• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
F6 D9 De0 49956222
 

F6 D9 De0 49956222

on

  • 1,193 views

 

Statistics

Views

Total Views
1,193
Views on SlideShare
1,193
Embed Views
0

Actions

Likes
1
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    F6 D9 De0 49956222 F6 D9 De0 49956222 Document Transcript

    • Linza Soasa 100 Montgomery St Jersey City, NJ 07302 Welcome Linza Soasa, Congratulations on your wise decision to enroll in this valuable insurance program – from National Union Fire Insurance Company of Pittsburgh, Pa. Welcome to the Good news: we’ve made managing your Essential Protection Plan online safe and easy. At www.EssentialProtectionPlans.com you can access your account anytime for instant Plan that provides policy news, account updates, access claim forms, tips for healthy living, and information for: about other Essential Protection products. Everything you need is available when you need it, 24 hours a day, with advanced security for your peace of mind. Hospital indemnity We have enclosed your Insurance Documents. Please read them carefully so that you coverage for covered understand the many benefits available to you. hospital stays Your coverage starts at $400 a day to a maximum of 365 days for hospital stays due to covered accidents or $200 a day for a covered illness, from the first day for each covered Cash benefits paid illness that requires a hospital stay of three consecutive days or more. direct to you or whomever you choose Best of all, your coverage amounts automatically increase every 3 months for 10 years with no increase in plan cost – regardless of whether or not you’ve used your coverage. Cash paid in addition to any other insurance Receive benefits for a covered extended hospital stay. you have To help ease the financial impact of an extended hospital confinement, the plan pays one of the following single lump-sum benefits in addition to your daily cash payouts: No restrictions on $5,000 after a 30 consecutive day stay or $10,000 after a 60 consecutive day stay. hospitals or doctors continued Linza Soasa Contact Us Member # 49956222 Insurance Claims: 1-866-960-0765 Insurance Customer Service: 1-877-219-1365 Discount Services Customer Service: 1-888-822-8906 24-Hour Nurse Line: 1-877-541-9189 DTC101BNJ-408-110-2 1 DTC101BNJ
    • You’ll also receive coverage for doctor visits, emergency room treatment and ambulances: • $50 for each covered doctor visit • $300 for each covered Emergency Room treatment (this amount increases every 3 months you remain covered) • $200 for each covered ambluance transportation (this amount also increases every 3 months) PLUS, save on prescriptions, doctor and dentist visits, eye care and get 24-hour nursing assistance.* Your plan includes full access to discounts which can save you 5-50% on routine doctor, hospital and lab visits while providing additional savings for prescription drugs, dentist and eye care at thousands of participating providers nationwide. You also have access to our 24-hour Nurse Hotline for answers to your family health questions. Please read the enclosed brochure to learn how to use this valuable benefit. Affordable monthly plan costs. Your affordable monthly plan cost will not increase due to your growing older, and cannot change due to the number of claims you make or how often you use your plan benefits. We want to be sure you make the most of your coverage. Don’t forget: information and answers about your Essential Protection plan are always available at www.EssentialProtectionPlans.com. If you have any questions regarding your policy, call the Customer Service Department at one of the toll free numbers in the box below. A Customer Service Representative will be available between the hours of 9 am and 10 pm Monday through Friday, Saturday 7 am to 3 pm Eastern Standard Time. We appreciate the opportunity to provide you with this valuable coverage and look forward to serving you. Sincerely, Insurance Claims:1-866-960-0765 Insurance Customer Service:1-877-219-1365 Discount Services Customer Service:1-888-822-8906 24-Hour Nurse Line:1-877-541-9189 Jonathan Yee Senior Vice President AIU Holdings, Inc. Customer Care: 1-888-822-8906 Monday - Friday 9 a.m. - 7 p.m. EST. Attention Participating Discount Medical Providers: For all membership inquires or to locate participating providers. To locate participating Call 1-888-822-8906 if you have any questions. The member agrees to pay 100% of the allowable providers online go to: www.mymemberinfo.com/EssentialHealth amount at the time of treatment. Please call to verify member eligibility and for repricing. Member is directly responsible for payment to the Participating Provider. 24 Hour Nurse Care Hotline: 1-877-541-9189 For physicians and hospital use only: 1-866-643-2230 ext.3 Pharmacy Help Desk: 1-800-847-7147 Members also have access to Call to determine members’s discounted fee. Provide the 24/7 Agelity Help Desk: For pharmacist use only the following networks Member’s ID number, your Provider number and the CPT Bin: 009265 codes. Collect full discounted payment at time of service PCN: AG unless other arrangements are made. Group: UH07 For ALL family members: Use person code 01 Through the use of this Membership, Member is acknowledging and accepting that he/she has read and is bound by the TERMS AND CONDITIONS of membership. C-139-062609-EH THIS IS NOT HEALTH INSURANCE THIS IS NOT HEALTH INSURANCE
    • 1-866-960-0765 1-877-219-1365 1-888-822-8906 24-Hour Nurse Line: 1-877-541-9189 Coverage may not be available in all states. This letter provides only a brief description of the insurance coverage available. The Policy contains reductions, limitations, exclusions and termination provisions. Full details of the insurance coverage are contained in each Policy. If there are any conflicts between this document and the Policy, the Policy (policy form numbers A30293NUFIC & C11695DBG) shall govern. Coverage may not be available in all states. Insurance is underwritten by National Union Fire Insurance Company of Pittsburgh, Pa., a Pennsylvania insurance company with its Administrative Offices at 80 Pine Street, New York, NY 10270. It is currently authorized to transact business in all states and the District of Columbia. NAIC No.19445 National Union Fire Insurance Company of Pittsburgh, Pa., assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services, or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers. Note: If you are 70 years of age or older on the date of a covered accident for which benefits are payable, the benefits listed below will be reduced by fifty percent (50%), except for the Physician’s Office Visits Indemnity Benefit. Benefit amounts for dependents are lower than your benefit amounts. *The Discount Medical Plans are provided by Patriot Health Florida, Inc., a discount medical plan organization. The features are not health insurance policies and are not available in all areas. The features provide discounts at certain health care providers for medical services and do not make payments directly to the providers of medical services. The member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York 11791. 800-292-3797 Not available in AK, FL, MT, ND, SD and VT. Coming soon to FL.
