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Consolidated Association of Resolute Employers
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Daily In-Hospital Indemnity Benefit: If a Covered Person, while insured, is confined in a hospital as a result of a covered accident or sickness, the policy will pay the benefit amount shown in the schedule. Payment will be for each day of confinement, for up to the maximum 30 days per confinement, as shown in the Schedule. No benefit will be paid for any day the Covered Person is not under the regular care and attendance of a physician.
Outpatient Physician Office Visit Indemnity Benefit: The policy will pay the amount shown in the schedule for a physician office visit as a result of a covered sickness or accident. Benefits are payable for a maximum of five visits per calendar year for you and your spouse each and a maximum of five visits per year for all children combined.
Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit: The policy will pay the benefit as shown in the Schedule when laboratory tests are performed for the purpose of diagnosis of a covered Accident or Sickness as indicated by symptoms that would suggest an Injury or Sickness has occurred, while the Covered Person is not confined in a Hospital. This benefit is limited to once per Testing Day, not to exceed three testing days per calendar year shown in the schedule.
Surgical and Anesthesia Indemnity Benefit: If a Covered Person undergoes a surgical procedure listed in the Schedule of Surgical Indemnity Benefits as a result of covered accident or sickness, the policy will pay the benefit shown in the Schedule of Surgical Indemnity Benefits based on the plan level selected. The policy will also pay the benefit amount, 20% of the surgical benefit amount, for the administration of anesthesia by a Physician in connection with the surgery. If two or more procedures are performed through the same incision or operative field, the benefit paid will be for only the procedure that has the larger benefit. If more than one procedure is performed, but each through a separate incision or in a separate operative field, the amount payable will be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed.
Off-the-Job Accidental Injury Benefit: The policy will pay benefits on the actual charges incurred, up to the amount shown in the Schedule for each covered person (maximum five covered accidents per covered person per calendar year), for x-rays used to diagnose an accidental injury and treatment of a covered accident by a physician in the physician’s office, clinic, or urgent care facility or hospital emergency room. Treatment must be received within 72hours of such accident for benefits to be payable. The policy will also pay the benefit shown in the Schedule if a covered person requires ambulance transportation to a hospital or emergency center for injuries sustained in an accident. Benefits will be provided in the amount of $350 per covered person, with a maximum of three trips per calendar year per family. Ambulance transportation must be within 72 hours of the Accident, and be provided by a licensed professional ambulance company.
Prescription Drug Indemnity Benefit: The policy will pay the amount specified in the Schedule when a Covered Person incurs expenses for prescription drugs, when such drugs are prescribed by a Physician, as a result of an Accident or Sickness. This benefit will be paid for the Maximum Number of Prescriptions per Calendar Year as shown in the Schedule.
Critical Illness Indemnity Benefits and Subsequent Critical Illness Indemnity Benefit: When you are first diagnosed with a covered critical illness, the appropriate percentage of the amount shown on the benefit page will be paid. Dependent coverage is equal to 50% of your benefit amount. This amount is payable up to two times for each covered person, first under the Critical Illness Indemnity Benefit and then under the Subsequent Critical Illness Indemnity Benefit, and is paid in addition to any other benefits paid by the TransChoice policy. The Subsequent Critical Illness Indemnity Benefit is not payable for Skin Cancer or Carcinoma In Situ. The Subsequent Critical Illness Indemnity Benefit is paid if the covered person is diagnosed for the first time as having a subsequent and separate covered critical illness more than sixty (60) days after the diagnosis of the first covered critical illness. For example: If you are first diagnosed with a heart attack, and then you are diagnosed for the first time with a stroke more than sixty (60) days later, you will receive the benefit amount selected for each illness. Each benefit is payable one time for each covered person. After the waiting period has expired, benefits are payable for the following critical illnesses: • Cancer (including leukemia and Hodgkin’s Disease, except Stage 1 Hodgkin’s Disease) • Heart attack (diagnosis must be based on EKG changes consistent with injury, elevation of cardiac enzymes, and confirmatory imaging studies) • Stroke (the diagnosis must be based on documented neurological deficits and confirmatory neuroimaging studies) • End Stage Renal Failure (chronic, irreversible failure of the function of both kidneys, such that a covered person must undergo regular hemodialysis or peritoneal dialysis at least weekly) • Major Organ Transplant (undergoing surgery as a recipient of a transplant of a human heart, lung, liver, kidney, or pancreas) • Skin Cancer including basal cell epitheloma or squamous cell carcinoma; does not include malignant melanoma or mycosis fungoides • Carcinoma In Situ (cancer that is confined to the site of origin without having invaded neighboring tissue) According to this table:
Dependent coverage is equal to 50% of this benefit.
