has a Total Disability and has applied for and been ap•
Proved by the Company for the Extension of Benefits Provision
64667 page 5 11194
FrFECTINE DATE OF DEPE\DE\T S CM"AGE
LPon She Insured Pe son s written request for Dependent s overage his Dependent s overage will become
Itfective
l) on a non ~ontnbutory basis on the date he satisfies the eligibdirv equirements as specified in the ap
piication
(2) on a contributory basis
ta) on the date he satisfies the eligibility requirements it such request is made on or before that date
(b) on the date or his request if such request is made within 31 duns after the date the Insured Person
satisfies the eligibility requirements or
(c) on the date specified by the Companv after it has reviewed and found the Dependent s evidence of
insurability which the Insured Person has submitted at his own expense to be satisfacton it ucn
request is made
U) more than 31 davs after the Dependent first becomes eligibiled for coverage
(u) by the Insured Person who had loss of coverage because he had not made premium payments
or
(u) by the Insured Person on re employment or on renewal of membership who had oreviously
been requested to submit evidence of insurability for the Dependent but had not don so
It the Insured Person is not Acnvelv At Work on the date his Dependent s coverage would become effective
or on the date of anv subsequent change in amount of benefits his Dependent s effective date of overage or
"netit change shall be the date the Insured Person returns to active full time work at his regular work station
This paragrapn applies oniv to EmployeriEmplovee groups
If the Insured Person is not an Active y ember/ Participant in good standing on the date his Dependent s
.overage would become errattve or on the date of any subsequent changes in the amount or benefits tis
Dependent s effective date of voverage or benefit change shall be the date the Insured Person is in good s an
wing with the Contractholder This paragraph applies only to Member Participant groups
It both the Insured Person and his spouse are eligible tot coverage under this Contract oniv one shall be ehet
ole to provide Dependent ~ overage under this Contract
Once the Insured Pe son has Dependent s coverage in force anv Dependent subsequentiv acquired b% the In
,ured Person will be automatically covered under this Contract provided
(1) the Insured Person gives the Contractholder the information needed to identify such Dependent within
31 davs at the date he acquires such Dependent
(2) if anv additional premium is needed to add such Dependent the Insured Person agrees to make such
additional premium payment, and
(3) the Insured Person's insurance is in force on the date of such Dependent s addition
4ny Dependent who on the date his coverage is to take effect
(1) is Hospital confined,
(2) is confined in any medical facility, or
(3) has a Total Disability,
will have such coverage delayed until
(1) the day following the date of his final release from all such confinement or
(2) the day following the date he no longer has a Total Disability
This does not apply to a newborn child, since he is covered from the moment of birth
64668 page 6 11/84
TERMINATION OF DEPENDENT 5 COVERAGE
The Covered Dependent s coverage shall stop immediately upon the earliest or the following dates
(1) the date the Insured Person fails to make the required premium contribution
(2) the date the Dependent becomes an Insured Person
(3) the date the Dependent no longer satisties the definition of a Dependent
(4) the date this Contract is changed to stop all Dependent coverage
the date he Insured Person s ~o%erage stops except if the Dependent has a Total Disability and has ap
plied for and been approved by the Companv for the Extension or Berettts Pro~iston or
(6) the date the Dependent enters any mihtar% forces or am nilian non combatant unit ,erring with an%
mihtar% forces
64669 page 7 11/94
TERMINATION OF THIS CONTRACT
This Contract shall terminate
(1) on the next Premium Due Date when all the premiums are paid and the Contractholder gives the Com
pany a written request for termination
(2) on the 31st day at ter the Premium Due Date when any unpaid premium remains due at the end of the
Grace Period or on an earlier date if written notice is received by the Company curing the Grace
Period or
(3) on any Premium Due Date when
(a) the total percentage of persons insured is less than
0) 'e0'o of those eligible on a contributory basis
00 100070 of those eligible on a non contributory basis or
(b) less than 10 persons are covered
The Companv on such date may cancel this Contract on the 31st day atter giving written notice to the
Contractholder
The Companv may terminate this Contract by giving the Contractholder a 31 day written notice on any
Premium Due Date
6466 10 page 8 11/84
COMPREHENSINE MAJOR MEDICAL BENEFITS
It a Covered Person incurs any of the following Insured Expenses due to an Injury or a Sickness the Corn
panv will pay
(1) after the Deductible amount if any has been paid
(2) at the Co insurance percent
(3) not to exceed anv specified limits and
(a) up to the Maximum Lifetime Benefit amount per Covered Person
as shown in the Schedule
INSL RED EXPENSES
(1) Hospital Expenses
Benefits will be pavable for the following charges (a) the Hospital s room and board up to the Dates
Hospital Room and Board Limit as shown in the Schedule (b) the Hospital's Necessary services ane
supplies (c) a Physician s administration of anesthetics and (d) local ambulance services
(2) Surgical Expenses
Benefits will be payable for a surgical procedure performed by a Physician
(3) Medical Expenses
Benefits will be parable for (a) Phvstcian s charges other than those for surgerv (b) private duty nurs
ing for other roan in patient treatment performed by a nurse who is not an Immediate Family Member
up to the amount shown in the Schedule (c) drugs and medicines which require a written prescription
and are prescribed bs a Phvsieian (d) diagnostic x rav and laboratorv services (e) x rav radium and
radioactive isotopic therapy (f) oxvgen and rental of equipment for its use (g) rental of duraDie
