Group Hospital Indemnity Insurance Certificate
Mid-America Apartments, L.P.
IMPORTANT NOTICES
GROUP HOSPITAL INDEMNITY
If you reside in one of the following states, please read the important notice applicable to you.
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.
Colorado residents:
THIS IS A SUPPLEMENTAL POLICY THAT IS NOT INTENDED TO PROVIDE THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). UNLESS YOU HAVE ANOTHER PLAN (SUCH AS MAJOR MEDICAL COVERAGE) THAT PROVIDES MINIMUM ESSENTIAL COVERAGE IN ACCORDANCE WITH THE ACA, YOU MAY BE SUBJECT TO A FEDERAL TAX PENALTY. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE.
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- 800-547-5515.
Idaho residents:
30 Day Right To Examine Policy If a Covered Person does not like the Policy 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 Policy will be void as if it had never been issued.
THIS COVERAGE IS NOT GUARANTEED RENEWABLE
Maine residents:
RENEWAL SUBJECT TO CONSENT OF COMPANY: PLEASE READ TERMINATION OF POLICY PROVISION IN THE GENERAL PROVISIONS SECTION.
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.
Maryland residents:
This Certificate may omit some of the benefits required for a Certificate issued and delivered in Maryland.
New Hampshire residents:
THIS IS A LIMITED POLICY. READ IT CAREFULLY.
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 Certificate If a Covered Person does not like the Certificate 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.
North Carolina residents:
This Certificate of Insurance provides all of the benefits mandated by the North Carolina Insurance Code, but it is issued under a group master policy located in another state and may be governed by that state's law.
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 Us.
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.
Ohio residents:
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM US.
Oklahoma residents:
NOTICE: The Policyholder has the right to return the Policy within ten (10) days of its delivery and to have the premium refunded if, after examination of the Policy, the Policyholder is not satisfied for any reason. If We do not return any premiums or money paid therefore within thirty (30) days from the date of cancellation, We will pay interest on the proceeds. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
South Dakota residents:
THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE FOR COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS.
Utah residents:
THIS IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM THE COMPANY. WITHIN 30 DAYS OF RECEIPT OF THIS POLICY, YOU CAN RETURN IT TO US FOR ANY REASON IF NOT SATISFIED. WE WILL RETURN ANY PREMIUM THAT HAS BEEN PAID AND THE POLICY VOID.
Virginia residents:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. IMPORTANT NOTICE REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have any questions you may contact Us at the address above or by calling toll-free 1-800-732-1603. If you are unable to contact or obtain satisfaction from the company or agent, you may contact the Virginia State Corporation Commission’s Bureau of Insurance at the following address and telephone numbers: P.O. Box 1157 Richmond Virginia 23218-1157 (804) 371-9741 (local) (800) 552-7945 (VA toll-free) (877) 310-6560 (national toll-free)
Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or Bureau of Insurance, have your policy number available.
West Virginia residents :
THIS POLICY DOES NOT QUALIFY FOR MINIMUM ESSENTIAL COVERAGE
TEN DAY RIGHT TO EXAMINE POLICY The Policyholder has the right to return this Policy to Us within 10 days of receipt, and to have the premium refunded if, after examination, the Policyholder is not satisfied with this Policy for any reason.
Cigna Health and Life Insurance Company 900 Cottage Grove Road, Bloomfield, Connecticut 06002 A Stock Insurance Company
GROUP HOSPITAL INDEMNITY CERTIFICATE
THIS CERTIFICATE PROVIDES LIMITED COVERAGE. PLEASE READ YOUR CERTIFICATE CAREFULLY.
THIS IS A GROUP HOSPITAL INDEMNITY INSURANCE POLICY. BENEFITS PROVIDED ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
THIS IS NOT A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE . THIS COVERAGE DOES NOT SATISFY THE INDIVIDUAL MANDATE OF THE AFFORDABLE CARE ACT (ACA).
