Group Accident Indemnity Insurance Certificate
Mid-America Apartments, L.P.
IMPORTANT NOTICES
If a Covered Person resides in one of the following states, the important notice will apply.
Arizona residents:
This certificate of insurance may not provide all benefits and protections provided by law in Arizona. Please read this certificate carefully.
California residents:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS OR MINIMUM ESSENTIAL COVERAGE AS DEFINED IN FEDERAL LAW. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON THE EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED.
Florida residents:
The benefits of the policy providing your coverage are governed primarily by the laws of a state other than Florida.
To make an inquiry, obtain information about your coverage or to resolve a complaint call 1- 800-754-3207.
Idaho residents:
Notice to Buyer: This is an accident only Certificate and it does not pay benefits for loss from Sickness. This Certificate provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. Read Your Certificate carefully with the Outline of Coverage. THIS POLICY IS RENEWABLE AT THE OPTION OF THE POLICYHOLDER AND/OR US We may terminate insurance on or after the first anniversary of the Policy Effective Date. The Policyholder/Subscriber may terminate insurance on any Premium Due Date. Written notice by certified mail must be given at least 31 days prior to such Premium Due Date. Failure by the Policyholder/Subscriber to pay premiums when due or within the Grace Period shall be deemed notice to Us to terminate insurance at the end of the period for which premium was paid.
Louisiana residents:
THIS CERTIFICATE DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE. THIS COVERAGE DOES NOT SATISFY THE INDIVIDUAL MANDATE OF THE AFFORDABLE CARE ACT (ACA).
Maryland residents:
This Certificate may omit some of the benefits required for a Certificate issued and delivered in Maryland.
New Hampshire residents:
NOTICE TO BUYER: This is an accident-only policy and it does not pay benefits for loss from sickness. Review your policy carefully. Benefits provided are supplemental and are not intended to cover all medical expenses
THIS POLICY PROVIDES LIMITED BENEFITS. BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
THIS POLICY IS RENEWABLE AT THE OPTION OF THE POLICYHOLDER AND/OR US
30 Day Right To Examine Policy This Policy may, at any time within 30 days after its receipt by the Policyholder, be returned by delivering it or mailing it to the Company or the agent through whom it was purchased. Immediately upon such delivery or mailing, the Policy will be deemed void from the beginning, and any premium paid on it will be refunded.
North Carolina residents:
The Policy is a legal contract between the Policyholder and Us
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is available from CIGNA HEALTH AND LIFE INSURANCE COMPANY. UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL: (1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT, AND (2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE OF THE PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO HEALTH
INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF THE GENERAL STATUTES. VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.
Texas residents:
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.
Vermont residents:
THIS POLICY DOES NOT MEET THE MINIMUM COVERAGE REQUIREMENTS OF THE AFFORDABLE CARE ACT. YOU SHOULD NOT PURCHASE THIS POLICY UNLESS YOU ARE ALREADY COVERED BY COMPREHENSIVE MAJOR MEDICAL INSURANCE.
Cigna Health and Life Insurance Company 900 Cottage Grove Road, Bloomfield, Connecticut 06002 A Stock Insurance Company
GROUP ACCIDENT INDEMNITY CERTIFICATE
THIS CERTIFICATE PROVIDES LIMITED COVERAGE. PLEASE READ YOUR CERTIFICATE CAREFULLY.
We, the Cigna Health and Life Insurance Company, have issued a Group Policy, AI111682 to Trustee of the Group Insurance Trust for Employers in the Finance, Insurance and Real Estate Industry.
We certify that We insure all eligible persons who are enrolled according to the terms of the Group Policy. Your coverage will begin according to the terms set forth in the Effective Date Provisions section.
This Certificate describes the benefits and basic provisions of Your coverage. It is not the insurance contract and does not waive or alter any terms of the Policy. If questions arise, the Policy language will govern. You may examine the Policy at the office of the Subscriber or the Administrator.
This Certificate replaces all prior Certificates issued to You under the Group Policy.
Geneva Campbell Brown Corporate Secretary
Julia M. Huggins Senior Vice President of US Markets President CHLIC
30 DAY RIGHT TO EXAMINE CERTIFICATE
Within 30 days of receipt of this Certificate, You can return it to Us for any reason if not satisfied with the insurance provided under this Certificate. We will return any premium that has been paid and this Certificate will be void as if it had never been issued.
THIS CERTIFICATE DOES NOT CONTAIN COMPREHENSIVE ADULT WELLNESS BENEFITS AS DEFINED BY WYOMING LAW.