Wellness Benefit: The policy will pay the amount shown in the Schedule for each Covered Person who has undergone the following: physical examinations, mammograms, pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings, after the Waiting Period shown in the Schedule has expired. This benefit is payable only once each 12-month period for each Covered Person. Services must be under the supervision of or recommended by a Physician, and a charge must be incurred.
Group Term Life Insurance Policy with AD&D Rider The policy pays the benefit amount shown on the benefit page upon the death of the insured, subject to any limitations/exclusions. Benefit amounts are selected by you. All eligible children in each family will be covered for the same amount. The AD&D coverage amount will match the amount of group term life insurance. Under the AD&D Rider, when a covered accident results in any of the following losses, benefits are paid for the following specified percentages of the coverage amount subject to any limitations and exclusions: Loss Percentage Payable Loss of Life or loss of two or more members (hand, foot, sight of an eye)............100% Quadriplegia (total and permanent paralysis of both upper and lower limbs).........100% Loss of speech AND hearing in both ears.........................................................100% Paraplegia (los or paralysis of both lower limbs)...............................................75% Loss of one member, or loss of speech, or loss of hearing in both ears................50% Hemiplegia (total and permanent paralysis of the upper and lower limbs of one side of the body).......................................50% Loss of hearing of one ear, or loss of thumb and index finger of same hand.........25%
Prescription Drug Indemnity Benefit The benefit pays the amount shown on the benefit page per prescription when you and your covered dependents incur expenses for prescription drugs prescribed by a physician as a result of a covered sickness or accident. The benefit pays for up to (12 prescriptions per calendar year for you and your spouse each and 12 prescriptions per year for all children combined). By presenting your Caremark prescription drug Discount card to one of Caremark's 55,000 participating providers, you can also receive a discount of at least 14% off the retail pharmacy price of brand-name drugs and up to 60% for generic drugs. The discount card will be included in the fulfillment package that you receive from KBA. You will continue to receive the discount even after your TransChoice prescription drug benefit has been used for the year.
Non-Insurance Benefits
Employee Discount Card: This discount card is provided by New Benefits, Ltd. It offers employees access to a discount Vision Plan, a Nurses Hotline, Counseling Services and benefits for Hearing Aids. This is not an insurance plan. The discount Vision Plan through the Coast to Coast network allows the employee to receive discounts of 20% to 60% on eyeglasses, non-prescription sunglasses, contact lenses (including disposables) and frames from over 10,000 independent retail optical locations nationwide. Providers include independent practitioners, regional chains, department store opticals, and the largest chains in the U.S.. Some of these providers are LensCrafters, Pearle Vision, Sears Optical and JC Penney Optical (among others).* The Nurses Hotline allows access to experienced registered nurses 24 hours a day, 7 days a week, 365 days a year. These hotline nurses are an immediate, reliable and caring source of health information, education and support. Services provided by this plan include: · General information on all types of health concerns · Information based on physician-approved guidelines · Answers about medication usage and interaction · Information on non-medical support groups · Translation services for non-English speaking callers · Full time medical director on staff The Counseling Services benefit allows the employee to speak with a counselor 24 hours a day, 7 days a week regarding any personal problems they may be facing. In addition, if the employee is referred to one of the 27,000 counseling providers nationwide, they will receive discounts of 25% to 30% off the normal billing charges from those providers.* The Hearing Aid benefit provides savings of up to 15% off the retail cost on over 70 models of hearing aids, and a free hearing test when utilizing one of the 1,200 participating Beltone® locations nationwide. Or, the employees can realize savings of up to 50% off suggested retail price on over 90 models of hearing aids in over 1,000 locations nationwide.* Contact Information New Benefits, Ltd. 1420 Proton Road Dallas, TX 75344 (800) 800-8304 Information on how to access the benefits of the Employee Discount card will be included in the fulfillment package that each insured employee receives from KBA. *Discounts on professional services are not available where prohibited by law.