We, the Cigna Health and Life Insurance Company, have issued a Group Policy, HC111341 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
GHIP1.2-CE1000.WY
TABLE OF CONTENTS
SECTION
PAGE NUMBER
SCHEDULE OF BENEFITS............................................................................................................................. 1
SCHEDULE OF BENEFITS FOR CLASS 1..................................................................................................... 2
DESCRIPTION OF COVERAGES AND BENEFITS....................................................................................... 4
GENERAL DEFINITIONS............................................................................................................................... 7
ELIGIBILITY ................................................................................................................................................ 12
ENROLLMENT ............................................................................................................................................. 13
EFFECTIVE DATE PROVISIONS ................................................................................................................ 13
DEFERRED EFFECTIVE DATE PROVISIONS ............................................................................................ 14
TAKEOVER PROVISION ............................................................................................................................. 16
TERMINATION OF INSURANCE ................................................................................................................ 16
CONTINUATION OF INSURANCE PROVISIONS ...................................................................................... 17
PORTABILITY PROVISIONS....................................................................................................................... 17
COMMON EXCLUSIONS............................................................................................................................. 19
CLAIM PROVISIONS ................................................................................................................................... 20
ADMINISTRATIVE PROVISIONS ............................................................................................................... 22
GENERAL PROVISIONS.............................................................................................................................. 23
MODIFYING PROVISIONS AMENDMENT ................................................................................................ 25
GHIP1.2-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.
GHIP1.2-1100.00
1
SCHEDULE OF BENEFITS FOR CLASS 1
Subscriber: Mid-America Apartments, L.P.
Effective Date: January 01, 2024
Minimum Participation Requirements:
10% of eligible Employees or 10 enrolled Employees, whichever is greater
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.
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, unless otherwise indicated. All Dependent Child(ren) benefits are payable at 100% of the Benefit Amount shown for the Employee, unless otherwise indicated
Benefit Waiting Period: 0 days unless otherwise specified
CONTINUATION OPTION(S): Applicable Coverage(s)
Hospital Indemnity Benefits for the Employee, His Spouse and Dependent Child(ren)
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 Benefit(s) 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
HOSPITAL INDEMNITY BENEFITS
PLAN 1
EMPLOYEE BENEFITS
HOSPITALIZATION BENEFITS
2
Benefit Type Hospital Admission Elimination Period
0 days $1,500
Benefit Amount
Maximum Benefit Period
1 day
Hospital Chronic Condition Admission Elimination Period
0 days $100 1 day
Benefit Amount
Maximum Benefit Period
Hospital Stay Elimination Period Benefit Amount
0 days
$150 per day Up to 30 days
Maximum Benefit Period
Hospital Intensive Care Unit Stay Elimination Period
0 days
Benefit Amount
$150 per day Up to 30 days
Maximum Benefit Period Hospital Observation Stay Elimination Period
24 hours
Benefit Amount
$150 per 24-hour period
Maximum Benefit Period
Up to 72 hours
PREMIUM INFORMATION
INITIAL PREMIUM
Premium:
Refer to your Schedule of Rates or 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.
GHIP1.2-1100.00
3
DESCRIPTION OF COVERAGES AND BENEFITS
This Description of Coverages and Benefits Section describes the Hospital Indemnity 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 and may be subject to a Benefit Waiting Period and/or an Elimination Period before benefits can be paid. The Benefit Amounts shown in the Schedule of Benefits will be paid regardless of the actual expenses incurred. 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.
HOSPITALIZATION BENEFITS
Hospitalization benefits will be paid on a per day basis and we will pay the maximum per day benefit as shown in the Schedule of Benefits .
HOSPITAL 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 Covered Injury or Covered Illness. This benefit will pay in addition to the Hospital Chronic Condition Admission Benefit, Hospital Stay and Hospital Intensive Care Unit Stay Benefit. Benefits are payable for up to the Maximum Benefit Period shown in the Schedule of Benefits .
Benefit Conditions 1.
The Hospital stay is as an Inpatient, as defined by the policy.
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. Treatment is for Hospital re-admission for the same Covered Injury or Covered Illness. 4. The benefit is limited to 1 Hospital admission per 365 days for different Covered Injury or Covered Illness.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
HOSPITAL CHRONIC CONDITION 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 Chronic Condition as specified in the Definitions section of the Policy. This benefit will pay in addition to the Hospital Admission, Hospital Stay or Hospital Intensive Care Unit Stay Benefit. Benefits are payable for up to the Maximum Benefit Period shown in the Schedule of Benefits .
Benefit Conditions 1.
The Hospital stay is as an Inpatient, as defined by the policy; and 2. Treatment, including an evaluation or consultation, for a Chronic Condition is provided by a specialist in that field of medicine.