Series 1.0
GAI-00-CE1000.WY
TABLE OF CONTENTS
SECTION
PAGE NUMBER
SCHEDULE OF BENEFITS...........................................................................................................................1
SCHEDULE OF BENEFITS FOR CLASS 1...................................................................................................2
DESCRIPTION OF COVERAGES AND BENEFITS.....................................................................................8
ELIGIBILITY ..............................................................................................................................................17
ENROLLMENT ...........................................................................................................................................17
EFFECTIVE DATE PROVISIONS ..............................................................................................................17
DEFERRED EFFECTIVE DATE PROVISIONS ..........................................................................................18
TAKEOVER PROVISION ...........................................................................................................................19
TERMINATION OF INSURANCE ..............................................................................................................20
CONTINUATION OF INSURANCE PROVISIONS ....................................................................................20
PORTABILITY PROVISIONS ..................................................................................................................... 20
COMMON EXCLUSIONS ........................................................................................................................... 22
CLAIM PROVISIONS .................................................................................................................................23
ADMINISTRATIVE PROVISIONS .............................................................................................................25
GENERAL PROVISIONS ............................................................................................................................ 26
ENHANCED BENEFITS RIDER .................................................................................................................28
WELLNESS TREATMENT, HEALTH SCREENING TEST AND PREVENTIVE CARE BENEFIT RIDER35
MODIFYING PROVISIONS AMENDMENT ..............................................................................................37
GAI-00-CE1000.WY
SCHEDULE OF BENEFITS
The Schedule of Benefits provides a brief outline of the coverage and benefits including the maximum benefit amount, benefit periods, and any limitations applicable to benefits provided in this Policy for each Covered Person , unless otherwise indicated.
This Policy is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations applicable to its benefits, please read all the Policy provisions carefully.
Covered Classes: Class 1
All active, Full-time Employees of the Employer who are regularly working in the United States a minimum of 20 hours per week and regularly residing in the United States and who are United States citizens or permanent resident aliens and their Spouse and Dependent Children who are United States citizens or permanent resident aliens and who are residing in the United States.
The following pages contain a Schedule of Benefits for each class of eligible Employees. For an explanation of these benefits, please see the Description of Benefits section.
GAI-00-1100a.00
1
SCHEDULE OF BENEFITS FOR CLASS 1
Subscriber: Mid-America Apartments, L.P.
Effective Date: January 01, 2024
Minimum Participation Requirements: 10 enrolled Employees
Eligibility Waiting Period: First of the month coinciding with or next following 90 days from date of hire or Active Service. Credit will be given for the period of time of Active Service before the Policy effective date.
Waiting Period: 0 days unless otherwise specified
BENEFIT AMOUNTS PAYABLE All Employee benefits are payable at 100% of the Benefit Amount shown for the Eligible Employee. All Spouse benefits are payable at 100% of the Benefit Amount shown for the Employee. All Dependent Child(ren) benefits are payable at 100% of the Benefit Amount shown for the Employee.
ACCIDENT INDEMNITY BENEFITS
EMPLOYEE BENEFITS
PLAN 1
INITIAL CARE AND EMERGENCY CARE BENEFITS
Benefit Type
Benefit Amount
Emergency Care Treatment Benefit Amount
$300
Physician Office Visit (Includes urgent care) Benefit Amount
$100
Diagnostic Exam Benefit Amount Ground Ambulance Benefit Amount Water Ambulance Benefit Amount Air Ambulance Benefit Amount
$300
$400
$400
$1,600
HOSPITALIZATION BENEFITS
Benefit Type Hospital Admission Benefit Waiting Period
0 days $1,500
Benefit Amount
Hospital Stay Benefit Waiting Period
0 days
Benefit Amount
$200 per day Up to 365 days
Maximum Benefit Period
2
Intensive Care Unit Stay Benefit Waiting Period
0 days
Benefit Amount
$400 per day Up to 365 days
Maximum Benefit Period
FRACTURES BENEFIT
Benefit Type FRACTURES Must be diagnosed and treated by a physician within 90 days of a Covered Accident
Non-Surgical/Closed
Surgical/Open
Benefit Amount
Benefit Amount
$4,000
$8,000
Skull
Pays for non-depressed or depressed skull fractures but not bones of face
$4,000
$8,000
Hip or Thigh
$4,000
$8,000
Vertebrae or Pelvis
Pays for vertebrae, body of vertebrae, or pelvis fracture Will not pay for Coccyx, leg, or vertebral processes fractures
$1,000
$2,000
Upper Arm
Pays for arm fractures located between elbow and shoulder Will not pay for Shoulder, Lower Arm, or Elbow fractures
$1,000
$2,000
Shoulder or Collarbone
Pays for shoulder or collarbone fractures only Will not pay for Upper Arm fractures
$1,000
$2,000
Leg
Will not pay for Thigh, knee, or ankle fractures
$800
$1,600
Ankle
Will not pay for leg, foot, or heel fractures
$800
$1,600
Kneecap
Will not pay for leg fractures
$800
$1,600
Lower Arm
Pays for arm fractures located to the elbow and below the elbow Will not pay for Upper Arm or Bones of Wrist fractures
$800
$1,600
Foot
Will not pay for toe, ankle, or heel fractures
$800
$1,600
Hand or Wrist
Will not pay for lower Arm or finger fractures
3
$600
$1,200
Upper Jaw
Will not pay for lower jaw, teeth, or bones of face fractures
$600
$1,200
Lower Jaw
Will not pay for Upper Jaw, Teeth, or Bones of face fractures
$600
$1,200
Bones of Face or Nose
Will not pay for Upper Jaw, Lower Jaw, or Teeth fractures
$600
$1,200
Vertebral Processes
$200
$400
Rib
More than 1 rib fracture pays 2 times the Benefit Amount
$200
$400
Coccyx
We will not pay for Vertebrae or Pelvis fractures
$100
$200
Finger
More than 1 finger pays 2 times the Benefit Amount. We will not pay for fractures to Hand or Wrist.
