Pre-Existing Condition Limitation We will not pay benefits for a Covered Injury or Covered Illness caused, contributed to by, or resulting from a Pre- existing Condition. The term “Pre - existing Condition” means any Illness or Injury for which a Covered Person received medical treatment, advice, care or services including diagnostic measures, took prescribed drugs or medicines within 6 months before the Covered Person’s most recent effective date of coverage, and the most recent effective date of any added or increased amount of coverage. The Pre-Existing Condition Limitation will apply to any added benefits or increases in benefits. This Limitation will not apply to a Covered Injury or Covered Illness that occurs after the Covered Person is insured under this Policy for at least 6 continu ous months after the Covered Person’s most recent effective date of coverage, and effective date of any added or increased amount of coverage. 5) Under the Claim Provisions section, the following changes are made:
a) Proof of Loss must be given within 90 days or when reasonably possible. A one year maximum is not permitted.
b) The Recovery of Overpayment provision is revised as follows:
If benefits are overpaid, We have the right to recover the amount overpaid by either of the following methods after We identify the reasons for the overpayment.
1. A request for lump sum payment of the overpaid amount. 2. A reduction of any amounts payable under this Policy.
Our right to recover is only from amounts that would be payable directly to the Covered Person, and only if the discovery of the overpayment and request for recovery occurs within one year after the overpayment.
If We reduce any amounts payable under this Policy, the Covered Person has the right to appeal the claim adjudication and the amount. If the overpayment is in dispute, the reduction of subsequent claims will be suspended until the dispute is resolved.
If there is an overpayment due when the Covered Person dies, We may recover the overpayment from the Covered Person’s estate.
6) Under the Administrative Provisions section, the following changes are made:
a) Under the Grace Period provision it is revised to state that All premiums due under the policy must be remitted by the employer of the persons insured, therefore optional language permitting payment of premium directly to the Us by the employee is not permitted.
b) The following provisions is added:
Policy Reinstatement This Policy may be reinstated within 45 days of lapse if it lapsed for nonpayment of premium. Requirements for reinstatement are written application of the Policyholder satisfactory to Us and payment of all overdue premiums. Any premiums accepted in connection with a reinstatement will be applied to a period for which premium was not previously paid, but not to any period more than 60 days prior to the date of reinstatement.
c) The Payment of Premium provision is revised as follows:
Covered Person The Covered Person may be responsible for the payment of premium directly to Us, as determined by the Employer from the Policy Effective Date, or following the expiration of 60 days from the date coverage is continued for a Covered Person under the Portability Provisions section of the Policy. Premium shall be due monthly, unless the Covered Person and We agree on some other period for premium payment. If premium is not paid when due, coverage will end as of the premium due date, except as provided in the Covered Person Grace Period provision below.
37
Made with FlippingBook - PDF hosting