    • E NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH,PA. Administrative Offices: 80 Pine Street, New York, NY 10005 (212) 770-7000 (a capital stock company, herein referred to as the Company) Policyholder: Group Insurance Trust Delaware Policy Number: 49956222 GROUP ACCIDENT INSURANCE CERTIFICATE ABOUT THIS CERTIFICATE. This certificate describes accident insurance the Company provides to Insured Persons under the Group Policy (herein called the Policy) issued to the Policyholder. RIGHT TO EXAMINE THIS CERTIFICATE. This certificate of insurance is issued to You, the Insured, and can be returned for any reason within the later of: (1) 30 days after it is received by You; or (2) 30 days after Your Coverage Effective Date. The certificate should be returned by mail or in person to the Company. Any premium paid will be refunded and the certificate will be treated as if it were never issued. The President and Secretary of National Union Fire Insurance Company of Pittsburgh, Pa. witness this Certificate: President Secretary PLEASE READ THIS CERTIFICATE CAREFULLY. THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CONTRACT. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from this Company. A30298NUFIC - NJ 1 DTC101BNJ
    • TABLE OF CONTENTS Schedule............................................................................................................................3 Classification of Eligible Persons .................................................................................3 Insured.........................................................................................................................3 Covered Activities ........................................................................................................3 Insured’s Coverage Effective Date ..............................................................................3 Premium Payments .....................................................................................................3 Benefit Schedule..........................................................................................................3 Definitions ........................................................................................................................10 Insured's Effective and Termination Dates ......................................................................10 Insured Dependent’s Effective and Termination Dates ...................................................10 Premium ..........................................................................................................................11 Benefits............................................................................................................................11 Maximum Amount ......................................................................................................11 Emergency Transportation and Treatment Benefit ....................................................11 In-Hospital Indemnity Daily Benefit ............................................................................12 In-Hospital Indemnity Single Payment Benefit...........................................................12 In-Hospital Indemnity Sickness Daily Benefit ............................................................13 In-Hospital Indemnity Sickness Single Payment Benefit ...........................................14 Physician’s Office Visits Benefit.................................................................................14 Limitations........................................................................................................................14 Limitation on Multiple Covered Activities ...................................................................14 Reduction Schedule...................................................................................................15 Exclusions........................................................................................................................15 Claims Provisions ............................................................................................................15 General Provisions ..........................................................................................................16 A30298NUFIC - NJ 2 DTC101BNJ
    • SCHEDULE CLASSIFICATION OF ELIGIBLE PERSONS: Class 1 All Members of Group Insurance Trust Delaware Class 2 Eligible Spouses of Class I Insureds Class 3 Eligible Dependent Child(ren) of Class 1 Insureds INSURED: Linza Soasa COVERAGE EFFECTIVE DATE: 02/25/2010 PREMIUM PAYMENTS: Monthly Premium: $45.95 COVERED ACTIVITIES: 24 Hour Coverage Benefit Schedule Benefit Maximum Amount Primary Insured Insured Insured Spouse Dependent Child(ren) Emergency Transportation Benefit Maximum Number of Transportation benefits Per Family Per Year: 4 Policy Month in which Injury causing the Emergency Transportation occurs: 1-3 $200.00 $100.00 $40.00 4-6 $205.00 $102.50 $41.00 7-9 $210.00 $105.00 $42.00 10-12 $215.00 $107.50 $43.00 13-15 $220.00 $110.00 $44.00 16-18 $225.00 $112.50 $45.00 19-21 $230.00 $115.00 $46.00 22-24 $235.00 $117.50 $47.00 25-27 $240.00 $120.00 $48.00 28-30 $245.00 $122.50 $49.00 31-33 $250.00 $125.00 $50.00 34-36 $255.00 $127.50 $51.00 37-39 $260.00 $130.00 $52.00 40-42 $265.00 $132.50 $53.00 43-45 $270.00 $135.00 $54.00 46-48 $275.00 $137.50 $55.00 49-51 $280.00 $140.00 $56.00 52-54 $285.00 $142.50 $57.00 55-57 $290.00 $145.00 $58.00 58-60 $295.00 $147.50 $59.00 61-63 $300.00 $150.00 $60.00 64-66 $305.00 $152.50 $61.00 67-69 $310.00 $155.00 $62.00 70-72 $315.00 $157.50 $63.00 73-75 $320.00 $160.00 $64.00 76-78 $325.00 $162.50 $65.00 79-81 $330.00 $165.00 $66.00 82-84 $335.00 $167.50 $67.00 85-87 $340.00 $170.00 $68.00 88-90 $345.00 $172.50 $69.00 91-93 $350.00 $175.00 $70.00 94-96 $355.00 $177.50 $71.00 97-99 $360.00 $180.00 $72.00 100-102 $365.00 $182.50 $73.00 103-105 $370.00 $185.00 $74.00 106-108 $375.00 $187.50 $75.00 109-111 $380.00 $190.00 $76.00 112-114 $385.00 $192.50 $77.00 115-117 $390.00 $195.00 $78.00 118-120 $395.00 $197.50 $79.00 120+ $400.00 $200.00 $80.00 A30298NUFIC - NJ 3 DTC101BNJ
    • Emergency Treatment Benefit Maximum Number of Visits Per Family Per Year: 6 Policy Month in which Injury causing the Emergency Treatment occurs: 1-3 $300.00 $150.00 $60.00 4-6 $307.50 $153.75 $61.50 7-9 $315.00 $157.50 $63.00 10-12 $322.50 $161.25 $64.50 13-15 $330.00 $165.00 $66.00 16-18 $337.50 $168.75 $67.50 19-21 $345.00 $172.50 $69.00 22-24 $352.50 $176.25 $70.50 25-27 $360.00 $180.00 $72.00 28-30 $367.50 $183.75 $73.50 31-33 $375.00 $187.50 $75.00 34-36 $382.50 $191.25 $76.50 37-39 $390.00 $195.00 $78.00 40-42 $397.50 $198.75 $79.50 43-45 $405.00 $202.50 $81.00 46-48 $412.50 $206.25 $82.50 49-51 $420.00 $210.00 $84.00 52-54 $427.50 $213.75 $85.50 55-57 $435.00 $217.50 $87.00 58-60 $442.50 $221.25 $88.50 61-63 $450.00 $225.00 $90.00 64-66 $457.50 $228.75 $91.50 67-69 $465.00 $232.50 $93.00 70-72 $472.50 $236.25 $94.50 73-75 $480.00 $240.00 $96.00 76-78 $487.50 $243.75 $97.50 79-81 $495.00 $247.50 $99.00 82-84 $502.50 $251.25 $100.50 85-87 $510.00 $255.00 $102.00 88-90 $517.50 $258.75 $103.50 91-93 $525.00 $262.50 $105.00 94-96 $532.50 $266.25 $106.50 97-99 $540.00 $270.00 $108.00 100-102 $547.50 $273.75 $109.50 103-105 $555.00 $277.50 $111.00 106-108 $562.50 $281.25 $112.50 109-111 $570.00 $285.00 $114.00 112-114 $577.50 $288.75 $115.50 115-117 $585.00 $292.50 $117.00 118-120 $592.50 $296.25 $118.50 120+ $600.00 $300.00 $120.00 In-Hospital Indemnity Daily Benefit (Maximum Number of Days: 365) Policy Month in which Injury causing Hospitalization occurs: 1-3 $400.00 $200.00 $80.00 4-6 $410.00 $205.00 $82.00 7-9 $420.00 $210.00 $84.00 10-12 $430.00 $215.00 $86.00 13-15 $440.00 $220.00 $88.00 16-18 $450.00 $225.00 $90.00 19-21 $460.00 $230.00 $92.00 22-24 $470.00 $235.00 $94.00 25-27 $480.00 $240.00 $96.00 28-30 $490.00 $245.00 $98.00 31-33 $500.00 $250.00 $100.00 34-36 $510.00 $255.00 $102.00 37-39 $520.00 $260.00 $104.00 40-42 $530.00 $265.00 $106.00 A30298NUFIC - NJ 4 DTC101BNJ