medical equipment for therapeutic treatment (h) Rehabilitation to blood and blood elements and heir
administration and (j) Prosthesis except for charges incurred in.onneccion with repairs maintenance
or replacement of i Prosthesis due to wear breakage or personal desire
DEDLCTIBLE CARRY OVER
Any Insured Expenses incurred during the last three months of one Calendar tear which are used to satists
the Deductible may be carried over and used toward satisfying the next Calendar Year s Deductible
COMMON ACCIDENT
If two or more Covered Persons in the same Family Unit sustain injuries in the same accident only one
Deductible shall be applied in connection with such Injuries
ANNUAL ALTO%IATIC RESTORATION OF BENEFITS
On January 1st of each Calendar Year, any portion of the Maximum Lifetime Benefit Amount per Covered
Person used in the prior Calendar Year will automatically be reinstated up to the Annual Restoration Amount
as shown in the Schedule Any Insured Expenses incurred under the Mental or Nervous Disorders and
Substance Abuse Benefit will not be eligible to be used toward this provision
4444 of a 11 94
PRE EXISTING CONDITION LIMITATIONS
No payment will be made under this Contract for any Pre Existing Condition until the earlier of
(I) six consecutive months within which the Covered Person has not received medical treatment or
diagnosis for the condition or
(2) twelve consecutive months during which the Covered Person has been insured under this Contract
This Pre Existing Condition Limitation will be modified for a Covered Person who wDas covered under a pnor
group contract of the Contractholder on the day immediately preceding the Conirac[ ale and who are eh¢i
ole for coverage under this Contract The time enrolled under a prior group ontract of the Contractholder
will be credited to the above Limitation
Benefits will be payable at the lesser of
(I) the level of benefits available under the prior group contract or
(2) the level of benettis available under this Contract without regard to a Pre Exisnne Condition
The Deductible will be modified to provide credit for any portion of the current Calendar Year deductible
ansfied under the prior group contract Only Insured Expenses covered under this Contract may be used in
tits modification
6466 12 1 page 10
1/86
MENT4L OR NER~OLS DISORDERS 4%D SLBST4\CE 48LSE BENEFIT
If a Covered Person receives treatment for mental or nervous disorders or ~:.bsiance 4buse the CompanN
will pay for the tollow(ng Insured Expenses atter the Deductible has been paid
(1) Hospital Inpatient Treatment
(a) at the Co insurance pervent
(b) up to the Daily Hospital Room and Board Limit and
(v) up to the Maximum Number of Davs Payable per Calendar Year
(2) Outpatient Treatment
(a) at the Co insurance percent payable
lb) up to the Maximum Amount Pavable per Calendar Year and
(cl up to the Maximum Number of Visits per Calendar Year
as shown in the Schedule
411 of these amounts pavable are subject to the Maximum Litetime Benetit per Covered Person tor Mental or
Nervous Disorders and Substance abuse and do not apply toward the ove all Maximum Lifetime Benent
amount per Covered Person Before anv benettts will be pavable for such S'astance 4buse a plan of treat
men( must be prepared by a Phvstvtan then submitted to and approved by he Compam
6466 13 page 11 12/84
APPLEME`TU ACCIDENT BENEFIT
If a Covered Person sustains an Injury and incurs am Insured Expenses for he treatment of urn In)ury
%yithm 90 days of its oc.urrence the Company will pay
( 1) at 100°'0
(2) not uDject to ie Deduytible and
(3) up to the Maximum Amount Payable
as shown in the Schedule
%%hen the Maximum Amount Payable for this benent has been paid any re-mining Insured Expenses will
oecome payable under he Comprehensive Mayor Medical Benents Rhile under the Comprehensive Major
Medical Benents these remaining Insured Expenses will be suD)ect to all apphvable deduc ibles limits or
maximums
6466 14 page 12 12/84
WEEKL1 I%CO%fE BE%EFIT
(Does not apply ro Covered Dependents)
If the Insured Person becomes disabled as a result of a- In)urv or a Sickness and is therebs presenteo om
pertormmg the main duties of his regular occupation at nis regular work cation the Company wdl pas
(1) on the Da% Benents Begin
at the Benent 4-ount and
3 up to the SInximum Benent
as ,hown in the S,heauie
Successlse periods or - sabdtty will be considered as one period unless ( I ) her are ,eparated bs at least wo
weeks of his tull time a, tie work at his regular work station or (2) the later period results rrom pauses en ire
s unrelated to the pauses of the earlier period and the Insured Person has returned to Lull time a~ ire worK at
his regular work ,cation for at least one full day between the periods of disability
The weekls benents % his Contract will be paid on a pro rata basis The rate will be l "h of the Bene it
Rate per day for am ^enod of disability that does nor extend through a tull week
Benefits parable under vs benetit will not atfect the Maximum Lifetime Benent amount per Cosered P-
on
6466 IS nave 17A 12 94
ORGAN TRJk\SPLA%T BENEFIT
1, a Cohered Person is ne donor or recipient in a transplant pro,edure ror the organs shown below in L >t I
tie Compann wdl pas or Insured Expenses
1) after the Deductible has been paid
at the Co msura- a percent and
1) up to the xlaxu-am Lifetime Benefit Amount per Co%e d Person
as >hown in the S,heduie
LIST I
Bone
Bone marrow
Cornea
hidnes
SKin
ENCLLSIONS
Charges for the pur6na5e storage or transportation of organs hown in List I shall not be an Insured Ex
pense
No pasment will be made for am charges for transplant procedures for organs not shown m List I
Insured Expenses will paid for a donor unless prodded for ,ender
i I) the recipient a -trait or
i-) am oiner ontra medical in origin or otherwi,e
6466 16 cage 1213 12/84
PRE ADMISSION TESTING BENEFIT
If a Covered Persons Phvstctan orders tests to be vonducted prior to Hospital confinement or treatment he
Companv will pay for tests performed on an outpatient basis
(1) at 10007o and
(2) not ,ub)ect to the Deductible