$100
$200
Toe
More than 1 toe fracture pays 2 times the Benefit Amount shown on schedule. We will not pay for Foot, Heel or Ankle fractures.
$100
$200
Sternum
$100
$200
Heel
We will not pay for Foot, Toe, or Ankle fractures
25% of Closed fracture benefit
Not Applicable
Chip Fracture
We will not pay in addition to Closed fracture benefit
200% of the single fracture benefit for multiple fractures to the same bone
Not Applicable
Multiple Fractures
We will not pay multiple fracture benefit in addition to single fracture benefits
DISLOCATIONS BENEFITS
Benefit Type DISLOCATIONS: Must be diagnosed and treated by a doctor within 90 days of a Covered Accident
Non-Surgical/Closed
Surgical/Open
Benefit Amount
Benefit Amount
$3,000
$6,000
Hip Joint
4
$3,000 $3,000 $1,000
$6,000 $6,000 $2,000
Knee Joint
Bones of Foot
Ankle We will not pay for Bones of Foot or Toes
$800 $600 $400 $400 $400 $400 $100
$1,600 $1,200
Wrist Elbow
$800 $800 $800 $800 $200
Shoulder
Hand
Collarbone Lower Jaw
Finger or Toe More than 1 finger or toe pays 2 times the benefit
FOLLOW UP CARE
Benefit Type
Benefit Amount
Follow up Physician (or medical professional) Office Visit Benefit is limited to 10 treatments per Accident
$150
Follow up Physical Therapy Visits Benefit is limited to 10 treatments per Accident
$50
5
OPTIONAL BENEFITS
ENHANCED ACCIDENT BENEFITS RIDER All Employee benefits under this Rider are payable at 100% of the Benefit Amount shown for the Eligible Employee. All Spouse benefits are payable at 100% of the Benefit Amount shown for the Employee. All Dependent Child(ren) benefits are payable at 100% of the Benefit Amount shown for the Employee.
EMPLOYEE BENEFITS
PLAN 1
Benefit Type Small Burns
Benefit Amount
$300
Large Burns (3rd degree pays 10x multiple)
$1,000
50% of the applicable Benefit amount for Small Burns or Large Burns
Skin-Graft Benefit
$100 $600 $100
Small Lacerations Large Lacerations
General Anesthesia Benefit
$10 $10
Medicine Benefit
Medical Supply Benefit
$1,250
Abdominal or Thoracic Surgery
$400 $150
Tendon, Ligament, Rotator Cuff, or Knee Surgery - Repair Tendon, Ligament, Rotator Cuff, or Knee Surgery - Exploratory
$750 $400 $200 $150
Ruptured Disc Surgery - repair
Eye Injury Surgery
Eye Injury - Removal of Foreign Object Emergency Dental - Extraction Emergency Dental - Broken Tooth
$75
$150
Concussion
$10,000
Coma
$150 $150
Diagnostic Advanced Exam
Appliance Prosthesis
$1,000 $5,000 $10,000
Paralysis - Paraplegia or Hemiplegia Benefit
Paralysis - Quadriplegia Blood, plasma, platelets
$200 $400
Transportation Family Lodging
$150 per day
WELLNESS TREATMENT, HEALTH SCREENING TEST AND PREVENTIVE CARE BENEFIT RIDER All Employee benefits under this Rider are payable at 100% of the Benefit Amount shown for the Eligible Employee. All Spouse benefits are payable at 100% of the Benefit Amount shown for the Employee. All Dependent Child(ren) benefits are payable at 100% of the Benefit Amount shown for the Employee.
Benefit Waiting Period
0 days
EMPLOYEE BENEFITS
PLAN 1
Benefit Type
Benefit Amount
Wellness Treatment Benefit
6
Health Screening Test Benefit Preventive Care Benefit Benefit Amount
$50 per day 1 per year
Maximum Benefit Period
Continuation Options
Applicable Coverage(s)
Accident Indemnity Benefits and Optional Benefits for Employee, His Spouse and Dependent Child
For Family Medical Leave Maximum Benefit Period
up to 6 months for family medical leave and up to 6 months for military family leave
For Leave of Absence
Maximum Benefit Period
up to 12 weeks
PORTABILITY
Portable Period
Coverage continues to age 100 for Employee, to age 100 for Spouse, to age 26 for Dependent Child, unless otherwise specified
Amount of Portable Insurance Coverage(s) that may be ported Benefits that may be ported
100%
Employee, Spouse, Dependent Child
All
Maximum Age
As of the date of porting, 100 for Employee, 100 for Spouse, 26 for Dependent Child, unless otherwise specified
PREMIUM INFORMATION
INITIAL PREMIUM
Premium:
Refer to your Plan and Rate Confirmation as provided at time of enrollment or application
Contribution(s):
The cost of coverage is paid by the Employee
PREMIUM DUE DATES
The Policy Effective Date and the first day of each succeeding modal period.