    • 43-45 $540.00 $270.00 $108.00 46-48 $550.00 $275.00 $110.00 49-51 $560.00 $280.00 $112.00 52-54 $570.00 $285.00 $114.00 55-57 $580.00 $290.00 $116.00 58-60 $590.00 $295.00 $118.00 61-63 $600.00 $300.00 $120.00 64-66 $610.00 $305.00 $122.00 67-69 $620.00 $310.00 $124.00 70-72 $630.00 $315.00 $126.00 73-75 $640.00 $320.00 $128.00 76-78 $650.00 $325.00 $130.00 79-81 $660.00 $330.00 $132.00 82-84 $670.00 $335.00 $134.00 85-87 $680.00 $340.00 $136.00 88-90 $690.00 $345.00 $138.00 91-93 $700.00 $350.00 $140.00 94-96 $710.00 $355.00 $142.00 97-99 $720.00 $360.00 $144.00 100-102 $730.00 $365.00 $146.00 103-105 $740.00 $370.00 $148.00 106-108 $750.00 $375.00 $150.00 109-111 $760.00 $380.00 $152.00 112-114 $770.00 $385.00 $154.00 115-117 $780.00 $390.00 $156.00 118-120 $790.00 $395.00 $158.00 120+ $800.00 $400.00 $160.00 In-Hospital Indemnity Single Payment Benefit Days of Confinement: 30 Days Policy Month in which Injury causing Hospitalization occurs: 1-3 $5,000.00 $2,500.00 $1,000.00 4-6 $5,125.00 $2,562.50 $1,025.00 7-9 $5,250.00 $2,625.00 $1,050.00 10-12 $5,375.00 $2,687.50 $1,075.00 13-15 $5,500.00 $2,750.00 $1,100.00 16-18 $5,625.00 $2,812.50 $1,125.00 19-21 $5,750.00 $2,875.00 $1,150.00 22-24 $5,875.00 $2,937.50 $1,175.00 25-27 $6,000.00 $3,000.00 $1,200.00 28-30 $6,125.00 $3,062.50 $1,225.00 31-33 $6,250.00 $3,125.00 $1,250.00 34-36 $6,375.00 $3,187.50 $1,275.00 37-39 $6,500.00 $3,250.00 $1,300.00 40-42 $6,625.00 $3,312.50 $1,325.00 43-45 $6,750.00 $3,375.00 $1,350.00 46-48 $6,875.00 $3,437.50 $1,375.00 49-51 $7,000.00 $3,500.00 $1,400.00 52-54 $7,125.00 $3,562.50 $1,425.00 55-57 $7,250.00 $3,625.00 $1,450.00 58-60 $7,375.00 $3,687.50 $1,475.00 61-63 $7,500.00 $3,750.00 $1,500.00 64-66 $7,625.00 $3,812.50 $1,525.00 67-69 $7,750.00 $3,875.00 $1,550.00 70-72 $7,875.00 $3,937.50 $1,575.00 73-75 $8,000.00 $4,000.00 $1,600.00 76-78 $8,125.00 $4,062.50 $1,625.00 79-81 $8,250.00 $4,125.00 $1,650.00 82-84 $8,375.00 $4,187.50 $1,675.00 85-87 $8,500.00 $4,250.00 $1,700.00 88-90 $8,625.00 $4,312.50 $1,725.00 91-93 $8,750.00 $4,375.00 $1,750.00 A30298NUFIC - NJ 5 DTC101BNJ
    • 94-96 $8,875.00 $4,437.50 $1,775.00 97-99 $9,000.00 $4,500.00 $1,800.00 100-102 $9,125.00 $4,562.50 $1,825.00 103-105 $9,250.00 $4,625.00 $1,850.00 106-108 $9,375.00 $4,687.50 $1,875.00 109-111 $9,500.00 $4,750.00 $1,900.00 112-114 $9,625.00 $4,812.50 $1,925.00 115-117 $9,750.00 $4,875.00 $1,950.00 118-120 $9,875.00 $4,937.50 $1,975.00 120+ $10,000.00 $5,000.00 $2,000.00 In-Hospital Indemnity Single Payment Benefit Days of Confinement: 60 Days Policy Month in which Injury causing Hospitalization occurs: 1-3 $5,000.00 $2,500.00 $1,000.00 4-6 $5,125.00 $2,562.50 $1,025.00 7-9 $5,250.00 $2,625.00 $1,050.00 10-12 $5,375.00 $2,687.50 $1,075.00 13-15 $5,500.00 $2,750.00 $1,100.00 16-18 $5,625.00 $2,812.50 $1,125.00 19-21 $5,750.00 $2,875.00 $1,150.00 22-24 $5,875.00 $2,937.50 $1,175.00 25-27 $6,000.00 $3,000.00 $1,200.00 28-30 $6,125.00 $3,062.50 $1,225.00 31-33 $6,250.00 $3,125.00 $1,250.00 34-36 $6,375.00 $3,187.50 $1,275.00 37-39 $6,500.00 $3,250.00 $1,300.00 40-42 $6,625.00 $3,312.50 $1,325.00 43-45 $6,750.00 $3,375.00 $1,350.00 46-48 $6,875.00 $3,437.50 $1,375.00 49-51 $7,000.00 $3,500.00 $1,400.00 52-54 $7,125.00 $3,562.50 $1,425.00 55-57 $7,250.00 $3,625.00 $1,450.00 58-60 $7,375.00 $3,687.50 $1,475.00 61-63 $7,500.00 $3,750.00 $1,500.00 64-66 $7,625.00 $3,812.50 $1,525.00 67-69 $7,750.00 $3,875.00 $1,550.00 70-72 $7,875.00 $3,937.50 $1,575.00 73-75 $8,000.00 $4,000.00 $1,600.00 76-78 $8,125.00 $4,062.50 $1,625.00 79-81 $8,250.00 $4,125.00 $1,650.00 82-84 $8,375.00 $4,187.50 $1,675.00 85-87 $8,500.00 $4,250.00 $1,700.00 88-90 $8,625.00 $4,312.50 $1,725.00 91-93 $8,750.00 $4,375.00 $1,750.00 94-96 $8,875.00 $4,437.50 $1,775.00 97-99 $9,000.00 $4,500.00 $1,800.00 100-102 $9,125.00 $4,562.50 $1,825.00 103-105 $9,250.00 $4,625.00 $1,850.00 106-108 $9,375.00 $4,687.50 $1,875.00 109-111 $9,500.00 $4,750.00 $1,900.00 112-114 $9,625.00 $4,812.50 $1,925.00 115-117 $9,750.00 $4,875.00 $1,950.00 118-120 $9,875.00 $4,937.50 $1,975.00 120+ $10,000.00 $5,000.00 $2,000.00 In-Hospital Indemnity Sickness Daily Benefit (Maximum Number of Days: 365) Policy Month in which Sickness causing Hospitalization occurs: 1-3 $200.00 $100.00 $40.00 4-6 $205.00 $102.50 $41.00 7-9 $210.00 $105.00 $42.00 10-12 $215.00 $107.50 $43.00 A30298NUFIC - NJ 6 DTC101BNJ
    • 13-15 $220.00 $110.00 $44.00 16-18 $225.00 $112.50 $45.00 19-21 $230.00 $115.00 $46.00 22-24 $235.00 $117.50 $47.00 25-27 $240.00 $120.00 $48.00 28-30 $245.00 $122.50 $49.00 31-33 $250.00 $125.00 $50.00 34-36 $255.00 $127.50 $51.00 37-39 $260.00 $130.00 $52.00 40-42 $265.00 $132.50 $53.00 43-45 $270.00 $135.00 $54.00 46-48 $275.00 $137.50 $55.00 49-51 $280.00 $140.00 $56.00 52-54 $285.00 $142.50 $57.00 55-57 $290.00 $145.00 $58.00 58-60 $295.00 $147.50 $59.00 61-63 $300.00 $150.00 $60.00 64-66 $305.00 $152.50 $61.00 67-69 $310.00 $155.00 $62.00 70-72 $315.00 $157.50 $63.00 73-75 $320.00 $160.00 $64.00 76-78 $325.00 $162.50 $65.00 79-81 $330.00 $165.00 $66.00 82-84 $335.00 $167.50 $67.00 85-87 $340.00 $170.00 $68.00 88-90 $345.00 $172.50 $69.00 91-93 $350.00 $175.00 $70.00 94-96 $355.00 $177.50 $71.00 97-99 $360.00 $180.00 $72.00 100-102 $365.00 $182.50 $73.00 103-105 $370.00 $185.00 $74.00 106-108 $375.00 $187.50 $75.00 109-111 $380.00 $190.00 $76.00 112-114 $385.00 $192.50 $77.00 115-117 $390.00 $195.00 $78.00 118-120 $395.00 $197.50 $79.00 120+ $400.00 $200.00 $80.00 In-Hospital Indemnity Sickness Single Payment Benefit Payable only once during the lifetime of the Insured Person Days of Confinement: 30 Days Policy Month in which Sickness causing Hospitalization occurs: 1-3 $5,000.00 $2,500.00 $1,000.00 4-6 $5,125.00 $2,562.50 $1,025.00 7-9 $5,250.00 $2,625.00 $1,050.00 10-12 $5,375.00 $2,687.50 $1,075.00 13-15 $5,500.00 $2,750.00 $1,100.00 16-18 $5,625.00 $2,812.50 $1,125.00 19-21 $5,750.00 $2,875.00 $1,150.00 22-24 $5,875.00 $2,937.50 $1,175.00 25-27 $6,000.00 $3,000.00 $1,200.00 28-30 $6,125.00 $3,062.50 $1,225.00 31-33 $6,250.00 $3,125.00 $1,250.00 34-36 $6,375.00 $3,187.50 $1,275.00 37-39 $6,500.00 $3,250.00 $1,300.00 40-42 $6,625.00 $3,312.50 $1,325.00 43-45 $6,750.00 $3,375.00 $1,350.00 46-48 $6,875.00 $3,437.50 $1,375.00 49-51 $7,000.00 $3,500.00 $1,400.00 52-54 $7,125.00 $3,562.50 $1,425.00 55-57 $7,250.00 $3,625.00 $1,450.00 58-60 $7,375.00 $3,687.50 $1,475.00 61-63 $7,500.00 $3,750.00 $1,500.00 A30298NUFIC - NJ 7 DTC101BNJ
    • 64-66 $7,625.00 $3,812.50 $1,525.00 67-69 $7,750.00 $3,875.00 $1,550.00 70-72 $7,875.00 $3,937.50 $1,575.00 73-75 $8,000.00 $4,000.00 $1,600.00 76-78 $8,125.00 $4,062.50 $1,625.00 79-81 $8,250.00 $4,125.00 $1,650.00 82-84 $8,375.00 $4,187.50 $1,675.00 85-87 $8,500.00 $4,250.00 $1,700.00 88-90 $8,625.00 $4,312.50 $1,725.00 91-93 $8,750.00 $4,375.00 $1,750.00 94-96 $8,875.00 $4,437.50 $1,775.00 97-99 $9,000.00 $4,500.00 $1,800.00 100-102 $9,125.00 $4,562.50 $1,825.00 103-105 $9,250.00 $4,625.00 $1,850.00 106-108 $9,375.00 $4,687.50 $1,875.00 109-111 $9,500.00 $4,750.00 $1,900.00 112-114 $9,625.00 $4,812.50 $1,925.00 115-117 $9,750.00 $4,875.00 $1,950.00 118-120 $9,875.00 $4,937.50 $1,975.00 120+ $10,000.00 $5,000.00 $2,000.00 In-Hospital Indemnity Sickness Single Payment Benefit Payable only once during the lifetime of the Insured Person Days of Confinement: 60 Days Policy Month in which Sickness causing Hospitalization occurs: 1-3 $5,000.00 $2,500.00 $1,000.00 4-6 $5,125.00 $2,562.50 $1,025.00 7-9 $5,250.00 $2,625.00 $1,050.00 10-12 $5,375.00 $2,687.50 $1,075.00 13-15 $5,500.00 $2,750.00 $1,100.00 16-18 $5,625.00 $2,812.50 $1,125.00 19-21 $5,750.00 $2,875.00 $1,150.00 22-24 $5,875.00 $2,937.50 $1,175.00 25-27 $6,000.00 $3,000.00 $1,200.00 28-30 $6,125.00 $3,062.50 $1,225.00 31-33 $6,250.00 $3,125.00 $1,250.00 34-36 $6,375.00 $3,187.50 $1,275.00 37-39 $6,500.00 $3,250.00 $1,300.00 40-42 $6,625.00 $3,312.50 $1,325.00 43-45 $6,750.00 $3,375.00 $1,350.00 46-48 $6,875.00 $3,437.50 $1,375.00 49-51 $7,000.00 $3,500.00 $1,400.00 52-54 $7,125.00 $3,562.50 $1,425.00 55-57 $7,250.00 $3,625.00 $1,450.00 58-60 $7,375.00 $3,687.50 $1,475.00 61-63 $7,500.00 $3,750.00 $1,500.00 64-66 $7,625.00 $3,812.50 $1,525.00 67-69 $7,750.00 $3,875.00 $1,550.00 70-72 $7,875.00 $3,937.50 $1,575.00 73-75 $8,000.00 $4,000.00 $1,600.00 76-78 $8,125.00 $4,062.50 $1,625.00 79-81 $8,250.00 $4,125.00 $1,650.00 82-84 $8,375.00 $4,187.50 $1,675.00 85-87 $8,500.00 $4,250.00 $1,700.00 88-90 $8,625.00 $4,312.50 $1,725.00 91-93 $8,750.00 $4,375.00 $1,750.00 94-96 $8,875.00 $4,437.50 $1,775.00 97-99 $9,000.00 $4,500.00 $1,800.00 100-102 $9,125.00 $4,562.50 $1,825.00 103-105 $9,250.00 $4,625.00 $1,850.00 106-108 $9,375.00 $4,687.50 $1,875.00 109-111 $9,500.00 $4,750.00 $1,900.00 112-114 $9,625.00 $4,812.50 $1,925.00 A30298NUFIC - NJ 8 DTC101BNJ