as ions as
(I) the tests are `ecessarv
the treatment is performed within tour davs of the tests unless the treatment is an,-fled because or a
,hange in the Covered Person s nealth and
(3) the tests would have been performed upon Hospital vontinement
EXCLLSION
Benefits will not be paid for anv duplication or the same tests after Hospital vontinement wnen not
`ecessarv
6466 17 page 12C 12/64
SECOND SLRGICAL OPINION BE44EFIT
10
When a Covered Person s Physician initially recommends that a surgical procedure be performed the Com
pany will pay
(1) at 100910
(2) not subject to the Deductible and
(3) up to the Maximum Amount Payable per Surgical Opinion as shown in the Schedule
for any second surgical opinion obtained from another Physician within forty fi%e days of the initial surgical
opinion
When the second surgical opinion does not confirm the initial opinion the Company will pay
(1) at 100%
(2) not subject to the Deductible and
(3) up to the Maximum Amount Pavable per Surgical Opinion as shown in tie Schedule
for anv third surgical opinion obtained from another Physician within fortv five says of the second surgical
opinion When the initial and second surgical opinions agree the Company will not pay for any subsequent
surgical opinions obtained
Any second or third surgical opinion must be obtained prior to the performance of the surgical procedure
The Physician making the second or third surgical opinion must
(1) be qualified to perform the proposed surgery
(2) be independent of am Phvsician who has given an opinion
(3) not be the one who actually pertorms the surgery or assists in that surgery and
(4) have no financial interest to the outcome of these recommendations
while a Covered Person may or may not obtain a second or third surgical opinion for most procedures a con
firming surgical opinion is required for the procedures shown in List 11
If a Covered Person does not secure a confirming second or third surgical opinion and undergoes one of the
procedures in List II the Company will only pay at a Co insurance of 50re If a Covered Person secures a
confirming second or third surgical opinion and undergoes one of the procedures is List 11 the Company % ill
pay at the Coinsurance percent as shown in the Schedule For any eligible surgical procedure not shown in
List 11, the Compan) will pay at the Coinsurance percent as shown in the Schedule Payments made for all
surgical procedures are subject to the Deductible and Maximum Lifetime Benefit Amounts per Covered Per
son as shown in the Schedule
LIST 11
'vertebral column surgery
Foot operation involving the exposure of bone tendon or ligament
Coronary arten bypass
Hemorrhoid surgery
Hysterectomy
Inguinal or femoral hernia surgery
' knee surgery (except independent diagnostic arthroscopy)
6466 18 1 page 12D 10185
SECOND SLRGICAL OPINION BENEFIT
hen a Covered Person s Physician initially recommends that a surgical procedure be performed the Com
panv will pay
I1 at IOO01o
not >ub)ect o the Deductible and
(3) up to the Maximum Amount Payable per Calendar Year as shown in the Schedule
or any second surgical opinion obtained from another Phvstctan within tortv rive days of the initial surgical
opinion
%%hen the second surgical opinion does not confirm the initial opinion the Company will pay
(1) at IOO0/o
C) not vubject to the Deductible and
(3) up to the Maximum Amount Payable per Calendar Year as shown in ne Schedule
or any third surgical opinion obtained from another Phvstctan within torts fire days of the second surgical
opinion Nkhen the initial and second surgical opinions agree the Company will not pay for any subsequent
urgical opinions obtained
4nv second or third ~urascal opinion must be obtained prior to the performance of the surgical procedL e
Tie Phvstctan making the vetond or third surgical opinion must
11) be qualified to perform the proposed surgery
i_1 be independent of any Phvstctan who has given an opinion
(3) not be the one who a.tually pertorms the surgery or assist, in that wraer) and
have no financial tlterest in the outcome of these recommendations
hile a Covered Person may or may not obtain a second or third surgical opinion for most procedures a on
arming surgical opinion is required for the procedures shown in List 11
If a Covered Person does not secure a confirming second or third surgical opinion and undergoes one of the
procedures in List II the Company will only pay at a Co insurance of 1OPO It a Covered Person secures a
.onhrming second or third surgical opinion and undergoes one of the procedures in List II the Company will
pay at the Co insurance percent as shown to the Schedule For an) eligible surgical procedure not shown in
List 11 the Company will pay at the Co insurance percent as shown in the Schedule Payments made for ail
eurgical procedures are subject to the Deductible and Maximum Lifetime Benefit Amounts per Covered Per
,on as shown in the Svhedule
LIST 11
'vertebral column surgery
Foot operation involving the exposure of bone tendon or ligament
Coronary artery bypass
Hemorrhoid surgery
Hysterectomy
Inguinal or femoral hernia surgery
Knee surgery (except independent diagnostic arthroscopy)
AA" II I'M 11/Yd
OLTP+LTIE%TSLRGERV BENEFIT
It a Covered Person undergoes outpatient surgery to a Physicians otfice an Ambulatory Surgt,al Canter or
a Hospital the Company will pav
(1) at 1000% and
(2) not subject to the Deductible
or Insured Expenses incurred
The Insured Expenses must be incurred on the day of the surgerv No Hospital ontinement must oc ur
ktthtn twenty tour hours or the surgerv
EXCLLSION
`o pavment will be made for 6harges incurred for a surgical room or suite when the procedure is pertormed in
a Physician s otfice
6466 20 page 12E 12/84
HOSPICE CARE BENEFIT
If a Covered Person s Physician
(1) determines that he is terminally QI with a life expectancy of less than six months and
(2) recommends a tormal program of hospice care
the Companv will pav
(1) at 1000/s and
(2) not subject to the Deductible
tar the following
(1) inpatient care in the hospice unit at a Hospital or a hospice care center
