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
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