    • 115-117 $9,750.00 $4,875.00 $1,950.00 118-120 $9,875.00 $4,937.50 $1,975.00 120+ $10,000.00 $5,000.00 $2,000.00 Physician’s Office Visits Benefit Maximum Number of Visits Per Family: Months 1 to 36: 5 Visits Maximum Number of Visits Per Family: Months 37+: 8 Visits Maximum Number of Visits Per Calendar Quarter Per Family: 2 Policy Month in which Physician’s Office Visits occurs: 1-3 $50.00 $50.00 $50.00 4-6 $50.00 $50.00 $50.00 7-9 $50.00 $50.00 $50.00 10-12 $50.00 $50.00 $50.00 13-15 $50.00 $50.00 $50.00 16-18 $50.00 $50.00 $50.00 19-21 $50.00 $50.00 $50.00 22-24 $50.00 $50.00 $50.00 25-27 $50.00 $50.00 $50.00 28-30 $50.00 $50.00 $50.00 31-33 $50.00 $50.00 $50.00 34-36 $50.00 $50.00 $50.00 37-39 $50.00 $50.00 $50.00 40-42 $50.00 $50.00 $50.00 43-45 $50.00 $50.00 $50.00 46-48 $50.00 $50.00 $50.00 49-51 $50.00 $50.00 $50.00 52-54 $50.00 $50.00 $50.00 55-57 $50.00 $50.00 $50.00 58-60 $50.00 $50.00 $50.00 61-63 $50.00 $50.00 $50.00 64-66 $50.00 $50.00 $50.00 67-69 $50.00 $50.00 $50.00 70-72 $50.00 $50.00 $50.00 73-75 $50.00 $50.00 $50.00 76-78 $50.00 $50.00 $50.00 79-81 $50.00 $50.00 $50.00 82-84 $50.00 $50.00 $50.00 85-87 $50.00 $50.00 $50.00 88-90 $50.00 $50.00 $50.00 91-93 $50.00 $50.00 $50.00 94-96 $50.00 $50.00 $50.00 97-99 $50.00 $50.00 $50.00 100-102 $50.00 $50.00 $50.00 103-105 $50.00 $50.00 $50.00 106-108 $50.00 $50.00 $50.00 109-111 $50.00 $50.00 $50.00 112-114 $50.00 $50.00 $50.00 115-117 $50.00 $50.00 $50.00 118-120 $50.00 $50.00 $50.00 120+ $50.00 $50.00 $50.00 The Maximum Amounts are used to determine amounts payable under each Benefit. Actual amounts payable will not exceed the maximums, and may be less than the maximums under circumstances specified in this Certificate. The Maximum Amounts specified above for an Insured Person who is age 70 or older on the date of an accident for which benefits are payable, except the Physician’s Office Visits Indemnity Benefit, will be reduced by 50%. A30298NUFIC - NJ 9 DTC101BNJ
    • DEFINITIONS covered under the Policy solely as an Insured Dependent. Any capitalized terms in this Certificate and any riders, endorsements, or other attached papers are to be given Insured Dependent – means Your Insured Spouse or the meanings as ascribed in this section or as later Insured Dependent Child. defined. Insured Dependent Child - means Your Eligible Age - means the age of the Insured Person on the Dependent Child: (1) whom You have elected to cover Insured Person's most recent birthday, regardless of the under the Policy; (2) for whom premium has been paid actual time of birth. when due; and (3) while covered under the Policy. Covered Activity (ies) - means those activities set out Insured Person – means the Insured or an Insured in the Covered Activities section of the Schedule with Dependent. respect to which Insured Persons are provided accident insurance under the Policy. Insured Spouse – means Your Eligible Spouse; (1) whom You have elected to cover under the Policy; (2) Eligible Spouse – means Your legal spouse. for whom premium has been paid when due; and (3) while covered under the Policy. Eligible Dependent – means an Eligible Spouse or Eligible Dependent Child. Physician - means a licensed practitioner of the healing arts acting within the scope of his or her license who is Eligible Dependent Child – means Your unmarried not: 1) the Insured Person; 2) an Immediate Family child(ren), including natural, step, foster or adopted Member; or 3) retained by the Policyholder. children from the moment of placement in Your home, under age 19 ( 23 if attending an accredited institution You, Your – means the Insured. of higher learning on a full time basis) and primarily dependent on You for support and maintenance. If the INSURED'S EFFECTIVE AND TERMINATION DATES Insured has a court order to provide coverage under the Policy to a child, the amount of support contributed by Effective Date. Your coverage under the Policy begins the Insured for such child will not be used to determine on the latest of: (1) the Policy Effective Date; (2) the whether or not such child is an “eligible dependent date for which the first premium for Your coverage is child.” paid when due; (3) the date You become a member of an eligible class of persons, as described in the Immediate Family Member - means a person who is Classification of Eligible Persons section of the related to the Insured Person in any of the following Schedule; (4) if individual enrollment is required, the ways: spouse, brother-in-law, sister-in-law, son-in-law, date enrollment is received. daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), grandparent, brother or sister Termination Date. Your coverage under the Policy ends (includes stepbrother or stepsister), or child (includes on the earliest of: (1) the date the Policy is terminated legally adopted or stepchild). (unless the Company and the Policyholder agree, in writing, to permit coverage to continue to the end of the Injury - means bodily injury: (1) which is sustained as a period for which premiums have been paid in lieu of a direct result of an unintended, unanticipated accident return of unearned premiums); (2) the premium due date that is external to the body and that occurs while the if premiums are not paid when due; (3) the date You injured person's coverage under the Policy is in force; cease to be a member of any eligible class(es) of (2) which directly (independent of sickness, disease, persons, as described in the Classification of Eligible mental incapacity, bodily infirmity or any other cause) Persons section of the Schedule; (4) the date You causes a covered loss; and (3) which occurs while such request that Your coverage be terminated; or (5) the person is participating in a Covered Activity. date You attain Age 85. Insured - means a person: (1) who is a member of an Termination of coverage will not affect a claim for a eligible class of persons as described in the covered loss that occurred while Your coverage was in Classification of Eligible Persons section of the force under the Policy. Schedule; (2) for whom premium has been paid when due; (3) while covered under the Policy; and (4) who has INSURED DEPENDENT’S EFFECTIVE AND enrolled for coverage under the Policy, if required. TERMINATION DATES However, an Insured does not include any person 10 DTC101BNJ