(2) outpatient care and
(3) Bereavement Counseling
(a) up to the Maximum Amount Payable
(b) for up to the Maximum Number of Davs Payable within 90 davs or the Covered Person s death
as shown in the Schedule
Bereavement Counseling will be provided only for Immediate Family Members of the Covered Person ev-iv
ing hospice care Such services may be pertormed by a licensed social worker or pastoral ounselor
The hospice care program must meet the standards established by the National Hospice Association and be
approved by the Company Such a program must also meet anv and all requirements of the state in which t( is
located
EXCLUSIONS
Payment will not be made under this benefit for
(1) services provided by volunteers or others who do not regularly charge for their services
(2) services by a person who resides in the Covered Person s home and
(3) any period during which the Covered Person is not under the care of a Physician
tie 1112A
HOME HE-kLTH CARE BENEF
If a Covered Person s Phvsician prescribes a home health care treatment plan and such plan has been appros
ed by the Company the Company will pay for Insured Expenses
(1) at loowe
(2) not subject to the Deductible
(3) up to the Maximum Amount per visit and
(4) up to the Maximum Number of Visits per Calendar Year
as shown in the Schedule
a visit of four hours or less by a home health aide shall be considered as one home health care nisi
In order to establish the Covered Person s eligibility for this benefit his attending Physician must
(1) decide that home health care is the appropriate treatment instead of a Hospital confinement or a ion
pnued Hospital confinement and
(2) review the home health care treatment everv thirty davs to determine it it complies with his treatment
plan
Home health care will consist of
(I) part time or intermittent nursing care by or under the supervision of a Registered Nurse
(2) part time or intermittent home health aide services
13) physical therapy
(4) occupational therapy
(S) speech therapy
(6) medical supplies
(7) drugs prescribed by a Physician and
(8) laboratory services
Charges for the above items are considered pavable if they would have been considered Insured Expenses
under the Hospital Benefit
EXCLLSIONS
Payment will not be made under this benefit for
(1) services or supplies not included in the Physician s home health care treatment plan,
(2) services of an Immediate Family Member
(3) Custodial Care and
(4) transportation services
iGdiNt 71 nest Or V) /RA
CONVALESCENT FACILITI BENEFIT
11 a Covered Person is confined in a Convalescent Facility for treatment of the same condition as hat tor a
-nor Hospital confinement the Company will pav for Insured Expenses
(1) at 1000*0
(2) not subject to the Deductible
(3) for up to 100'a of the Hospital of prior onttnement s average semi prisate room rate and
(s) up to the Maximum Number of Dais Parable
>hown in the Schedule
9444 1 q na¢e 121 12/86
BIRTHING CENTER BENEFIT
If a Covered Person incurs Insured Expenses due to prenatal vare and normal dehvery at a Birthing Center
the Company will pav
(1) at 100016 and
not subject to the Deductible
If Hospital vonttnement occurs during or atter dehverv no Insured Expenses will be oavable unae his
benettt Insured Expenses would then be pavable under the Comprehensive Medical Expense Benefits and
subject to all deductibles limits and maximums
6466 23 page 12H 12/84
MEDICAL CHECK LP BENEFIT
If a Covered Person incurs Insured Expenses for Medical Check ups pertormec by a Physician the Company
will pay
(I) at 100014
(2) not subject to the Deductible and
(3) up to the Maximum amount Payable per Calendar Year
as shown in the Schedule
The Covered Person may use the Insured Expenses trom more than one Medicai Cehck up to satisty this limit
each Calendar Year
EXCLLSIONS
Payment will not be made under this benefit for Medical Check Lps relating o
(1) obtaining
(a) insurance or
(b) a job or
(2) a yondition of ontinued employment or
(3) treatment of
la) an Injury or
Ib) a Sickness
6466 25 page 12J 12/84
BENEFITS
If while insured an Insured Person or Covered Dependent
(I) because of sickness or accidental bodily injury
(2) incurs covered drug expenses
the Company will pay the amount over the deductible
No Eligible Charges for drugs or medicines shall be paid under any other provisions of this Contract if they are pavable
under the Prescription Drug Benefit provisions
DEDUCTIBLE FOR PRESCRIMON DRUGS
The Deductible For Prescription Drugs is that part of the cost the Insured Person must pay for each eligible charge as shown
n the Schedule
DEFINMONS
Eligible Charges mean charges which are
(a) Necessary for treatment of the Insured Person or covered dependent
(b) Usual and Prevailing
(c) for drugs and medicine that require a written prescription by a Physician
(d) for insulin
when the drugs and medicines are dispensed by a licensed pharmacist
Maintenance drugs or medicine means
(a) nitroglycerine
(b) phenobarbital
(c) thyroid and thyroid synthetics
(d) digitalis and its derivatives and
(e) oral anti-diabetic agents
Pharmacist means a person who is duly qualified and legally licensed to
(a) prepare
(b) compound and
(c) dispense
drugs
Excluded charges mean charges not included under Eligible Charges and
(a) drugs for treatment of a sickness or injury covered by Worker s Compensation of similar law
(b) drugs for treatment of injury due to
00 employment or
(u) occupation
for pay or profit
(c) drugs or medicines that do not require a prescription except for insulin
(d) any drug or medicine which except for oral contraceptives is not required in the treatment of bodily injury or sickness
(e) devices or appiuncn of any kind including
(4 neddles
(it) syringes
(tit) support garmenu and
(iv) other non medical items
(f) drugs furnished under
(q local
(u) state or
(u) federal
programs unless the law denies their exclusions
6466 38
pale 12 it 10i87
charges for giving or injecting anv drugs
n) drugs or medicines
(4 to be taken by
111) given to
an insured person while he is in a
(0 Hospital
(it) surgical center
On) rest home
Ov) sanitarium
(v) extended care facility