Premium rates are subject to change in accordance with the Changes in Premium Rates provision of the Administrative Provisions section of this Policy.
GAI-00-1100a.00
7
DESCRIPTION OF COVERAGES AND BENEFITS
This Description of Coverages and Benefits Section describes the Accident Coverages and Benefits provided by this Policy. Benefit amounts, benefit periods and any applicable aggregate and benefit maximums are shown in the Schedule of Benefits. Certain words capitalized in the text of these descriptions have special meanings within this Policy and are defined in the General Definitions section. Please read these and the Common Exclusions sections in order to understand all of the terms, conditions and limitations applicable to these coverages and benefits.
INITIAL CARE AND EMERGENCY BENEFITS
EMERGENCY CARE TREATMENT
We will pay the benefit shown in the Schedule of Benefits, if a Covered Person requires Emergency Room Treatment due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident.
Benefit Conditions 1.
This benefit is payable once per Covered Accident, per Covered Person. 2. Treatment must occur within 30 days of accident for benefit to be payable.
For purposes of this benefit: Emergency Room means a trauma center or a special area in a Hospital that is equipped and staffed to give people emergency treatment on an outpatient basis. An Emergency Room is not a clinic or Physician’s office. Immediate Family Member means a person who is related to the Insured in any of the following ways: Spouse, and child (includes legally adopted child or stepchild).
Definition
Benefits will not be payable for treatment provided by an Immediate Family Member.
Exclusions
Other exclusions that apply to this benefit are in the Common Exclusions Section.
PHYSICIAN OFFICE VISIT
We will pay the benefit shown in the Schedule of Benefits, if a Covered Person requires a Physician Office Visit due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident. (Includes urgent care)
Benefit Conditions Must be diagnosed and treated by a Physician within 90 days of the Covered Accident.
Benefit Limitations 1. This benefit is not payable if a Covered Person is eligible to receive a benefit under Emergency Care Treatment. 2. Only 1 benefit will be paid for each Covered Person per Covered Accident.
This benefit is not payable for visits by a surgeon while confined in a Hospital.
Exclusions:
Other exclusions that apply to this benefit are in the Common Exclusions Section.
DIAGNOSTIC EXAM BENEFIT
We will pay the benefit shown in the Schedule of Benefits if the Covered Person requires diagnostic x-ray and laboratory examinations due to a Covered Injury as prescribed by a Physician that results directly and independently of all other causes from a Covered Accident. This benefit will be payable in addition to Emergency Care Treatment and/or Physician Office Visit benefits.
Benefit Conditions Examination must occur within 90 days of the Covered Accident.
8
Benefit Limitations 1.
This benefit pays for 1 diagnostic examination per Covered Accident.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions:
AMBULANCE BENEFIT
We will pay the benefit shown in the Schedule of Benefits, if the Covered Person requires ambulance services due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident.
Benefit Conditions 1.
The ambulance services provided must be for ground, water, and air transportation from the scene of the Covered Accident to the nearest Hospital that is able to provide appropriate care, or for transportation to the nearest Hospital within 90 days of the Covered Accident or between Hospitals. 2. This benefit is payable once per Covered Accident, per Covered Person.
Benefit Limitations 1.
We will pay this benefit in addition to the Emergency Care Treatment benefit. 2. We will only pay one benefit, ground, water, or air ambulance whichever is the greater amount.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions:
HOSPITAL BENEFITS
HOSPITAL ADMISSION
We will pay the benefit shown in the Schedule of Benefits, if the Covered Person requires a Hospital Admission. This benefit will pay in addition to the Emergency Care Treatment benefit, Hospital Stay Benefit or Intensive Care Unit Stay Benefit.
Benefit Conditions 1.
admission occurs within 90 days of the Covered Accident; and 2. the Hospital Stay is as an inpatient, as defined by the Policy; and 3. the admission is the first Hospital admission for such Covered Accident; and 4. the benefit is payable on Day 0; and 5. this benefit will be paid only one time per Covered Accident.
Benefit Limitation This benefit will not be payable if: 1.
treatment is given in the emergency room; or 2. treatment is provided on an Outpatient basis; or 3. treatment is for Hospital re-admission for the same Covered Accident.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions:
HOSPITAL STAY BENEFIT
We will pay the daily Hospital Stay benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, if the Covered Person requires a Hospital Stay due to a Covered Loss resulting directly and independently of all other causes from a Covered Accident. Benefits are payable for up to 365 days.