    • Effective Date. Your Eligible Dependent’s coverage Person’s class in the Benefit Schedule, subject to the under the Policy begins on the latest of: (1) the date Reduction Schedule shown in the Limitations section. Your coverage under the Policy begins, (2) the date the first premium for the Eligible Dependent’s coverage is paid when due; (3) the date the person becomes an Eligible Dependent; or 4) if individual enrollment is Emergency Transportation and Treatment Benefit required, the date Your enrollment is received. Emergency Transportation Benefit. If an Insured Termination Date. An Insured Dependent’s coverage Person suffers an Injury that requires Emergency under the Policy ends on the earliest of: (1) the date Treatment within 24 hours of the date of the accident Your coverage under the Policy ends; (2) the premium that caused the Injury and it is determined that it is due date if premiums for the Insured Dependent are not Medically Necessary that such Insured Person be paid when due; (3) the date You request that coverage transported to a Hospital or a Satellite Emergency for the Insured Dependent be terminated; or (4) the date Center by Ambulance, the Company will pay 100% of the Insured Dependent ceases to meet the definition of the Emergency Transportation Maximum Amount shown an Eligible Dependent. in the Benefit Schedule. Only one Emergency Transportation Benefit is payable for any one accident Termination of coverage will not affect a claim for a per Insured Person. The maximum number of covered loss that occurred while the Insured Emergency Transportation Benefits payable per Dependent’s coverage was in force under the Policy. calendar year per Insured Person regardless of the number of accidents incurred, is shown in the Benefit PREMIUM Schedule. Premiums. The Company provides insurance in return Emergency Treatment Benefit. If an Insured Person for premium payments. The premium shown in the suffers an Injury that, within 24 hours of the date of the Schedule is payable to the Company in the manner accident that caused the Injury, requires him or her to described in the Schedule. The Company may change receive Medically Necessary Emergency Treatment in a the required premiums due by giving the Policyholder at Hospital emergency room or a Satellite Emergency least 31 days advance written notice. The Company Center, the Company will pay 100% Emergency may also change the required premiums at any time Treatment Benefit Maximum Amount shown in the when any coverage change affecting premiums is made Benefit Schedule. Only one Emergency Treatment in the Policy. Benefit is payable for any one accident per Insured Person. The maximum number of Emergency Treatment Grace Period. A Grace Period of 31 days will be Benefits payable per calendar year per Insured Person provided for the payment of any premium due after the regardless of the number of accidents incurred, is shown first. An Insured Person’s coverage will not be in the Benefit Schedule. terminated for nonpayment of premium during the Grace Period if all premiums due are paid by the last day of the Definitions Grace Period. An Insured Person’s coverage will terminate on the last day of the period for which all Ambulance – means any publicly or privately owned premiums have been paid if all premiums due are not surface, water or air vehicle, including a helicopter, that paid by the last day of the Grace Period. is specifically designed and constructed or modified and equipped to be used, maintained or operated primarily If the Company expressly agrees to accept late payment for the transportation of individuals who are sick, injured of a premium without terminating coverage under the or wounded. Ambulance does not include a surface, Policy, the Company does so in accordance with the water or air vehicle that is owned and operated to Noncompliance with Policy Requirements provision of accommodate an incapacitated or disabled person who the General Provisions section. does not require medical monitoring, care or treatment during transport. No Grace Period will be provided if the Company receives notice to terminate the Insured Person’s Emergency Treatment – means treatment for a medical coverage under the Policy prior to a premium due date. condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a BENEFITS prudent layperson with average knowledge of health and medicine could reasonably expect the absence of Maximum Amount. As applicable to each Benefit immediate medical attention to result in: provided by the Policy for each Insured Person, 1. Placing the health of the person (or with respect to a Maximum Amount means the amount shown as the pregnant woman, the health of her unborn child) in maximum amount for that Benefit for the Insured serious jeopardy; 2. Serious impairment to bodily functions; or 11 DTC101BNJ
    • 3. Serious dysfunction of any bodily organ or part. Day(s) of Confinement - means a day of Hospital confinement as an Inpatient. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured Hospital - means a facility which: (1) is operated and sick people; (2) has organized facilities for diagnosis according to law for the care and treatment of injured and surgery on its premises or in facilities available to it and sick people; (2) has organized facilities for diagnosis on a prearranged basis; (3) has 24 hour nursing service and surgery on its premises or in facilities available to it by registered nurses (R.N.’s); and (4) is supervised by on a prearranged basis; (3) has 24 hour nursing service one or more Physicians. A Hospital does not include: by registered nurses (R.N.’s); and (4) is supervised by (1) a nursing, convalescent or geriatric unit of a hospital one or more Physicians. A Hospital does not include: when a patient is confined mainly to receive nursing (1) a nursing, convalescent or geriatric unit of a hospital care; or (2) a facility that is, other than incidentally, a rest when a patient is confined mainly to receive nursing home, nursing home, convalescent home or home for care; or (2) a facility which is, other than incidentally, a the aged; nor does it include any ward room, wing, or rest home, nursing home, convalescent home or home other section of the hospital that is used for such for the aged; nor does it include any ward room, wing, or purposes. other section of the hospital that is used for such purposes. Medically Necessary – means an Emergency Treatment or Transportation is: (1) essential for the Inpatient - means a person: (1) who is confined in a diagnosis, treatment and care of the Injury; (2) meets Hospital as a registered bed patient; and (2) for whom at generally accepted standards of medical practice; (3) is least one day's room and board is charged by the ordered by a Physician and performed under the Hospital unless the Insured Person is confined as an Physician’s care, supervision or order; or (4) with regard Inpatient in any military, veterans or other government to Emergency Transportation, is subsequently supported or sponsored Hospital for which a charge for authorized by a Physician as appropriate due to the room and board is not made. nature of the Injury. Medically Necessary – means that confinement as an Satellite Emergency Center - means a licensed facility In-patient in a Hospital is (1) essential for the diagnosis, providing outpatient care under the direction of a treatment and care of the Injury; (2) in accordance with Physician on a 24 hour basis. Available services must generally accepted standards of medical practice; and include: (1) diagnostic care, including laboratory services (3) ordered by a Physician. and diagnostic x-rays; and (2) treatment or medical care, including availability of the means for stabilization of Period of Confinement - means a period of emergency medical conditions. A Satellite Emergency consecutive Days of Confinement as an Inpatient for all Center does not include a Hospital or an office Injuries caused by the same accident. However, maintained by a Physician for the practice of medicine or successive confinements as an Inpatient for all Injuries dentistry. caused by the same accident are considered to be part of the same Period of Confinement, unless the In-Hospital Indemnity Daily Benefit discharge date for the prior confinement is separated from the admission date for the next confinement by at If an Insured Person suffers an Injury that, within 90 least 60 days. days of the date of the accident that caused the Injury, requires him or her to be confined in a Hospital as an In-Hospital Indemnity Single Payment Benefit Inpatient, the Company will pay a benefit after 1 Day of Medically Necessary Confinement due to that Injury, If an Insured Person suffers an Injury that, within 90 retroactive to the first Day of Confinement. No benefit is days of the date of the accident that caused the Injury, provided for any Day(s) of Confinement that are not requires him or her to be confined in a Hospital as an Medically Necessary. The amount of the benefit is equal Inpatient, the Company will pay a benefit after 30 to 100% of the Daily Maximum Amount shown for the In- consecutive Day(s) of Medically Necessary Confinement Hospital Indemnity Daily Benefit in the Benefit Schedule due to that Injury. No benefit is provided if the Insured per day of Medically Necessary Inpatient confinement Person is confined for less than 30 consecutive due to that Injury. It is payable monthly up to the Medically Necessary Days of Confinement. The amount Maximum Number of Days shown for the In-Hospital of the benefit is equal to 100% of the Maximum Amount Indemnity Daily Benefit in the Benefit Schedule during shown for the In-Hospital Indemnity Single Payment any one Period of Confinement. Only one benefit is Benefit in the Benefit Schedule. Only one benefit is provided for any one Day of Confinement, regardless of provided for any one accident per Insured Person the number of Injuries for which the confinement is regardless of the number of Injuries for which the required. confinement is required or the number of times the Insured Person must be confined due to Injuries resulting from the same accident. 12 DTC101BNJ