(vi) dulled nursing facility
(Vol nursing home or
(vw) similar place
refills in excess of the number set out by the Physician
U) drugs or medicines dispensed more than I year afar the date of the prescription
Ik) drugs medicine or injectable insulin which
(t) are not approved under the United States Food and Drug Act and its successor or
(it) fall into the catagory of supplies for which no benefits are payable to accordance with the Major Medical provisions
of this Policv
(l) mom than one purchase of a drug medicine or injectable insulin during the dosage period recommended by the
prescribing Physician
m) charges for
O) immunization agents
(it) biological sera
(wl blood or
1)v) blood plasma
including giving them
(n) that portion or anv single purchase
(t) of an oral contraceptive which is not a 3 month supply or
(11) of a maintenance drug or medicine or injectable insulin which exceeas a 34 day supply or a 100 unit dosage
whichever is greater when consumed or used in accordance with the directions or the prescribing Phvsician or
(m) of any other drug or medicine which exceed a 34 day supply when consumed or used in accordance with the directions
of the prescribing Physician
6466 39 page 12 1 10/87
EXTENDED 8hNhkIf:s
t an insured person or Cover lependent incurs any eligible drug expense of is insurance ceases benefits will be paid
as if it had not ceased if
(1) the charge is due to sickness or injury which began before the insurance ceased
(2) he was Totally Disabled by the sickness or injury when the insurance ceased
(3) he remains disabled until the date of the charge and
(4) the maxunuma of other benefits in this Policy are still being pud
No pavment will be mark for any charges incurred
(1) after the length of time for Extended Benefits During Disability as shown in the Schedule of Benefits for the Major
Medical Provision or
(2) after this Contract terminates if the person is eligible for similar coverage under any other group or prepayment plan
whichever is sooner
6466 40
page 12 m
1047
•.tv11111, G%l Lr IIVN7
`o benertts Khali be p^ ble under this Contract with respect to exp incurred
11) For an Injury wnich arises out of or in the ourse of anv employment for wage or prom or am
Sickness which is compensable under anv %~Orker s Compensation Law or similar legislation unless the
words 24-hour coverage appear in the Slhedule
(1) while confined in a Hospital where there would be no charges made were insurance not in torce w hick
is operated by or under the direction of
(a) the Lmted States Government
(b) anv state government
(c) anv local government or
(d) the government of anv other country
(3) Resulting from
(a) participation in a riot or act of civil disturbance
(b) participating n or an attempt to commit an assault or a telonN
(c) a war declared or undeclared
(d) anv act of war or
(e) service in he military naval or air forces or anv country or anv civilian non combatant unit serving
vith such torves
(4) In yonnection wu^
(a) am dental treatment except for replacement or repair of natural teeth caused by an Iniurv o~curing
while a Covered Person is insured provided that the procedure is begun within 90 days of the in
jury and is completed within one vear
(b) application or oral appliances orthodontics orally related orthopedic devices or equilibration or
(c) the repositioning altering implanting or replacement of teeth
(1) In vonnection wim
(a) radial keratotomy,
(b) anv eye retrac tons
(c) anv other eve exam to determine the need for or the proper adjustment of eve glasses or
(d) the purchase of eyeglasses or corrective lenses except for corrective lenses after the removal or the
lens system
(6) In connection with the purchase and fitting of any hearing aids except as required by the jurisdiction
where this Contract is issued and the Contractholder has elected such a benefit
(7) In connection with or caused by or arising from or the result of cosmetic surgerv except when
Necessary for the repair of an Injury caused by an accident occuring while covered under this Contract
for the care and treatment of medically diagnosed congenital detects and birth abnormalities or except
as expressiv provided elsewhere in this Contract
6466 261 page 13
6/85
(8) Resulting from
(a) the treatment o
(i) weak ,trained or flat foot
00 mstabilin or imbalance of the toot
(uq any bursitis tendomtis tarsalgia metatarsalgia
(iv) bunion except for an open cutting operation involving tendons ligaments and bones or
(v) toenails or of superficial lesions of the toot including corns valluses and wara exvept for the
removal of the nail root or matrix or
(b) the cost of orthomechanical or orthotic devices for the toot and the vharges for testing and titling
euvh devices except when such expenses are incurred because of a ventral nervous ~%btem or
generalized neuromusvular Injury or Sivkness
(9) In connection with
(a) food supplements
(b) minerals
(c) vitamins
(d) drugs which can be purchased without a written prescription
(e) participation in weight reduction program
M participation in physical fitness programs or
(g) a Medical Check up except as expressly provided elsewhere in this Contract
(10) In connection with
(a) Custodial Care or
(b) private dun nursing unless such services vould not be performed by Hospital staff or an Immediate
Family Member and such services are not housekeeping or Custodial Care
(11) Resulting from anv intentionally self inflicted Injury while sane
(12) In vonnection with repairs maintenance or replacement of a Prosthesis due to wear breakage or per
sonal desires
(13) In connection with speech therapv except if for restorative or rehabilitative speech therapy It the
therapy is for speech loss or impairment due to a Sickness other than a functional nervous disorder or
to surgerv on account of the Sickness In the event the loss or impairment is due to a ongemtal anoma
Iv surgery to correct such anomaly must have been performed prior to the therapy all therapv per
formed must be by a qualified speech therapist
(14) Which is an educational or training procedure used in connection with speech hearing or si,ton