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. Treatment is for Hospital re-admission for the same Chronic Condition. 4. The benefit is limited to 1 Hospital admission per 365 days for different Chronic Conditions.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
4
HOSPITAL STAY BENEFIT We will pay per day the Benefit Amount shown in the Schedule of Benefits, subject to the following conditions and limitations, if the Covered Person is confined in a Hospital due to a Covered Injury or Covered Illness. Benefits are payable for up to the Maximum Benefit Period shown in the Schedule of Benefits .
Benefit Conditions The Hospital Stay must meet all of the following: 1. Must be at the direction and under the care of a Physician; and 2. Must be admitted 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 Elimination 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.
The benefit is limited to 1 Hospital Stays within a 365 day period. 2. If a benefit is payable under the Hospital Stay Benefit as well as under the Hospital Intensive Care Unit Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever 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 Injury or Covered Illness, 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 Injury or Covered Illness, we will count that as a different Hospital Stay.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
HOSPITAL INTENSIVE CARE UNIT (ICU) STAY BENEFIT We will pay per day the Benefit Amount shown in the Schedule of Benefits , subject to the following conditions and limitations, if the Covered Person is confined in an ICU of a Hospital due to a Covered Injury or Covered Illness. Benefits are payable for up to the Maximum Benefit Period shown in the Schedule of Benefits .
Benefit Conditions The Hospital ICU Stay must meet all of the following: 1. Must be at the direction and under the care of a Physician; 2. Must be admitted on an Inpatient basis.
The benefit will be paid for each day of a continuous Hospital ICU Stay. If the Hospital ICU Stay begins during the Benefit Waiting Period, the benefit will be paid for each continuous day that extends after the end of the Elimination 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.
The benefit is limited to 1 Hospital ICU Stays within a 365 day period. 2. If a benefit is payable under the Hospital Stay Benefit as well as under the Initial Hospital Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is the greater amount. 3. If the Covered Person leaves the Hospital ICU and then returns within 90 days for the same or a related Covered Injury or Covered Illness, we will still count that as one Hospital ICU Stay. However, if the Covered Person is out of the Hospital ICU for at least 90 days and then returns for the same or a related Covered Injury or Covered Illness, we will count that as a different Hospital ICU Stay.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
5
HOSPITAL OBSERVATION STAY BENEFIT 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 receives treatment for a Covered Injury or Covered Illness in a Hospital, including an observation room, or an Ambulatory Surgical Center, for a period in excess of 24 hours on a non-Inpatient basis and a charge is incurred.
Benefit Conditions The Hospital Observation Stay must meet all of the following: 1. Be at the direction and under the care of a Physician.
Benefit Limitations 1. This benefit is not payable if a benefit is payable under the Hospital Stay Benefit or Hospital Intensive Care Unit Stay Benefit.
The exclusions that apply to this benefit are in the Common Exclusions Section.
Exclusions
GHIP1.2-2201.00
6
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 Care or confined in a rehabilitation or convalescence center or receiving Outpatient care for chemotherapy or radiation therapy; 2. confined at home under the care of a Physician for Illness or Injury; For purposes of Initial Premium calculations upon initial eligibility unless otherwise stated, a Covered Person's age is His Age attained on the date coverage becomes effective for Him under this Policy. 1. For purposes of increases to coverage, including Enrollment Events and Life Status Changes, a Covered Person's Age, will be His Age as of the effective date of such increase. 2. For purposes of premium calculation for Portability prior to group policy termination, a Covered Person's Age is His Age as of His last birthday. 3. For the purposes of Portability, except as to premium calculations, a Covered Person's Age is His Age as of His last birthday. 4. For all other purposes, changes in rates due to age and age-based terminations, a Covered Person's Age will be His Age on the Policy Anniversary Date coinciding with or following the Covered Person's birthday.
Active Service
Age
The period in each calendar year agreed upon by the Employer and Us when an eligible Employee may enroll for or change his or her benefit elections under the Policy.
Annual Group Enrollment Period
The period of time, shown in the Schedule of Benefits , immediately following the effective date of the Covered Person’s coverage. No benefits will be paid under the Schedule of Benefits for Hospital Indemnity Benefits or any Additional or Optional Benefits for a covered event or a Covered Loss that occurs during the Benefit Waiting Period as shown in the Schedule of Benefits . 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. has been diagnosed and treated during a Hospital Stay for which benefits are payable; and 2. Is any of the following conditions: 1. asthma, chronic obstructive pulmonary disease (COPD), emphysema and chronic bronchitis A condition that: 1.