    • provided for any Day(s) of Confinement that are not If an Insured Person suffers an Injury that, within 90 Medically Necessary. The amount of the benefit is equal days of the date of the accident that caused the Injury, to 100% of the In-Hospital Indemnity Sickness Daily requires him or her to be confined in a Hospital as an Benefit shown in the Benefit Schedule per day of Inpatient, the Company will pay a benefit after 60 Medically Necessary Inpatient confinement due to that consecutive Day(s) of Medically Necessary Confinement Sickness. The benefit is payable monthly up to the due to that Injury. No benefit is provided if the Insured Maximum Number of Days shown for the In-Hospital Person is confined for less than 60 consecutive Indemnity Sickness Daily Benefit in the Benefit Schedule Medically Necessary Days of Confinement. The amount during any one Period of Confinement. Only one benefit of the benefit is equal to 100% of the Maximum Amount is provided for any one Day of Confinement, regardless shown for the In-Hospital Indemnity Single Payment of the number of Sicknesses for which the confinement Benefit in the Benefit Schedule. Only one benefit is is required. provided for any one accident per Insured Person regardless of the number of Injuries for which the Day(s) of Confinement - means a day of Hospital confinement is required or the number of times the confinement as an Inpatient. Insured Person must be confined due to Injuries resulting from the same accident. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured Day(s) of Confinement - means a day of Hospital and sick people; (2) has organized facilities for diagnosis confinement as an Inpatient. and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service Hospital - means a facility which: (1) is operated by registered nurses (R.N.’s); and (4) is supervised by according to law for the care and treatment of injured one or more Physicians. A Hospital does not include: and sick people; (2) has organized facilities for diagnosis (1) a nursing, convalescent or geriatric unit of a hospital and surgery on its premises or in facilities available to it when a patient is confined mainly to receive nursing on a prearranged basis; (3) has 24 hour nursing service care; or (2) a facility which is, other than incidentally, a by registered nurses (R.N.’s); and (4) is supervised by rest home, nursing home, convalescent home or home one or more Physicians. A Hospital does not include: for the aged; nor does it include any ward room, wing, or (1) a nursing, convalescent or geriatric unit of a hospital other section of the hospital that is used for such when a patient is confined mainly to receive nursing purposes. care; or (2) a facility which is, other than incidentally, a rest home, nursing home, convalescent home or home Inpatient - means a person: (1) who is confined in a for the aged; nor does it include any ward room, wing, or Hospital as a registered bed patient; and (2) for whom at other section of the hospital that is used for such least one day's room and board is charged by the purposes. Hospital unless the Insured Person is confined as an Inpatient in any military, veterans or other government Inpatient - means a person: (1) who is confined in a supported or sponsored Hospital for which a charge for Hospital as a registered bed patient; and (2) for whom at room and board is not made. least one day's room and board is charged by the Hospital unless the Insured Person is confined as an Medically Necessary – means that confinement as an Inpatient in any military, veterans or other government In-patient in a Hospital is (1) essential for the diagnosis, supported or sponsored Hospital for which a charge for treatment and care of the Sickness; (2) in accordance room and board is not made. with generally accepted standards of medical practice; and (3) ordered by a Physician. Medically Necessary – means that confinement as an In-patient in a Hospital is (1) essential for the diagnosis, Period of Confinement - means a period of treatment and care of the Injury; (2) in accordance with consecutive Days of Confinement as an Inpatient for the generally accepted standards of medical practice; and same Sickness. However, successive confinements as (3) ordered by a Physician. an Inpatient for the same Sickness are considered to be part of the same Period of Confinement, unless the In-Hospital Indemnity Sickness Daily Benefit discharge date for the prior confinement is separated Not applicable to Insured Persons Age 75 or older from the admission date for the next confinement by at least 60 days. If, after an Insured Person has been covered under the Policy for at least 0 consecutive months and that Insured If the same Insured Person is again confined due to the Person suffers a Sickness that requires him or her to be same Sickness or a new Sickness and such successive confined in a Hospital as an Inpatient, the Company will confinement is separated from the admission date for pay a benefit after 3 consecutive Day(s) of Medically the first confinement by at least 60 days and the Insured Necessary Confinement due to that Sickness, Person has not been paid the Maximum Number of retroactive to the first Day of Confinement. No benefit is Days shown in the In-Hospital Indemnity Sickness Daily 13 DTC101BNJ
    • Benefit for previous Medically Necessary Days of and sick people; (2) has organized facilities for diagnosis Confinement, benefits will continue to be payable under and surgery on its premises or in facilities available to it this benefit for the same Sickness or a new Sickness in on a prearranged basis; (3) has 24 hour nursing service accordance with the requirements specified above until by registered nurses (R.N.’s); and (4) is supervised by the Maximum Number of Days shown in the In-Hospital one or more Physicians. A Hospital does not include: Indemnity Sickness Daily Benefit in the Benefit (1) a nursing, convalescent or geriatric unit of a hospital Scheduled have been paid for that Insured Person. when a patient is confined mainly to receive nursing Once the maximum has been reached, no benefits are care; or (2) a facility which is, other than incidentally, a payable for any additional confinements due to Sickness rest home, nursing home, convalescent home or home for the lifetime of the Insured Person. for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such Sickness – means an illness or disease which is purposes. diagnosed or treated by a Physician after the effective date of coverage under this Policy. Inpatient - means a person: (1) who is confined in a Hospital as a registered bed patient; and (2) for whom at Any exclusion within the Exclusions section regarding least one day's room and board is charged by the sickness or disease; stroke or cerebrovascular accident