Benefit Conditions
9
The Hospital Stay must meet all of the following: 1.
be at the direction and under the care of a Physician; 2. begin within 90 days of the Covered Accident; 3. begin while the Covered Person’s insurance is in effect; and 4. The Covered Person must be admitted for at least 23 hours or on an Inpatient basis.
The benefit will be paid for each day of a continuous Hospital Stay. If the Hospital Stay begins during the Benefit Waiting Period, the benefit will be paid for each continuous day that extends after the end of the Benefit Waiting Period, as shown in the Schedule of Benefits. If benefits are calculated on a monthly basis, pro rata payments will be made for confinements of less than one month.
Benefit Limitations 1.
This benefit will not be payable for hospital re-admission for same Covered Accident. 2. If a benefit is payable under the Hospital Stay Benefit as well as under the Intensive Care Unit Stay Benefit, only 1 benefit will be paid for the same Covered Accident, which is the greater amount. 3. If the Covered Person leaves the Hospital and then returns within 90 days for the same or a related Covered Accident, We will still count that as one Hospital Stay. However, if the Covered Person is out of the Hospital for at least 90 days and then returns for the same or a related Covered Accident, We will count that as a different Hospital Stay.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions:
INTENSIVE CARE UNIT STAY BENEFIT
We will pay the benefit shown in the Schedule of Benefits subject to the following conditions and exclusions, if the Covered Person is confined in an ICU of a Hospital due to a Covered Accident resulting directly and independently of all other causes from a Covered Accident. Benefits are payable only for up to 365 days spent in an ICU for each Stay.
Benefit Conditions The ICU Stay must meet all of the following: 1.
be at the direction and under the care of a Physician; 2. begin within 90 days of the Covered Accident; 3. begin while the Covered Person’s insurance is in effect. 4. the Covered Person must be admitted for at least 23 hours or on an Inpatient basis.
The benefit will be paid for each day of a continuous ICU Stay. If the ICU Stay begins during the Benefit Waiting Period, the benefit will be paid for each continuous day that extends after the end of the Benefit Waiting Period, as shown in the Schedule of Benefits. If benefits are calculated on a monthly basis, pro rata payments will be made for confinements of less than one month.
Benefit Limitations 1.
This benefit will not be payable for Hospital re-admission for same Covered Accident. 2. If a benefit is payable under the Hospital Stay Benefit as well as under the Initial Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Accident, which is the greater amount. 3. If the Covered Person leaves the ICU and then returns within 90 days for the same or a related Covered Accident, We will still count that as one Stay. However, if the Covered Person is out of the ICU for at least 90 days and then returns for the same or a related Covered Accident, we will count that as a different Stay in an ICU.
For purposes of this benefit:
Definition
ICU means an Intensive care or cardiac care unit of a Hospital that: a. is for the treatment of patients who are in acute or critical condition; b. is furnished with emergency life-saving equipment and supplies that are immediately at hand; c. is staffed 24 hours a day by Nurses who are specially trained to work in an intensive care unit; and d. is equipped and staffed to monitor each patient's vital signs around-the-clock.
10
An intensive care or cardiac care unit is not a recovery room. This means that it is not an area used primarily for post-operative or post-anesthesia care.
Stay in an ICU means the period of days that the Covered Person is in an ICU for the same or a related Injury. We will count all days that the Covered Person must spend in an ICU for the same or a related Injury as one Stay. The Covered Person must be admitted to a Hospital for at least 23 hours.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
FRACTURES BENEFIT
We will pay the benefit shown in the Schedule of Benefits subject to the following conditions and exclusions, if the Covered Person sustains a Fracture or Chip Fracture due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident.
Benefit Condition Must be diagnosed and treated by a Physician within 90 days of the Covered Accident.
Benefit Limitations If the Covered Person sustains more than one fracture as a result of such Covered Accident, We will pay one benefit which is the greater amount.
For purposes of this benefit:
Definition
Fracture means a bone that is broken as diagnosed by a Physician and corrected by open or closed reduction.
Chip Fracture means a fragment of a bone has been broken off as diagnosed by a Physician.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
DISLOCATIONS BENEFIT
We will pay the benefit shown in the Schedule of Benefits subject to the following conditions and exclusions, if the Covered Person sustains a Dislocation or Partial Dislocation due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident.
Benefit Condition Must be diagnosed and treated by a Physician within 90 days of the Covered Accident.
Benefit Limitations If the Covered Person sustains more than one Dislocation as a result of such Covered Accident, We will pay one benefit which is the greater amount.
For purposes of this benefit:
Definition
Dislocation means a completely separated joint as diagnosed by a Physician that can be corrected by open or closed reduction. A Partial Dislocation is an incomplete separated joint as diagnosed by a Physician.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
11
FOLLOW-UP CARE
FOLLOW UP PHYSICIAN OFFICE VISIT BENEFIT
We will pay the benefit shown in the Schedule of Benefits, if a Covered Person requires a Follow-up Physician Office Visit due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident and is examined or treated by a Physician or medical professional in such individual’s office ( Office includes virtual care visits ) .