(IS) In connection with charges incurred on a
(a) Friday and/or a Saturday in a Hospital fora non emergency confinement when such vonfinement
begins on either day
(b) Saturday, Sunday and/or Mondav when confinement is extended for reasons other than medical
Necessity, for a discharge on a Monday,
(16) In connection with
(a) in vitro fertilization,
(b) artificial insemination or
(c) other unnatural methods which attempt to
(Q achieve fertilization of an ovum, or
(it) initiate a pregnancy, or
(17) In connection with payment for any Insured Expenses under any other benefit once pavment has been
made for the same expenses under another benefit in this Contract
6466 271 page Ia
RiAS
PROW 9 FOR COORDINATION OF BENEFITS TH MEDICARE
DEFINITIONS
Medicare' means that portion of Tide XVIII Social Security Act of 1969 as amended
Full Medicare Coverage means coverage for all of the benefits provided under Medicare including any
benefits provided on an optional basis For the purpose of this Provision a Fully Insured Person who has less
than full Medicare coverage will be considered to have full Medicare coverage
EFFECT OF BENEFITS
11) For an Insured Person age 63 through age 69 who has chosen this Contract as primary the benefits
payable under this Contract for Insured Expenses for all Covered Persons will be paid before yom
parable benefits under Full Medicare Coverage
If an Insured Person under age 65 has a Covered Dependent spouse who is age 65 through age 69 and
such Covered Dependent spouse has notified the Contractholder in writing of the election to remain
vovered under this Contract the benefits payable under this Contract for Insured Expenses of such
spouse will be paid before comparable benefits under Full Medical Coverage
For an Insured Person age 65 through 69 who has elected Medicare as his primary varrier no benefit
shall be payable under this Contract for all Covered Persons
If the Insured Person under age 65 has a Covered Dependent spouse who is age 65 through 69 and such
Covered Dependent spouse has notified the Contractholder in writing of the election not to remain
covered under this Contract no benefit shall be payable under this Contract for suvh spouse
(3) For all other Covered Persons the benefits payable under this Contract for Insured Expenses shall be
reduced to the extent necessary so that the sum of such reduced benefits and all benefits pavaole ror In
sured Expenses shall not exceed the total of all Insured Expenses
Any benefits received from Full Medicare Coverage not covered by this Contract shall not be payable under
his Contract
a,tFa Iat nape 16 9 85 1M0)
PROVISION FOR COORDINATION OF BENEFITS LNDER THIS CONTRACT
WITH OTHER BENEFITS
BENEFITS SUBJECT TO THIS PROVISION
all of the benefits under this Contract are subject to this provision
DEFINITIONS
(1) Plan means any plan providing benefits or services for or by reason of medical or dental are or
treatment which benefits or services are provided by (a) group or blanket insurance coverage except
group or group tvpe hospital indemnity benefits of fiftv dollars per day or less and student accident
coverages written on either an individual group or blanket basis Student accident coverages are detin
ed to mean coverage covering grammar school and high school students for accidents only including
athletic injuries etcher on a twenty four hour basis or 'to and from school for which the parent pavs
the entire premium (b) service plan contracts group practice individual practice and other prepavment
coverage (c) any coverage under labor management trusteed plans union welfare plans emplover
organization plans or employee benefit organization plans (d) anv coverage under governmental pro
grams other than Medicare and any coverage required or provided by any statue and (e) anv group or
individual automobile 'no tault" contract but as to the traditional automobile fault contract only
the medical benefits written on a group tvpe will be applicable
The term Plan ' shall be construed separately with respect to (a) each poltcv contract or other ar
rangement for benefits or services (b) that portion of anv such poltcv contract or other arrangement
which reserves the right to take the benefits or services of other Plans into consideration in determining
its benefits and that portion which does not
(2) This Plan means that portion of this Contract which provides the benefits that are subject to this
provision
(3) Allowable Expense means any necessary reasonable and customary item of expense at least a por
Lion of which is covered under at least one of the plans covering the person for whom claim is made An
allowable expense to a secondary plan includes the value or amount of anv deductible amount or co
insurance percentage or amount of otherwise allowable expenses which was not paid by the primarv or
first paving plan
When a Plan provides benefits in the form of services rather than cash pavments the reasonable cash
value of each service rendered shall be deemed to be both an Allowable Expense and a benetit paid
(4) Claim Determination Period" means calendar year or that portion of a Calendar Year during which
the person for whom claim is made has been Covered under this Plan
EFFECT ON BENEFITS
(1) This provision applies in determining the benefits a person has under this Plan for anv Claim Deter
initiation Period if, for the Allowable Expenses incurred during such Claim Determination Period the
sum of the benefits that would be payable under
(a) this Plan in the absence of this Provision, and
(b) all other Plans in the absence therein of provisions of similar purpose of this provision would exceed
such Allowable Expenses
(2) The benefits that would be payable under this Plan in the absence of this provision for the Allowable
Expenses incurred as to a person during a Claim Determination Period shall be reduced to the extent
necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Ex
penes under all other Plans except as provided in item 3 of this section shall not exceed the total of