Hospital unless the Insured Person is confined as an or event; cardiovascular accident or event; myocardial Inpatient in any military, veterans or other government infarction or heart attack; coronary thrombosis or supported or sponsored Hospital for which a charge for aneurysm is hereby waived for this benefit. room and board is not made. In-Hospital Indemnity Sickness Single Payment Medically Necessary – means that confinement as an Benefit In-patient in a Hospital is (1) essential for the diagnosis, Not applicable to Insured Persons Age 75 or older treatment and care of the Sickness; (2) in accordance with generally accepted standards of medical practice; If, after an Insured Person has been covered under the and (3) ordered by a Physician. Policy for at least 0 consecutive months and that Insured Person suffers a Sickness that requires him or her to be Sickness – means an illness or disease which is confined in a Hospital as an Inpatient, the Company will diagnosed or treated by a Physician after the effective pay a benefit after 30 consecutive Day(s) of Medically date of coverage under this Policy. Necessary Confinement due to that Sickness. No benefit is provided if the Insured Person is confined for less than Any exclusion within the Exclusions section regarding 30 consecutive Medically Necessary Days of sickness or disease; stroke or cerebrovascular accident Confinement. The amount of the benefit is equal to or event; cardiovascular accident or event; myocardial 100% of the Maximum Amount shown for the In-Hospital infarction or heart attack; coronary thrombosis or Indemnity Sickness Single Payment Benefit in the aneurysm is hereby waived for this benefit. Benefit Schedule. The maximum number of In-Hospital Indemnity Sickness Single Payment Benefits payable is Physician’s Office Visits Indemnity Benefit shown in the Benefit schedule. If the Insured visits a Physician’s office for treatment of If, after an Insured Person has been covered under the Routine Well Care, an Injury or Sickness while the Policy for at least 0 consecutive months and that Insured Insured’s coverage under this Benefit is in force, the Person suffers a Sickness that requires him or her to be Company will pay a benefit equal to the Per Visit Benefit confined in a Hospital as an Inpatient, the Company will shown in the Benefit Schedule, subject to Maximum pay a benefit after 60 consecutive Day(s) of Medically Number of Visits and the Maximum Benefit Amount Necessary Confinement due to that Sickness. No benefit shown in the Benefit Schedule. is provided if the Insured Person is confined for less than 60 consecutive Medically Necessary Days of Definitions Confinement. The amount of the benefit is equal to 100% of the Maximum Amount shown for the In-Hospital Routine Well Care - means a physical examination or Indemnity Sickness Single Payment Benefit in the appropriate immunization. Service must be under the Benefit Schedule. The maximum number of In-Hospital supervision of or recommended by a Physician. Indemnity Sickness Single Payment Benefits payable is shown in the Benefit schedule. Sickness – means an illness or disease which is diagnosed or treated by a Physician after the effective Day(s) of Confinement - means a day of Hospital date of coverage under the Policy. confinement as an Inpatient. The Sickness exclusions in the Exclusions section of the Hospital - means a facility which: (1) is operated Certificate or as amended shall not apply with respect to according to law for the care and treatment of injured 14 DTC101BNJ
    • benefits payable under the Physician’s Office Visits (Loss caused while on short-tem National Guard or Indemnity Benefit. reserve duty for regularly scheduled training LIMITATIONS purposes is not excluded). 8. travel or flight in or on (including getting in or out of, Reduction Schedule. The Maximum Amount used to or on or off of) any vehicle used for aerial navigation, determine the amount payable for a loss will be reduced if the Insured Person is: if an Insured Person is age 70 or older on the date of the a. riding as a passenger in any aircraft not accident causing the loss with respect to any of the intended or licensed for the transportation of following Benefits provided by the Policy: Emergency passengers; or Transportation and Treatment Benefit, In-Hospital b. performing, learning to perform or instructing Indemnity Daily Benefit, In-Hospital Indemnity Single others to perform as a pilot or crew member Payment Benefit, In-Hospital Indemnity Sickness Daily of any aircraft; or Benefit, In-Hospital Indemnity Sickness Single Payment c. riding as a passenger in an aircraft owned, Benefit. The Maximum Amount is reduced to a leased or operated by the Policyholder or percentage of the Maximum Amount that would be used the Insured’s employer; if the Insured Person were under age 70 on the date of 9. the Insured Person being under the influence of the accident, according to the following schedule: intoxicants. 10. the Insured Person being under the influence of AGE ON DATE PERCENTAGE OF UNDER- drugs unless taken under the advice of and as OF ACCIDENT AGE-70 MAXIMUM AMOUNT specified by a Physician. 11. the medical or surgical treatment of sickness, 70 or older 50% disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly from the Premium for an Insured Person age 70 or older is based treatment. on 100% of the coverage that would be in effect if the 12. stroke or cerebrovascular accident or event; Insured Person were under age 70. cardiovascular accident or event; myocardial infarction or heart attack; coronary thrombosis; EXCLUSIONS aneurysm. 13. any condition for which the Insured Person is No coverage shall be provided under the Policy and no entitled to benefits under any Worker’s payment shall be made for any loss resulting in whole or Compensation Act or similar law. in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded 14. the Insured Person riding in or driving any type of risks even if the proximate or precipitating cause of the motor vehicle as part of a speed contest or loss is an accidental bodily Injury. scheduled race, including testing such vehicle on a track, speedway or proving ground. 1. suicide or any attempt at suicide or intentionally self- 15. any loss incurred while outside the United States, its inflicted Injury or any attempt at intentionally self- Territories or Canada. inflicted Injury or autoeroticism. 2. sickness, disease, mental incapacity or bodily CLAIMS PROVISIONS infirmity whether the loss results directly or indirectly from any of these Notice of Claim. Written notice of claim must be given 3. the Insured Person's commission of or attempt to to the Company within 20 days after an Insured Person's commit a felony. loss, or as soon thereafter as reasonably possible. 4. infections of any kind regardless of how contracted, Notice given by or on behalf of the Insured Person to the except bacterial infections that are directly caused Company at LOTSolutions, Claims Department, P. O. by botulism, ptomaine poisoning or an accidental cut Box 2066, Jacksonville, FL 32203-2066, with information or wound independent and in the absence of any sufficient to identify the Insured Person, is deemed underlying sickness, disease or condition including notice to the Company. but not limited to diabetes. 5. declared or undeclared war, or any act of declared Claim Forms. The Company will send claim forms to or undeclared war, except if specifically provided by the claimant upon receipt of a written notice of claim. If the Policy. such forms are not sent within 15 days after the giving of 6. participation in any team sport or any other athletic notice, the claimant will be deemed to have met the activity, except participation in a Covered Activity. proof of loss requirements upon submitting, within the 7. full-time active duty in the armed forces, National time fixed in the Policy for filing proofs of loss, written Guard or organized reserve corps of any country or proof covering the occurrence, the character and the international authority. (Unearned premium for any extent of the loss for which claim is made. The notice period for which the Insured Person is not covered should include Your name, the Insured Person’s name, if due to his or her active duty status will be refunded) 15 DTC101BNJ