Benefit Waiting Period
Certificate
Chronic Condition
7
2. low back pain, metabolic syndrome, osteoarthritis, peripheral arterial disease, behavioral: anxiety, bipolar disorder, depression 3. diabetes mellitus: Type 1, Type 2 4. cardiac concerns: acute myocardial infarction, angina, congestive heart failure, coronary artery disease, heart disease.
Complications of Pregnancy Whether or not the pregnancy is terminated, any condition: 1. that requires hospital confinement; and 2.
whose diagnosis is distinct from pregnancy but is adversely affected or caused by pregnancy.
Examples include: acute nephritis; nephrosis; cardiac decompensation; missed abortion; and similar conditions of comparable severity, non-elective caesarean section; ectopic pregnancy which is terminated; and spontaneous termination of pregnancy which occurs during a period of gestation when a viable birth is not possible. Complications of pregnancy do not include: false labor; occasional spotting; physician prescribed rest during pregnancy; morning sickness; hyperemesis gravidarum; pre- eclampsia; and similar conditions associated with a difficult pregnancy but not considered a classifiable, distinct complication of pregnancy. A physical or mental disease or disorder including pregnancy and Complications of Pregnancy, that results in a Covered Loss. A Covered Illness includes medically-necessary quarantine in a Hospital in conjunction with medically-necessary preventive treatment due to an identifiable exposure to a life-threatening contagious and infectious disease.
Covered Illness
Any bodily harm that results directly from a Covered Loss.
Covered Injury
A loss that is: 1.
Covered Loss
specified in the Schedule of Benefits .
2. 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 and 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:
Dependent Child
1.
A child from live birth to 26 years old;
2. A child who is 26 or more years old, primarily supported by the Employee and 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 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
8
The cumulative period of time during a continuous period of employment that an Employee must be in Active Service in order to be eligible for coverage under the Policy. It will be extended by the number of days the Employee is not in Active Service. The continuous period of time that must be satisfied before a benefit shown in the Schedule of Benefits is payable. An Elimination Period may be satisfied during the Policy’s Benefit Waiting Period. A designated area in a Hospital that is supervised by Physicians and equipped and staffed to render immediate medical attention on an outpatient basis, 24 hours a day, 7 days a week for the sudden onset of symptoms related to a Covered Injury or Covered Illness. An Emergency Room is not a clinic, an Urgent Care Facility or Physician’s office.
Eligibility Waiting Period
Elimination Period
Emergency Room
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
A program established and maintained by the Employer to provide benefits to plan participants and their beneficiaries.
Employer’s Plan
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
Care provided at a designated facility by licensed health care professionals primarily engaged in providing medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness. An institution that meets all of the following: 1. 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.); and 5. It has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available to it on a prearranged basis. The term Hospital does not include a clinic or facility for: 1. Rehabilitation, convalescent, custodial, educational, hospice, or skilled nursing care; 2. The aged, drug addiction or alcoholism; or 3. A facility primarily or solely providing psychiatric services to mentally ill patients.
Hospice Care
Hospital
The term Hospital also does not include a unit of a Hospital for rehabilitation, convalescent, custodial, educational, hospice, or skilled nursing care.
A physical or mental disease or disorder including pregnancy. An illness includes medically-necessary quarantine in a Hospital in conjunction with medically-necessary preventive treatment due to an identifiable exposure to a life-threatening contagious and infectious disease.
Illness
9
The period during a calendar year when an eligible Employee who was hired on or before the Policy Effective Date may enroll for the first time for coverage under this Policy. This period must be agreed upon by the Employer and Us.
Initial Open Enrollment Period
Any accidental loss or bodily harm.
Injury
A Covered Person who is A Covered Person who is formally admitted and confined to a Hospital or facility under a Physician’s order for a period of time requiring at least one overnight stay. Evidence of good health that is submitted by the Eligible Person and is satisfactory to Us before the coverage subject to this requirement becomes effective. An eligible person satisfies the insurability requirement on the day We agree in writing to accept him as insured for the amount subject to this requirement. We may require that the evidence of good health be provided at the eligible person's expense. is for the treatment of patients who are in acute or critical condition; 5. is furnished with emergency life-saving equipment and supplies that are immediately at hand; 6. is staffed 24 hours a day by Nurses who are specially trained to work in an intensive care unit; 7. is equipped and staffed to monitor each patient's vital signs around-the-clock; and 8. is not a recovery room or an area used primarily for post-operative or post- anesthesia care. A designated area of a hospital that: 4.