such Allowable Expenses Benefits payable under another Plan include the benefits that would have
been payable had claim been duly made thereof
n V! ..I1
(5) When this provision operates to reduce the total amount of benefits otherwise pavable as to a person
covered under this Plan during anv Claim Determination Period each benefit that would be pavable in
the absence of this provision shall be reduced proportionately Sucn reduced amount shall be harped
against any applicable benefit limit of this Plan
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
For the purposes or determining the applicability of and implementing the terms of this provision of this Plan
or any provision of similar purpose of anv other Plan the Companv may without the consent of or notice to
any person release to or obtain from any other insurance company or other organization or person anv infor
-nation with respect to any person which the Companv deems to be necessary for such purposes Any person
.laiming benefits under this Plan shall furnish to the Company such information as may be necessary to im
plement this provision
FACILITY OF MMENT
Whenever payments which should have been made under this Plan in accordance with this provision have
been made under any other Plans the Company shall have the right exercisable alone and in its sole discre
ion to pav over to anv organization making such other payments any amounts it shall determine to be war
ranted in order to satisfy the intent of this provision Amounts so paid shall be deemed to be benefits paid
under this Plan and to the extent of such pavments the Company shall be fully discharged from liabilitv
under this Plan
RIGHT OF RECOVERY
Whenever pavments have been made by the Company with respect to Allowable Expenses in a total amount
which is at anv time in excess of the maximum amount of pavment necessarv at that time to satisfy the intent
of this provision the Company shall have the right to recover such payments to the extent of such excess
from among one or more of the following as the Companv shall determine any persons to or for or w th
espect to whom such payments were made any other insurance companies any other organizations
646631 page 18 11/84
EXTENSION OF BENEFITS
7
I) a Covered Person s coverage under this Contract terminates due to
o (a) his termination of employment or membership or
tUi wlmmauwn of this Contract and
(2) such Covered Person has made application and been approved by the Company for an Extension of
Benetits
benefits will be payable for a period of 12 months from the date of termination subject to the tollowing
(1) the Covered Person has a Total Disability as a result of an Injury or Sickness when his coverage er
minated
(2) the Covered Person s Total Disability is continuous until the date the Insured Expenses are incurred
(3) the Insured Expenses are incurred as a result of such Total Disability and
(4) the Covered Person does not become eligible for similar benefits under another group contract pros id
ed by the Contractholder in which case this provision would become null and void
Anv Covered Dependent child whose coverage has been continued beyond his limiting age due to mental
retardation or physical handicap will not be eligible for this Extension of Benefits provision
a
6466 32E page 19 3/83 (NM)
CONVERSION PRIVILEGE
The Companv will issue an individual contract in a form customarilv issued by it with benefits not greater
than the benefits provided by this Contract to the Insured Person who
( I) has been covered under this Contract for at least 3 months and
(2) has his coverage not end because
(a) he tailed to make timely payment of anv required contributions or
(b) the group poltcv terminated or an emplover s participation terminated and the insurance is repla,ea
by similar coverage under another group poltcv within thirtv one davs of the date of such termina
tion
provided that he sends the first premium pavmeni along with his application to the Companv within 31 das s
after his coverage ends
This individual contract will be issued according to
(1) his attained age
(2) the class of risk to which he belongs and
(3) the selection of benefits and persons to be covered
-Xn individual contract will also be issued in each of the followin events provided that the Gerson so atfectea
makes the first premium pavment and his application to the Companv within 31 davs of such event
(1) the Insured Person s death to his surviving Covered Dependent
t2) a Dependent child s attainment of the limiting age to such vhild solelv with respect to himself ano
(3) termination of marriage to the Insured Person s former spouse
The issuance of an individual contract is subject to the Companv s havm¢
(1) a license in the state where the Insured Person resides and
(2) an approved individual contract for conversion in the state where the Insured Person resides
6466 331 naae 20 A ac
GkAIM CONTRACT PBOVISIOk
ENSIEE CONTRACT. The entire contract shall include (1) this Contract with
endorsements; (2) the attached application of the Contractholder, and (3) any
Insured Person's Evidence of Insurability Only the Company's authorized officers
can change this Contract.
STATEPMVTS NOT WARRANSINS All written and signed statements made by the
Contractholder or the Insured Person are true and complete to the best of the
knowledge and belief of the persons making them No such statements will be used to
avoid the insurance, reduce benefits, or defend a claim under this Contract, unless
a copy of the statement is given to the Insured Person or to his beneficiary
INCONTESTABILITY The validity of this contract shall not be contested except (1)
for failure to pay premiums; or (2) for fraudulent misstatements, after it has been
in force two years
The validity of any coverage an an Insured Person and his dependents, if any, shall
not be contested excepts (1) for failure to pay premiums, if any, or (2) for
fraudulent misstatements, after the individual's coverage has been in force two
years
The validity of the Contract or any individual's coverage can be contested only if
based on a written statement.
