Out-of-Pocket Protection Plan
This is a Hospital Confinement Protection Insurance Policy Underwritten by ManhattanLife Assurance Company of America and Family Life Insurance Company
GAP15-BR 0320
Not available in all states.
Out-of-Pocket Protection Plan
A Hospital Confinement Protection Insurance Policy
With today’s rising cost of medical care and health insurance premiums, many individuals and groups have selected higher deductibles, fewer co-pays and more out-of-pocket costs. This has been done to make health insurance premiums more affordable.* *National Center Biotechnology information.
But, out-of-pocket costs may still cause unnecessary burdens on many individuals.
What’s the solution?
THE NEW OUT-OF-POCKET PROTECTION PLAN!
• Pays directly to you, unless you assign your benefits to your provider(s). • Your choice of benefits and premiums. • Pays in addition to all other insurance. • No deductibles. • No networks.
How Our Plan Works
Once you have met the requirements, fill out the necessary claims form and attach your itemized statement. It’s that easy!
Benefits can be paid in a lump sum directly to you!
DAILY INPATIENT HOSPITAL CONFINEMENT BENEFIT** (per hospital admission) If you are confined in a hospital as a resident inpatient*. Pays the daily inpatient benefit you select (maximum of 10 days) (in ME, TX and UT, 31 days) per hospital confinement. In FL, payable for first 20 days of confinement then $10/$20 for next 11 days - depending on benefit level selected. This benefit is not payable for the treatment of Mental/Nervous disorders and substance abuse (in UT, or substance disorder).
You may choose a daily inpatient benefit of either:
q $ 100 a day q $ 200 a day
You may choose your hospital admission benefit below:
HOSPITAL ADMISSION BENEFIT (1 per year) (in UT, 1 per each period of confinement) If you are admitted to a hospital as a resident inpatient*. Pays the Hospital Admission Benefit you selected.
q $ 2,500 q $ 5,000 q $ 6,350
$ 50
DOCTOR OFFICE VISIT (2 per year) 2 per year, per insured persons
You may choose a benefit of either:
OUTPATIENT SURGERY BENEFIT*** (2 per year)
q $ 1,000 q $ 2,000 q $ 3,000
For surgical services rendered in an Ambulatory Surgical Center or Outpatient Hospital Facility, pays the amount you selected for outpatient surgery.
EMERGENCY ACCIDENT BENEFIT (4 per year) (FL maximum 2 per year)
$ 250 Maximum benefit per injury
If you sustain an injury which requires emergency care by a physician in a emergency room or urgent care facility, pays the amount per emergency treatment. The treatment must be received within 72 hours of the injury. In FL, this benefit is payable only if you are confined as an inpatient within 24 hours of emergency treatment.
* Confined as a resident inpatient means assigned to a hospital bed for an overnight stay for medically necessary reasons resulting from injury or illness on the advice of a physician ** A day is a 24 hour period where room and board is charged ***Refer to policy for limitations on this benefit This policy covers complications of pregnancy, but not the pregnancy itself. Conditionally renewable to age 69 (in CA, age 65) - Your Policy cannot be canceled regardless of changes in health or the number of times benefits are received. You have the right to renew this Policy until the earliest of when You become insured under Medicare or attain age 69 (in CA, age 65) if You pay the correct premium when due or within the Grace Period. The Company reserves the right to change the rates on all policies of this class in the entire state.
Underwritten by: ManhattanLife Assurance Company of America and Family Life Insurance Company Administrative Office: 10777 Northwest Freeway, Houston, TX 77092 Toll Free Telephone: 800-669-9030
THIS HOSPITAL INDEMNITY INSURANCE PLAN 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.
Benefits and riders may vary by state and may not be available in all states. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Out-of-Pocket Protection Plan product at disclosure.manhattanlife.com . Please review this information before applying for coverage. The amounts of benefits provided depend on the plan selected. Premiums will vary according to the selection made. THIS POLICY PROVIDES LIMITED BENEFITS. Policy Form Numbers C-GAPJ15, C-GAPJ15-LA, C-GAPJ15-OK, C-GAPJ15-TX; F-GAPJ15 (including state variations)
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