PPO Network Benefit - Offered by KBA: You have the option of accessing the Preferred Provider Network(PPO). If you utilize one of the member providers (hospitals or physicians) in the National Preferred Provider Network (NPPN), then discounts will apply that could lower out-of-pocket expenses. NPPN's network is comprised of more than 700,000 physician locations, approximately 4,400 acute care facilities, and more than 100,000 ancillary care provider locations. This network is provided by Plan Vista Solutions. In the stat eof Indiana the PPO network is provided by IHN. As Indiana's largest PPO, IHN has more health care providers than any other PPO Network in the state. The IHN network is comprised of 142 general acute care hosiptals, over 25,000 physician locations and over 1,500 ancillary facilities. The PPO discounts continue to apply to the member's medical bills even after the TransChoice benefits have been exhausted. Information on accessing either of these networks will be included in the fulfillment package that you will received from KBA.
Prescription Discount Card: By presenting your Caremark prescription drug Discount card to one of Caremark's 55,000 participating providers, you can also receive a discount of at least 14% off the retail pharmacy price of brand-name drugs and up to 60% for generic drugs. The discount card will be included in the fulfillment package that you receive from KBA. You will continue to receive the discount even after your TransChoice prescription drug benefit has been used for the year.
Limitations and Exclusions (TransChoice): No benefits will be payable as the result of: • suicide or any attempt thereof, while sane or insane; • any intentionally self-inflicted injury or sickness; • rest care or rehabilitative care and treatment; • immunization shots and routine examinations such as physical examinations, mammograms, pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings unless the Wellness Benefit is included; • routine newborn care, including routine nursery charges; • the treatment of mental illness; functional or organic nervous disorder, regardless of cause; alcohol abuse; and drug use, unless such drugs were taken on the advice of a physician and taken as prescribed. In such circumstances and with respect to payment of the Daily In-Hospital Indemnity Benefit, benefits will be limited to no more than 10 days in any calendar year; • participation in a riot, civil commotion, civil disobedience, or unlawful assembly; • committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; • participation in an organized contest of speed, parachuting, parasailing, bungee jumping, or hang gliding; • air travel, except as a fare-paying passenger on a commercial airline on a regularly scheduled route, or as a passenger for transportation only and not as a pilot or crew member; • any accident caused by the participation in any activity or event, including the operation of a vehicle, while under the influence of a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated (intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred); • any procedure or treatment to change physical characteristics to those of the opposite sex and other treatment related to sex change; • the reversal of tubal ligation and vasectomies; • artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or physician’s services, unless required by law; • any loss incurred while on active duty status in the armed forces (if the insured notifies Transamerica of such active duty, Transamerica will refund any premiums paid for any period for which no coverage is provided as a result of this exception); • accidents or sicknesses arising out of and in the course of any occupation for compensation, wage, or profit OR expenses which are payable under Occupational Disease Law or similar law, whether or not application for such benefits has been made; • pre-existing conditions during the first 12 months after the effective date (only applies to the Critical Illness Indemnity Benefit and Subsequent Critical Illness Benefit); • air or ground ambulance transportation (unless the Ambulance Benefit has been included); • routine eye examinations or fitting of eye glasses; • hearing aids or fitting of hearing aids; • dental examinations or dental care other than expenses resulting from an accident; • care or treatment of an accident or sickness not specifically provided for in the plan; • any surgical procedure not specifically listed in the Schedule of Surgical Indemnity Benefits; • with respect to the Off-the-Job Accidental Injury Benefit only, charges that the covered person is not legally required to pay, or charges which would not have been made if this coverage had not existed; or • treatment of an accident or sickness made necessary by or arising from war, declared or undeclared, or any act of war.
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