Benefit Amount: $20,000 Age Employee
Employee + Spouse
Employee + Children
Employee + Family
<25
$2.11 $2.41 $3.25 $4.44 $5.76 $7.67 $10.91 $15.05 $22.25 $26.98 $37.74 $53.42 $68.76 $86.10 $86.10 $86.10
$3.45 $3.90 $5.19 $7.20 $9.31 $12.53 $17.41 $23.55 $34.50 $42.16 $58.65 $79.64 $99.24 $136.05 $136.05 $136.05
$2.11 $2.41 $3.25 $4.44 $5.76 $7.67 $10.91 $15.05 $22.25 $26.98 $37.74 $53.42 $68.76 $86.10 $86.10 $86.10
$3.45 $3.90 $5.19 $7.20 $9.31 $12.53 $17.41 $23.55 $34.50 $42.16 $58.65 $79.64 $99.24 $136.05 $136.05 $136.05
25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89 90 to 94
95+
Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding. The policy’s rate structure is based on attained age, which means the premium can increase due to the increase in your age. Important Policy Provisions and Definitions: Covered Person: An eligible person who is enrolled for coverage under the Policy. Covered Loss: A loss that is specified in the Policy in the Schedule of Benefits section and suffered by the Covered Person within the applicable time period described in the Policy. When your coverage begins: Coverage begins on the later of the program’s effective date, the date you become eligible, the first of the month following the date your completed enrollment form is received, or if evidence of insurability is required, the first of the month after we have approved you (or your dependent) for coverage in writing, unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for all other Covered Persons will not begin on the effective date if the covered person is confined to a hospital, facility or at home, disabled or receiving disability benefits or unable to perform activities of daily living. When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued. Be sure to read the provisions in your Certificate about when coverage may continue.) 30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate of Insurance for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued. Benefit Reductions, Common Exclusions and Limitations: Exclusions: In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Loss that is caused directly or indirectly, in whole or in part by any of the following:• intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane; • commission or attempt to commit a felony or an assault; • declared or undeclared war or act of war; • a Covered Loss that results from active duty service in the military, naval or air force of any country or international organization (upon our receipt of proof of service, we will refund any premium paid for this time; Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days); • voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage; • operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant (‘’Under the influence of alcohol’’, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the Covered Loss occurred); • a diagnosis not in accordance with generally accepted medical principles prevailing in the United States at the time of the diagnosis. Specific Definitions, Benefit Exclusions and Limitations: The date of diagnosis must occur while coverage is in force and the condition definition must be satisfied. Only one Initial Benefit will be paid for each Covered Condition per person. Skin Cancer, basal cell/squamous cell carcinoma or certain forms of melanoma. Invasive Cancer, uncontrolled/abnormal growth or spread of invasive malignant cells. Excludes pre-malignant conditions or conditions with malignant potential. Carcinoma in Situ, non-invasive malignant tumor. Excludes premalignant conditions or conditions with malignant potential, skin cancers, invasive cancer (basal/squamous cell carcinoma or melanoma/melanoma in situ). Heart Attack , excludes Sudden Cardiac Arrest, takotsubo syndrome, congestive heart failure, and myocarditis. Stroke , excludes Transient Ischemic Attack (TIAs), brain injury related to trauma or infection, brain injury associated with hypoxia or anoxia, vascular disease affecting eye or optic nerve or ischemic disorders of the vestibular system.
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