Recommendation from Physician is required and the Covered Person is entitled to payable Initial Care and/or Emergency Care benefits.
Benefit Conditions Examination or treatment must be provided within 90 days of the Covered Accident. Treatment must be completed within 365 days from the Covered Accident.
Benefit Limitations 1.
Only 10 benefits will be paid for each Covered Person per Covered Accident.
For purposes of this benefit:
Definitions
Medical professional can include providers that are appropriately licensed professionals, including but not limited to those practicing chiropractic care, speech therapy, occupational therapy, vocational therapy, respiratory therapy, and mental health treatment associated with Covered Accidents.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
FOLLOW UP PHYSICAL THERAPY BENEFIT
We will pay the benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, if the Covered Person requires Follow up Physical Therapy due to a Covered Injury resulting directly and independently of all other causes from a Covered Accident. Recommendation from a Physician is required and the Covered Person is entitled to payable Initial Care and/or Emergency Care benefits.
Benefit Conditions 1.
Physical therapy must begin within 120 days of the Covered Accident. 2. All treatments must be completed within 365 days of the Covered Accident.
Benefit Limitations 1.
Only 10 benefits will be paid for each Covered Person per Covered Accident.
For purposes of this benefit:
Definitions
Physical Therapy means manipulation by physical and mechanical means including heat treatment or diathermy, ultrasonic, microtherm, manipulation, adjustment, massage therapy and acupuncture as performed by a licensed Physical Therapist.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
GAI-00-2201.00
12
GENERAL DEFINITIONS
Please note that certain words used in this Policy have specific meanings. The words defined below and capitalized within the text of this Policy have the meanings set forth below.
An Employee will be considered in Active Service with His Employer on any day that is either: 1. one of the Employer’s scheduled work days on which the Employee is performing His regular duties on a Full- time basis, either at one of the Employer’s usual places of business or at some other location to which the Employer’s business requires the Employee to travel; or 2. a scheduled holiday, vacation day or period of Employer-approved paid leave of absence, other than disability or sick leave after 7 days, only if the Employee was in Active Service on the preceding scheduled workday. A Covered Person is not considered in Active Service if he is: 1. Inpatient in a Hospital, receiving hospice or confined in a rehabilitation or convalescence center or custodial care facility; 2. confined at home under the care of a Physician for Sickness or Injury; A Covered Person’s Age, for purposes of initial premium calculations, is His Age attained on the date coverage becomes effective for him under this Policy. Thereafter, it is His Age attained on the last Policy anniversary.
Active Service
Age
A vehicle which: 1.
Aircraft
has a valid certificate of airworthiness; and
2. is being flown by a pilot with a valid license to operate the Aircraft.
The Certificate, including the Certificate Schedule, amendments, riders and supplements, if any, is a written statement prepared by us to set forth a summary of: 1. benefits to which the covered person is entitled; 2. to whom the benefits are payable; and 3. limitations or requirements that may apply. A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions: 1. occurs while the Covered Person is insured under this Policy; 2. is not contributed to by disease, Sickness, mental or bodily infirmity; 3. is not otherwise excluded under the terms of this Policy.
Certificate
Covered Accident
Any bodily harm that results, directly and independently of all other causes, from a Covered Accident.
Covered Injury
A loss that is: 1.
Covered Loss
the result, directly and independently of all other causes, from a Covered Accident; and 2. one of the Covered Losses specified in the Schedule of Benefits . 3. suffered by the Covered Person within the applicable time period specified in the Schedule of Benefits. An eligible person, as defined in the Schedule of Benefits , who is enrolled where required, has been accepted by Us, required premium has been paid when due and coverage under this Policy remains in force.
Covered Person
An Employee’s child who meets the following requirements: 1. A child from live birth to 26 years old. 2.
Dependent Child
A child who is 26 or more years old, primarily supported by the Employee and
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incapable of self-sustaining employment by reason of mental or physical handicap.
A child, for purposes of this provision, includes an Employee’s: 1. natural child; 2. adopted child, from the earlier of the date the petition for adoption is filed or entry of the child in the adoptive home, or in the case of a child who is in the custody of the state, coverage shall begin at the date of entry of a final decree of adoption. It also means the legally adopted child of the Employee’s Spouse provided the child is living with, and is financially dependent upon the Employee; 3. stepchild who resides with the Employee and is financially dependent upon the Employee; 4. child for whom the Employee is the court-appointed legal guardian, as long as the child resides with the Employee and primarily depends on the Employee for financial support. Financial support means that the Employee is eligible to claim the dependent for purposes of Federal and State income tax returns. Emergency medical services and care given in a Hospital as an out or inpatient, for a sudden, unexpected onset of a medical condition of such nature that failure to render immediate care could reasonably result in deterioration to the point of placing a Covered Person’s life in jeopardy or cause serious impair ment to bodily functions.