Inpatient
Insurability Requirement
Intensive Care Unit (ICU)
An Intensive Care Unit includes a critical care or cardiac care unit.
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 an Ambulatory Surgical Center, Hospital, lab, medical clinic, Physician’s office, or radiologic center and is not confined for a day’s room and board.
Nurse
Outpatient
Regularly working the number of hours set by the Subscriber as a regular work week for Employees, other than Full- Time, temporary or seasonal, in the Employee’s eligibility class.
Part-Time
Activities used in measuring levels of personal functioning capacity. These activities are normally performed without assistance, allowing personal independence in everyday living. These activities include the following: 1. Transfer and mobility - The ability to move into or out of a bed, chair or wheelchair or to move from place to place, either via walking, a wheelchair, cane, crutches, walker or other equipment; 2. Continence - The ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter, urostomy, or colostomy bag); 3. Dressing - Putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs; 4. Toileting - Getting to and from the toilet, transferring on and off the toilet and performing associated personal hygiene; 5. Eating - Feeding oneself by consuming food or fluids manually from a receptacle (such as a plate, cup or table); or
Physical Activities of Daily Living
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6. Bathing - Washing oneself by sponge bath; or in either a tub or a shower, including the task of getting into or out of the tub or shower.
A licensed medical, osteopathic or podiatric practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer medication and to perform surgery 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. The plan of insurance providing similar benefits sponsored by the Employer and in effect directly prior to the Policy Effective Date. A Prior Plan will include the plan of an employer in effect on the day prior to: 1. That employer’s addition to this policy; or 2. With Our approval, the addition of all employees, or all of a defined group of employees, of an employer, as a result of an agreement to which that employer (or a parent or shareholder of that employer) is a party. The Employee's current 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. The term includes a common-law Spouse who is recognized as a common-law Spouse under the laws of the jurisdiction where the common-law marriage was formed.
Physician
Prior Plan
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
Cigna Health and Life Insurance Company.
We, Us, Our, Insurance Company
The person to whom the certificate is issued
You, Your
GHIP1.2-1200.00
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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 as shown in the Schedule of Benefits . An Employee is not required to satisfy a new Eligibility Waiting Period if coverage ends because He 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. Limitations on Multiple Eligibility A Covered 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. Eligible Employee Insured As Spouse - Loss of Eligibility as a Spouse If an Employee is eligible and has enrolled as the Spouse of another Employee, but ceases to be eligible to maintain the amount of coverage for which he or she has enrolled as a Spouse, that Employee may, within 31 days, enroll for coverage as an Employee, in an amount equal to the lesser of: 1. The amount of the Spouse’s coverage terminating; or 2. The maximum amount of Employee coverage of the class for which he or she is eligible.
Evidence of Insurability is not required. If this amount is not equal to an available Benefit Amount, it will be adjusted to the next higher available Benefit Amount.
An Employee shall not also be eligible for an increase in coverage due to a Life Status Change when eligible under this provision. Premium will be based upon the Employee’s Age as of the Effective Date of the Employee’s coverage under this provision. Eligible Spouse Insured As Employee – Loss of Eligibility as an Employee If a Spouse is eligible and has enrolled for coverage as an Employee but ceases to be eligible to maintain the amount of coverage for which he or she has enrolled as an Employee, that Spouse may, within 31 days, be enrolled for coverage as a Spouse in an amount equal to the lesser of: 1. The amount of Employee coverage terminating; or 2. The maximum amount of Spouse coverage for which he or she is eligible.
Evidence of Insurability is not required. If this amount is not equal to an available Benefit Amount, it will be adjusted to the next higher available Benefit Amount.
A Spouse shall not also be eligible for an increase in coverage due to a Life Status Change when eligible under this provision. Premium will be based upon the Employee’s Age as of the Effective Date of the Spouse’s coverage under this provision.
Special Rules for Dependent Children An Employee who is insured will not be insured as a Dependent Child of another Employee.
