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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 a,ICHmawav