Emergency Room Treatment
For eligibility purposes, an Employee of the Employer who is in one of the Covered Classes.
Employee
The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule of Affiliates and which are covered under this Policy on the date of issue or subsequently agreed to by Us.
Employer
Full-time means the number of hours set by the Subscriber as a regular work week for Employees in the Employee’s eligibility class .
Full-time
Refers to any individual, male or female.
He, His, Him, Himself
An institution that meets all of the following: 1.
Hospital
It is licensed as a Hospital pursuant to applicable law; 2. It is primarily and continuously engaged in providing medical care and treatment to sick and injured persons; 3. It is managed under the supervision of a staff of medical doctors; 4. It provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.); 5. It has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available to it on a prearranged basis; 6. It charges for its services.
The term Hospital does not include a clinic, facility, or unit of a Hospital for: 1. rehabilitation, convalescent, custodial, educational or nursing care; 2. the aged, drug addicts or alcoholics.
A confinement in a Hospital, ordered by a Physician, over a period of time when room and board and general nursing care are provided at a per diem charge made by the Hospital. The Hospital Stay must result directly and independently of all other causes from a Covered Accident/Loss. Separate Hospital Stays due to the same Covered Accident/Loss will be treated as one Hospital Stay unless separated by at least 90 days.
Hospital Stay
The period in the calendar year when an eligible Employee who was hired on or before the Policy Effective Date may enroll for the first time for Insurance Benefits under this Policy.
Initial Open Enrollment Period
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Any accidental loss or bodily harm.
Injury
A Covered Person who is confined for at least one full day's Hospital room and board.
Inpatient
A licensed graduate registered Nurse (R.N.), a licensed practical Nurse (L.P.N.), or a licensed vocational Nurse (L.V.N.) who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; or 3. a parent, sibling, spouse or child of the Covered Person. A Covered Person who receives medical tests, treatment, or services from a Hospital, Ambulatory Surgical Center, medical clinic, or Physician’s office and is not charged for room and board.
Nurse
Outpatient
The complete and permanent loss of the use of two or more limbs.
Paralysis
A Physician who is licensed to practice pathological anatomy by the American Board of Pathology. Pathologist also means an osteopathic pathologist who is certified by the Osteopathic Board of Pathology.
Pathologist
A practitioner of physical therapy who is duly licensed in the state where he is practicing and who is practicing within the scope and limitations of that license.
Physical Therapist
A licensed health care provider practicing within the scope of His license and rendering care and treatment to a Covered Person that is appropriate for the condition and locality and who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; or 3. a parent, sibling, spouse or child of the Covered Person.
Physician
The plan of insurance, providing similar benefits, sponsored by the Employer in effect immediately prior to this Policy’s Effective Date.
Prior Plan
A legally operating institution or part of an institution which has a transfer agreement with one or more Hospitals and which: 1. is primarily engaged in providing comprehensive multi-disciplinary physical rehabilitative services or rehabilitation Inpatient care; 2. is duly licensed by the appropriate government agency to provide such services; and 3. is required to be accredited by the Joint Commission on Accreditation of Health Care Organizations or the Commission on Accreditation of Rehabilitation Facilities. A Rehabilitation Facility does not include institutions which provide only minimal care, custodial care, care for the terminally ill, part-time care, or services or facilities for drug abuse or alcoholism.
Rehabilitation Facility
A physical or mental illness including pregnancy.
Sickness
The Employee’s lawful Spouse who is at least Age 18 but not yet Age 100. Except for purposes of determining initial eligibility, the term includes a Spouse who is widowed or divorced or legally separated from an Employee.
Spouse
Any participating organization that subscribes to the Trust to which this Policy is issued.
Subscriber
The Group Insurance Trust for Employers named on the face page of this Policy.
Trust
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Waiting Period means the period of time shown in the Schedule of Benefits following the effective date of the Covered Person’s insurance. No benefits will be paid for a Covered Loss which occurs during the Waiting Period.
Waiting Period
Cigna Health and Life Insurance Company.
We, Us, Our, Insurance Company
The person to whom the certificate is issued
You, Your
GAI-00-1200.WY
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ELIGIBILITY
Employee An Employee becomes eligible for coverage under this Policy on the date He meets all of the requirements of one of the Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits . The Eligibility Waiting Period will not apply to an Employee, in Active Service on the Policy Effective Date, who was covered under the Prior Plan and satisfied the Eligibility Waiting Period, if any, of that plan. Credit will be given for any time that was satisfied. Except as noted in the Reinstatement Provision, if an Employee terminates coverage and later wishes to reapply , or if a former Employee is rehired, a new Eligibility Waiting Period must be satisfied. An Employee is not required to satisfy a new Eligibility Waiting Period if coverage ends because he or she is no longer in a Class of Eligible Employees, but continues to be employed by the Employer, and within one year becomes a member of an eligible class. Spouse and Dependent Children A Spouse and Dependent Children of an eligible Employee become eligible for any dependent coverage provided by this Policy on the later of the date the Employee becomes eligible or the date the Spouse or Dependent Child meets the applicable definition shown in the General Definitions section of this Policy. The Employee must be insured under the Policy in order to elect coverage for a Spouse or Dependent Child. An eligible person may be insured only once as of any given date under the Policy as a Covered Person, even though He may be eligible under more than one class of insureds.
