900 Cottage Grove Road Bloomfield, Connecticut 06002
HOSPITAL BENEFIT RIDER - PANDEMIC INFECTIOUS DISEASE ADMISSION ONLY BENEFIT This Rider is attached to and made a part of your group insurance Policy. It is subject to the terms, conditions, limitations and exclusions contained in the Policy as well as those set forth in this Rider. Rider Effective Date: January 01, 2024 DESCRIPTION OF COVERAGES AND BENEFITS The following provisions explain the benefits available under this Rider. Please see the Schedule of Benefits for the applicability of these benefits on a class level. Elimination Period The Elimination Period is the period of time as shown in the Schedule of Benefits that a Covered Person must wait before benefits are payable. HOSPITAL BENEFITS This coverage is payable when a Covered Person is admitted to and confined in a Hospital due to any Pandemic Infectious Disease (PID) hospitalization, including COVID-19. This Rider provides limited Hospital Benefits. The Benefit Amounts shown in the Schedule of Benefits will be paid regardless of the actual expenses incurred. Benefits are subject to any applicable Benefit Waiting Period. HOSPITAL PANDEMIC INFECTIOUS DISEASE ADMISSION We will pay the per day Benefit Amount shown in the Schedule of Benefits, subject to the following conditions and limitations, if the Covered Person is admitted to and confined in a Hospital due to a Pandemic Infectious Disease following the Elimination Period. Benefits are payable for up to the Maximum Benefit Period shown in the Schedule of Benefits . Benefit Conditions 1. The Hospital Pandemic Infectious Disease Admission benefit will be payable after Day 1. Benefit Limitation This benefit will not be payable if:
1. Treatment is given only in the emergency room; 2. Treatment is provided on an Outpatient basis; 3. The benefit is limited to 1 Hospital admission per 12 months. Definitions For purposes of this benefit: PANDEMIC INFECTIOUS DISEASE:
A condition that is any of the following conditions: COVID- 19 and any global scale pandemic infectious disease that is spread over multiple countries including the US as declared by World Health Organization (WHO).
Exclusions The exclusions that apply to these benefits are in the Common Exclusions section of the Policy. Renewability/Termination of Coverage
This Rider is renewable. However, this Rider shall automatically terminate on the earliest of the following dates: 1. the date the Covered Person’s coverage ends for any reason under the Policy to which this Rider is attached; 2. the last day of the period for which premium is paid for this Rider, subject to the Policy’s Grace Period provision;
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