AFLAC HOSPITAL
WHAT IS NoT CovErEd, LImITATIoNS ANd EXCLUSIoNS, ANd TErmS YoU NEEd To KNoW
eXclusions We will not pay benefits for loss caused by Pre-Existing Conditions. We will not pay benefits for loss contributed to, caused by, or resulting from: • War – participating in war or any act of war, declared or not, or participating in the armed forces of or contracting with any country or international authority. We will return the prorated premium for any period not covered by this certificate when you are in such service. • Suicide – committing or attempting to commit suicide, while sane or insane. • Self-Inflicted Injuries – injuring or attempting to injure yourself intentionally. • Traveling – traveling more than 40 miles outside the territorial limits of the United States, Canada, Mexico, Puerto Rico, the Bahamas, Virgin Islands, Bermuda, and Jamaica, except under the Accidental Common Carrier Death Benefit. • Racing – Riding in or driving any motor-driven vehicle in a race, stunt show, or speed test. • Aviation – operating, learning to operate, serving as a crew member on, or jumping or falling from any aircraft, including those which are not motor-driven. • Intoxication – being legally intoxicated, or being under the influence of any narcotic, unless such is taken under the direction of a Physician. • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job. • Sports – participating in any organized sport: professional or semiprofessional. • Custodial Care. This is care meant simply to help people who cannot take care of themselves. • Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications. • Services performed by a relative. • Services related to sex change, sterilization, in vitro fertilization, or reversal of a vasectomy or tubal ligation. • A service or a supply furnished by or on behalf of any government agency unless payment of the charge is required in the absence of insurance. • Elective abortion. • Treatment, services, or supplies received outside the United States and its possessions or Canada. • Dental services or treatment. • Cosmetic surgery, except when due to medically necessary reconstructive plastic surgery. • Mental or emotional disorders without demonstrable organic disease. • Alcoholism, drug addiction, or chemical dependency. • Injury or sickness covered by workers’ compensation. • Routine physical exams and rest cures. pre-eXisting condition limitation pre-existing condition means within the 12-month period prior to the Effective Date of the certificate those conditions for which medical advice or treatment was received or recommended. We will not pay benefits for any loss or injury which is caused by, contributed to by, or resulting from a Pre- Existing Condition for 12 months after the Effective Date of the certificate, or for 12 months from the date medical care, treatment, or supplies were received for the Pre-Existing Condition, whichever is less. A claim for benefits for loss starting after 12 months from
a convalescent home; a rest home or a home for the aged; a place for alcoholics or drug addicts; or a mental institution. a hospital intensive care unit is not any of the following step-down units: a progressive care unit; a sub-acute intensive care unit; an intermediate care unit; a private monitored room; a surgical recovery room; an observation unit; or any facility not meeting the definition of a hospital intensive care unit as defined in the certificate. effective date – The date as shown in the Certificate Schedule if you are on that date actively at work for the policyholder. If not, the certificate will become effective on the next date you are actively at work as an eligible employee. The certificate will remain in effect for the period for which the premium has been paid. The certificate may be continued for further periods as stated in the plan. The certificate is issued in consideration of the payment in advance of the required premium and of your statements and representations in the application. A copy of your application will be attached and made a part of the certificate. The certificate, on its Effective Date, automatically replaces any certificate or certificates previously issued to you under the plan. individual termination – Your insurance will terminate on the earliest of the date the plan is terminated; on the 31st day after the premium due date if the required premium has not been paid; on the date you cease to meet the definition of an employee as defined in the plan; on the premium due date which falls on or first follows your 70th birthday; or on the date you are no longer a member of an eligible class. Termination of any Covered Person’s insurance under the certificate shall be without prejudice to his or her rights as regarding any claim arising prior thereto. portable coverage – When coverage would otherwise terminate because the employee ends employment with the employer, coverage may be continued. The employee will continue the coverage that is in force on the date employment ends, including dependent coverage then in effect. The employee will be allowed to continue the coverage until the earlier of the date the employee fails to pay the required premium or the date the group master policy is terminated. Coverage may not be continued if the employee fails to pay any required premium, the insured attains age 70, or the group master policy terminates.
the Effective Date of a certificate, as applicable, will not be reduced or denied on the grounds that it is caused by a Pre- Existing Condition. Pregnancy is a “Pre-Existing Condition” if conception was before the effective date of a certificate. Treatment means consultation, care, or services provided by a Physician, including diagnostic measures and taking prescribed drugs and medicines. If a certificate is issued as a replacement for a certificate previously issued under the Plan, then the Pre-Existing Condition limitation provision of the new certificate applies only to any increase in benefits over the prior certificate. Any remaining period of Pre-Existing Condition limitation of the prior certificate would continue to apply to the prior level of benefits. terms you need to KnoW you and your – Refer to an employee as defined in the Plan. spouse – Means your legal Spouse who is between that ages of 18 and 64. dependent children – Means your natural children, stepchildren, foster children, legally adopted children, or children placed for adoption, who are under age 26. Your natural children born after the Effective Date will be covered from the moment of live birth. No notice or additional premium is required. Coverage on Dependent Children will terminate on the child’s 26th birthday. However, if any child is incapable of self- sustaining employment due to mental retardation or physical handicap and is dependent on his parent(s) for support, the above age of 26 shall not apply. Proof of such incapacity and dependency must be furnished to the company within 31 days following such 26th birthday. covered person – If the certificate is issued as: Individual coverage, the Covered Person means you; Employee/Spouse coverage, Covered Person means you and your legal Spouse; Single Parent Family coverage, Covered Person means you and your covered Dependent Children, as defined in the applicable rider, that have been accepted for coverage; Family coverage, Covered Person means you and your Spouse and covered Dependent Children, as defined in the applicable rider, that have been accepted for coverage. injury or injuries – An accidental bodily Injury or Injuries caused solely by or as the result of a Covered Accident. covered accident – An accident, which occurs on or after a Covered Person’s Effective Date, while the certificate is in force, and which is not specifically excluded. sickness – An illness, infection, disease, or any other abnormal condition, which is not caused solely by or the result of an Injury. covered sickness – An illness, infection, disease, or any other abnormal physical condition which is not caused solely by or the result of any Injury which occurs while the certificate is in force; and was not treated or for which a Covered Person did not receive advice within 12 months before the Effective Date of his/her coverage; and is not excluded by name or specific description in the certificate. doctor or physician – A person, other than you or a member of your immediate family, who is licensed by the state to practice a healing art; performs services which are allowed by his or her license; and performs services for which benefits are provided by the certificate. a hospital is not a nursing home; an extended care facility;
We’ve got you under our wing. ® aflacgroupinsurance.com 1.800.433.3036 the certificate to which this sales material pertains is written only in english; the certificate prevails if interpretation of this material varies.
this brochure is a brief description of coverage and is not a contract. read your certificate carefully for exact terms and conditions. this brochure is subject to the terms, conditions, and limitations of policy form series ca8500-mp. Underwritten by: Continental American Insurance Company 2801 Devine Street | Columbia, South Carolina 29205
Yates LLC 2024 Benefits Guide |
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