ENROLLMENT
An eligible Employee may apply for insurance, subject to the Deferred Effective Date Provisions section of this Policy, for Himself or any eligible Spouse or Dependent Child or to increase coverage for any Covered Person under this Policy during the Initial Open Enrollment Period or the Annual Re-enrollment period as agreed to by Us and the Subscriber.
An eligible Employee must be insured for coverage for which He is required to contribute to the cost of insurance in order to apply for coverage for an eligible Spouse or Dependent Child.
During the Initial Open Enrollment Period, an Employee, His eligible Spouse or Dependent Child may become insured under the coverage provided by this Policy.
Any Employee who is not in Active Service on the date His coverage would otherwise become effective under this Policy, may not become covered under this Policy until He returns to Active Service.
If an Employee's eligible dependent is not in Active Service on the date the coverage would otherwise be effective, it will be effective on the date the dependent returns to Active Service.
Continuity of Coverage Subject to the Deferred Effective Date Provisions an Employee and His eligible Spouse or Dependent Child insured under the Prior Plan will be covered without further enrollment under this Policy for the amount(s) inforce under the Prior Plan on the day before the Policy Effective Date, not to exceed the Maximum Benefit Amount under this Policy. For purposes of determining premium rates, a Covered Person's age will be his or her Age as defined under this Policy.
EFFECTIVE DATE PROVISIONS
Subscriber Effective Date Insurance becomes effective for each Subscriber in consideration of the Subscriber’s application, Subscription Agreement and payment of the initial premium when due. Insurance for the Subscriber becomes effective on the Effective date of Subscriber Participation as long as the Minimum Participation Requirements shown in the Schedule of Benefits have been satisfied.
Effective Date for Individuals (Newly Eligible and Life Status)
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Voluntary Benefit For all Employee coverage, Evidence of Insurability is not required.
If the Employee applies for coverage and agrees to make required contributions within 31 days after the date He becomes eligible and, subject to the Deferred Effective Date Provisions section below, coverage becomes effective on the later of: 1. the effective date of the Subscriber's participation under this Policy; or 2. the first of the month following the date We or the Employer receive the Employee’s completed enrollment form.
For all Spouse coverage, Evidence of Insurability is not required.
If the Spouse is eligible for coverage, and the Employee applies for coverage and agrees to make required contributions within 31 days after the date the Spouse becomes eligible and, subject to the Deferred Effective Date Provisions section below, coverage becomes effective on the later of: 1. the effective date of the Subscriber's participation under this Policy; 2. the date the Employee becomes eligible; 3. the date the Employee’s coverage becomes effective; 4. the date the dependent meets the definition of Spouse as applicable; 5. the first of the month following the date We or the Employer receive the completed enrollment form.
For all Dependent Child coverage, Evidence of Insurability is not required.
If the Dependent Child is eligible for coverage, and the Employee applies for coverage and agrees to make required contributions within 31 days after the date the Dependent Child becomes eligible and, subject to the Deferred Effective Date Provisions section below, coverage becomes effective on the later of: 1. the effective date of the Subscriber's participation under this Policy; 2. the date the Employee becomes eligible; 3. the date the Employee’s coverage becomes effective; 4. the date the dependent meets the definition of Dependent Child as applicable; 5. the first of the month following the date We or the Employer receive the completed enrollment form for Dependent Child coverage.
If coverage for a Dependent Child is in force and another Dependent Child becomes eligible, coverage for that child is effective on the date the child qualifies as a Dependent Child.
EFFECTIVE DATE OF CHANGES Any increase or decrease in the amount of insurance for the Covered Person resulting from: 1. a change in benefits provided by this Policy; or 2. a change in the Employee’s Covered Class, will take effect on the date of such change. Increases will take effect subject to any Active Service requirement.
DEFERRED EFFECTIVE DATE PROVISIONS
Active Service The effective date of coverage will be deferred for any Employee or any eligible Spouse or Dependent Child who is not in Active Service on the date coverage would otherwise become effective. Coverage will become effective on the later of the date He returns to Active Service, or the date coverage would otherwise have become effective. Annual Re-Enrollment and Life Status Change An Annual Re-Enrollment is a period of time once per year as agreed to by Us and the Subscriber when an Employee can apply for coverage or to increase coverage on Himself, Spouse or Dependent Child under this Policy. Life Status Change A Life Status Change is an event that the Employer has determined qualifies an Employee to apply for coverage or to increase coverage on Himself, His Spouse or Dependent Child due to a Life Status Change under this Policy.
Life Status Changes that qualify an Employee to apply or increase coverage for Himself include:
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