GRACE PERIOD. If the Contractholder has not written the Company that the coverage
under this Contract is to be cancelled, the Company will allow a 31 day grace period
in which to pay the premium. During this time the coverage will remain in force if
the premium is not paid before the and of the 31 days, the coverage will
automatically terminate on the 31st day. If the Company is given earlier written
notice, then the coverage will terminate on the earlier date The Contractholder
will have to pay the Company the premium for the period of time the coverage stayed
in force
NOTICE OF CLAIM. The Insured Person must write to the Company within 20 days of
the date the Injury or Sickness begins Notice given to (1) the Company at its
Administrative Office, or (2) any authorised agent of the Company, with sufficient
information to identify the person on whom claim is based, will be deemed notice to
the Company.
CLL M POEMS. The company will send the Insured Person claim forms within 15 days
after notice of claim is received. If the Company does not send the forms within 15
days, the Insured Person shall be deemed to have complied with the requirements if
he has furnished: (1) the date the Injury or Sickness started; (2) the cause of the
Injury or Sickness; (3) and how serious the Injury or Sickness In
PROOF OF LOSE. Writtem proof of 1088 of tins on account of: (1) an Injury or
Sickness; (2) disability# with respect to the Weekly Income Benefit, if applicable,
or (3) confinement in a Hospital; for which claim is made must be furnished: (1) to
the Company; (2) within 90 days after the and of the period for which claim is
made Written proof of any other lose on which claim may be based must be
furnishads (1) to the Company; (2) not later than 90 days after such lose begins
Failure to furnish notice within the time required will not invalidate or reduce any
claim if it is shown: (1) notice could not be reasonably furnished within the
required time; and (2) notice was furnished as soon as vu reasonably possible
4-
6466.34 page 21 4/AO
PREMILM STATEMENTS 4ND DATA REQUIRED The Company will send to the Contractholder a
premium statement prior to each premium due date The Contractholder shall supply the Company all inror
matron necessary for the preparation of such premium statement For tact verification the Company shall
have the right to inspect the Contractholder s records
TERM OF CONTRACT AND RENEWAL PRIVILEGE This Contract a esued for a period of one vear
commencing with the Contract Date it may be renewed on each subsequent Contract Anniversary for further
terms of one year each subject to the provision entitled Termination of This Contract
CERTIFICATES The Company will issue to the Contractholder for dehvmv to each Insured Person an in
dividual certificate This certificate will set forth a statement as to (1) the insurance protection to which a
Covered Person is entitled (2) whom the insurance benefits are payable and (3) the rights and conditions of
the Conversion Privilege
CONFIRMITY WITH STATE STATLTES Any provision of this Contract which on its Contract Date is in
conflict with the statutes of the State whose laws govern this Contract is hereby amended to conform to the
minimum requirements of such statutes
NONPARTICIPATING PREMIUM REFUNDS This Contract does not share in the surplus earnings of the
Company
NEW ENTRANTS To the group or class thereof originally insured shall be added from time to time all new
eligible persons of the Contractholder who request insurance
MALE PRONOLN whenever used includes the female whenever the Context requires
6466 33 page 22 11/84
PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY
AMENDMENT TO
GROUP ACCIDENT AND HEALTH CONTRACT
The Group Accident and Health Contract between Philadelphia
American Life Insurance Company and the City of Denton, Texas,
awarded by the City Council on the 5th day of November, 1991, to be
effective 12 00 a m , January 1, 1992 through 11 59 p m , December
31, 1992, is hereby amended to reflect the changes indicated below
All other terms and conditions of the Contract are unchanged
Philadelphia American Life Insurance Company agrees to provide
coverage under this Plan for each of the Group's retirees, employee
with Social Security Number 291-46 -4326, their eligible depen-
dents, and any other individuals for whom the City and Philadelphia
American mutually agree to provide coverage This coverage shall
become effective 12 00 a m on January 1, 1992 and continue through
11 59, December 31, 1992, and shall be subject to the provisions of
Section II hereof
II
Philadelphia American Life Insurance Company agrees to provide
coverage for the individuals designated in Section I hereof at the
following rates to be paid by said individuals
A Monthly Premium Payment for Retiree Under 65
Retiree
Only
$237
06
Retiree
+ Spouse
458
03
Retiree
+ Children
370
16
Retiree
+ Family
561
01
B Monthly Premium Payment for Retiree With Medicare Supple-
ment
Retiree only
2 On
1 On, 1 Off
1 on, 1 off + Family
2 On + Family
80 49
164 98
337 84
493 00
326 40
CITY OF DENTON, TEXAS
PHILADELPHIA AMERICAN LIFE
INSURANCE COMPANY
BY ,,ef-,
TITLE t Res 4f-=t.-W- ZLZ
ATTEST•
SECRETARY
EXHIBIT "B"
OITT OF DRBTOR
PROPOSALS SUBMISSION FORM
FOR FULL!-INSORRD Managed Care RID
Carrier/vendors Philadelphia American Life Insurance Company
Dates October 26. 1991
completed By$ Susanna I Behrens. vice-President (same a Title)
Phone Numbers (713) 071-4860
1 Premium Rate for the Realth Plan, net of comminsiouss
a Rmployee only $ 176.00
b. Rmployee a spouse $ 272.00
c Rmployse i child $ 236.00
d employee a Family $ 340.00
e now long are rates guaranteed? One year m/yr
2 Are there any other fees in addition to the Premium Rates? If yes,
identify and state the amount.
identification card
medical Conversion
Large claim management
$ No additional charce
$ 176/ conversion
Ranh Reconciliation $ not Applicable
0
0
0
5
PHILADELPHIA AMERICAN LIFE
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