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A Dependent Child of two or more Employees may only be insured once under the Policy. If a Dependent Child of two or more Employees who have enrolled Dependent Children incurs a claim, then any payable benefit will be divided equally among the Employees who have insured the Dependent Child unless the Employees otherwise agree.
If an Employee who has elected to insure Dependent Children ceases to do so, then the Employee’s Spouse may, within 31 days, elect to insure Dependent Children, provided he or she is insured as an Employee.
In all cases, a Dependent Child shall be defined with respect to the Employee who has enrolled Dependent Children.
ENROLLMENT
An eligible Employee may apply for coverage, 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 as agreed to by Us and the Subscriber.
Group Enrollment Events New Enrollees
Subject to the Deferred Effective Date Provisions , an Employee who is newly eligible to apply, or has been eligible but did not previously enroll, may apply for coverage for Himself or any eligible Spouse or Dependent Child for an amount shown as Guaranteed Issue without satisfying any Evidence of Insurability, during the Enrollment Events shown in the Policy. Current Insureds Subject to the Deferred Effective Date Provisions , an eligible Employee insured under this Policy, may apply for an increase in coverage for Himself or for coverage on any insured Spouse or Dependent Child for an amount shown as Guaranteed Issue without satisfying any Evidence of Insurability, during the Enrollment Events shown in the Policy.
An eligible Employee must apply for Himself and 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 and His eligible Spouse or Dependent Child may become insured under the coverage provided by this Policy without satisfying any Evidence of Insurability.
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 Status.
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 Subscriber Effective Date Coverage becomes effective for each Subscriber in consideration of the Subscriber's application, Subscription Agreement and payment of the initial premium when due. Coverage 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; 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 Certain Changes Any increase or decrease in the amount of coverage 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
Not in 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 insurance 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.
INDIVIDUAL ENROLLMENT EVENTS
Annual Re-Enrollment and Life Status Change An Annual Re-Enrollment is a period of time once per year, no more than twice 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.
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Life Status Changes that qualify an Employee to apply or increase coverage for Himself include: 6. marriage; 7. loss of a spouse; whether by death, divorce, annulment or legal separation; 8. birth or adoption of a child, or acquiring a child through marriage; 9. a change in the group benefit plan available to the Employee’s Spouse; 10. a change in the Employee’s employment status that affects eligibility for group benefits for either the Employee or His Spouse; 11. termination of a Spouse’s employment; and 12. as specified in the Employer’s Plan which this Policy insures. Life Status Changes that qualify an Employee to apply or increase coverage for His eligible Spouse and Dependent Child include: 3. marriage; 4. loss of a spouse; whether by death, divorce, annulment or legal separation; 5. birth or adoption of a child, or acquiring a child through marriage; 6. a change in the group benefit plan available to the Spouse; 7. a change in the Spouse’s employment status that affects eligibility for group benefits for either the Employee or His Spouse; 8. termination of a Spouse’s employment; and 9. as specified in the Employer’s Plan which this Policy insures. Annual Re-Enrollment An Employee who is eligible to apply, but did not previously enroll, may apply or is insured may apply for an increase for coverage. Changes to coverage for an Employee who applies during the enrollment period and agrees to make required contributions 31 days after enrollment period ends are as follows:
The Employee may apply for an increase in coverage on an insured Spouse or for coverage on a Spouse who is eligible to be insured but was not previously enrolled by the Employee.
The Dependent Child who is eligible to apply, but was not previously enrolled by the Employee, the Employee may apply or is insured the Employee may apply for an increase for coverage.
For all Employee, Spouse and Dependent Child coverage, Evidence of Insurability is not required.
Coverage for which an Employee, Spouse and Dependent Child is eligible will be effective on the effective date of this Policy’s anniversary following the enrollment period.
Group Enrollment Effective Dates Annual Group Enrollment Period Coverage up to the Guaranteed Issue amount for which an Employee, Spouse and Dependent Child is eligible, will be effective on the effective date of this Policy's anniversary following the enrollment period.
For all Employee and Spouse coverage up to the Guaranteed Issue amount, Evidence of Insurability is not required.
The Employee may apply for an increase in coverage on an insured Spouse or for coverage on a Spouse who is eligible to be insured but was not previously enrolled by the Employee.
For all Dependent Child coverage Evidence of Insurability is not required.
The Dependent Child who is eligible to apply, but was not previously enrolled by the Employee, the Employee may apply or is insured the Employee may apply for an increase for coverage.
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