    • different, the Policyholder's name and the Policy Assignment. You may not assign any of your rights, number. privileges or benefits under the Policy. Proof of Loss. Written proof of loss must be furnished to the Company within 90 days after the date of the loss. Clerical Error. Clerical error, whether by the If the loss is one for which the Policy requires continuing Policyholder or the Company, will not void the insurance eligibility for periodic benefit payments, subsequent of any Insured Person if that insurance would otherwise written proofs of eligibility must be furnished at such have been in effect nor extend the insurance of any intervals as the Company may reasonably require. Insured Person if that insurance would otherwise have Failure to furnish proof within the time required neither ended or been reduced as provided in the Policy. invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, Conformity With State Statutes. Any provision of the provided such proof is furnished as soon as reasonably Policy which, on its effective date, is in conflict with the possible and in no event, except in the absence of legal statutes of the state in which the Policy is delivered is capacity of the claimant, later than one year from the hereby amended to conform to the minimum time proof is otherwise required. requirements of those statutes. Payment of Claims. Upon receipt of due written proof Entire Contract; Changes. The Policy, the of death, payment for loss of life of an Insured Person Application(s), this Certificate, any individual Enrollment will be made to the Insured Person’s beneficiary as Forms, riders, endorsements and any other attached described in the applicable Beneficiary Designation and papers make up the entire contract between the Change provision. Policyholder and the Company. In the absence of fraud, all statements made by the Policyholder or any Insured Upon receipt of due written proof of loss, payments for Person will be considered representations and not all losses, except loss of life, will be made to (or on warranties. No written statement made by an Insured behalf of, if applicable) the Insured Person suffering the Person will be used in any contest unless a copy of the loss. If an Insured Person dies before all payments due statement is furnished to the Insured Person or his or have been made, the amount still payable will be paid to her beneficiary or personal representative. his or her beneficiary as described in the applicable Beneficiary Designation and Change provision. No change in the Policy will be valid until approved by an officer of the Company. The approval must be noted If any payee is a minor or is not competent to give a on or attached to the Policy. No agent may change the valid release for the payment, the payment will be made Policy or waive any of its provisions. to the legal guardian of the payee’s property. If the payee has no legal guardian for his or her property, a Incontestability. After an Insured Person has been payment not exceeding $1,000 may be made, at the insured under the Policy for two year(s) during his Company’s option, to any relative by blood or connection lifetime, no statement made by You or an Insured by marriage of the payee, who, in the Company’s Dependent, if applicable, except a fraudulent one, will be opinion, has assumed the custody and support of the used to contest a claim under the Policy. The Company minor or responsibility for the incompetent person’s may only contest coverage if the misstatement is made affairs. by You. Any payment the Company makes in good faith fully Insured Beneficiary Designation and Change. Your discharges the Company's liability to the extent of the designated beneficiary(ies) is (are) the person(s) so payment made. named by You as shown on the Company’s records kept on the Policy. Time of Payment of Claims. Benefits payable under the Policy for any loss other than loss for which the If You are an Insured over the age of majority and legally Policy provides any periodic payment will be paid competent, You may change Your beneficiary immediately upon the Company’s receipt of due written designation at any time, unless an irrevocable proof of the loss. Subject to the Company’s receipt of designation has been made, without the consent of the due written proof of loss, all accrued benefits for loss for designated beneficiary(ies), by providing the Company, which the Policy provides periodic payment will be paid with a written request for change. When the request is at the expiration of each month during the continuance received by the Company, whether You are then living of the period for which the Company is liable and any or not, the change of beneficiary will relate back to and balance remaining unpaid upon termination of liability take effect as of the date of execution of the request, but will be paid immediately upon receipt of such proof. without prejudice to the Company on account of any payment made by it prior to receipt of the request. GENERAL PROVISIONS If there is no designated beneficiary or no designated beneficiary is living after Your death, the benefits will be 16 DTC101BNJ
    • paid, in equal shares, to the survivors in the first surviving class of those that follow: Your (1) spouse; (2) Workers' Compensation. The Policy is not in lieu of children; (3) parents; or (4) brothers and sisters. If no and does not affect any requirements for coverage by class has a survivor, the beneficiary is Your estate. any Workers' Compensation Act or similar law. Insured Dependent’s Beneficiary Designation and Change. The Insured Dependent’s beneficiary is You unless You have named (a) different beneficiary(ies) for Your Insured Dependent’s coverage as shown on the Company’s records kept on the Policy. If You are over the age of majority and legally competent, You may change the beneficiary designation for Your Insured Dependent’s coverage at any time, unless an irrevocable beneficiary designation has been made, without the consent of the Insured Dependent or the designated beneficiary(ies), by providing the Company with a written request for change. When the request is received by the Company, whether You or Your Insured Dependent is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request. If no beneficiary is living on the date of an Insured Dependent’s death, the beneficiary is Your estate. Legal Actions. No action at law or in equity may be brought to recover on the Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action may be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. Misstatement of Age. If premiums for the Insured Person are based on age and the Insured Person has misstated his or her age, there will be a fair adjustment of premiums based on his or her true age. If the benefits for which the Insured Person is insured are based on age and the Insured Person has misstated his or her age, there will be an adjustment of said benefit based on his or her true age. The Company may require satisfactory proof of age before paying any claim. Noncompliance with Policy Requirements. Any express waiver by the Company of any requirements of the Policy will not constitute a continuing waiver of such requirements. Any failure by the Company to insist upon compliance with any Policy provision will not operate as a waiver or amendment of that provision. Physical Examination and Autopsy. The Company at its own expense has the right and opportunity to examine the person of any individual whose loss is the basis of claim under the Policy when and as often as it may reasonably require during the pendency of the claim and to make an autopsy in case of death where it is not forbidden by law. 17 DTC101BNJ