Group Administration Manual

Transcription

1 Group Administration Manual Welcome To Greater Georgia Life Insurance Company THANK YOU... for selecting Greater Georgia Life Insurance Company to provide benefits for your employees. We at Greater Georgia Life Insurance Company want to make the administration of your plan a successful experience. This manual has been designed to supplement the personal attention you will receive from your Personal Service Representative. This manual is not a part of the policy and should not be viewed as such. The coverage provided under this plan is governed at all times by the terms of your policy, and you should refer to your Group Insurance Policy and Certificate for rate amounts and plan provisions. You have selected Greater Georgia Life Insurance Company to provide benefits for your most important asset... your employees. We are dedicated to that commitment. Greater Georgia Life Insurance Company, Inc. is a wholly owned subsidiary of Blue Cross and Blue Shield of Georgia, an Independent Licensee of the Blue Cross Blue Shield Association. Registered Mark of the Blue Cross Blue Shield Association.

2 TABLE OF CONTENTS SECTION DESCRIPTION PAGE Section A. CONTACT INFORMATION 3 Section B. BILLING - General Information 4 Section C. SAMPLE GROUP BILLING STATEMENT 5 Section D. ELIGIBILITY 16 D1. New Enrollments D2. Late Enrollees D3. Changes D4. Employee Terminations D5. Conversions Section E. TERMINATING THE GROUP POLICY 22 Section F. LIFE CLAIMS 23 F1. Life and Dependent Claims F2. Beneficiary Designations F3. Accidental Death and Dismemberment Claims F4. Accelerated Death Benefit Claims F5. Waiver of Premium Claims Section G. SHORT TERM AND LONG TERM DISABILITY CLAIMS 27 G1. Short Term Disability Claims G2. Long Term Disability Claims Section H. FORMS 30 H1. Member Enrollment Forms H2. Member Change Forms H3. Claim Forms 2

3 Section A. CONTACT INFORMATION LIFE and AD&D CLAIMS Topic: Phone: Fax: Claims - Customer Service, Life and AD&D Claims, Absolute Assignment, Waiver of Premium (800) ((770) Mailing Address: Greater Georgia Life Insurance Company - Life Claims Service Center P.O. Box , Atlanta, GA SHORT TERM and LONG TERM DISABILITY CLAIMS Topic: Phone: Fax: Claims - Customer Service (800) (770) (800) Mailing Address: Greater Georgia Life Insurance Company Disability Service Center P.O. Box , Atlanta, GA MEMBERSHIP, BILLING and GENERAL LIFE & DISABILITY QUESTIONS Topic: Phone: Fax: Membership/Billing (678) OR (800) (678) Mailing Address: Greater Georgia Life Insurance Company P.O. Box 4445 Atlanta, GA Payment Address: Greater Georgia Life Insurance Company P.O. Box Atlanta, GA

4 Section B. BILLING - General Information B1. What is included on the group bill? The group billing statement provides the total amount due for all Greater Georgia Life Insurance Company (GGL) coverages included in your policy. B2. When will I receive the bill? Approximately ten days before each billing due date, you will receive a group billing statement that identifies the total amount due. B3. When is payment due? Payment is due on the first day of the billing period, which for customers billed monthly would be the first of each month. For example, the premium for March 1 to April 1 billing period is due on March 1. If premium is not received prior to the expiration of your grace period (31 days), your policy will lapse. B4. What do I return with the payment? Along with your remittance check made payable to Greater Georgia Life, you should include a copy of the group billing statement. All enrollment application and change request forms should be mailed to the billing address in Section A Membership. B5. How are new enrollments and changes reflected on the bill? A signed enrollment application form or an enrollment change form is necessary to ensure proper coverage for your members. These forms may be submitted at any time during the month and should be mailed to the address shown in Section A - Membership. GGL s membership and billing department will review and determine the eligibility of new enrollments and change requests. Approved membership changes processed between billing periods will be recapped in the Eligibility Adjustments section of your bill. Check your statement carefully to ensure all eligible employees are included on the statement and that benefits are correct. B6. What is the Total Amount Due? Your monthly premium payment should always equal the Total Amount Due as shown on your group billing statement. There is no need to adjust or recalculate your monthly bill. Any adjustments due to eligibility changes to the Total Amount Due will be made on a future billing statement. B7. Whom do I call for help? Your billing statement will include the name of the Personal Service Representative assigned to your group. Your assigned representative can be contacted at and is available to answer any questions you may have regarding your membership records or your group billing statement. For specific claim related questions, please contact either the Life Claims Service Center or the Disability Service Center by using the numbers provided in Section A - Contact Information. 4

5 Section C. SAMPLE GROUP BILLING STATEMENT C1. Overview The group billing statement includes the following three (3) sections: Cover Page Product Summary Billing Detail - Eligibility Adjustments - Manual Adjustment Detail - Membership Detail C2. Cover Page The Cover Page is a summary of all of the billing and payment activity that has occurred since your last month s billing statement. It gives pertinent information regarding the following: - your prior billed and paid amounts - a premium subtotal of any eligibility adjustments submitted and processed since your last bill - a premium subtotal of any manual adjustments made since your last bill - a premium subtotal of all membership for the current billing period - a total amount due for the bill The Cover Page is designed to be folded in half and placed in the remittance window envelope and returned along with your premium payment. To help us identify the payment when returned, your group name, bill entity number, billing period, and due date are displayed on this page. C3. Product Summary Page The Product Summary page displays the contract count totals for all product types, the current month s charges, current volume, any retroactive adjustments and the rate for each product. This provides you with a detailed breakdown of the total amount due for each product. C4. Billing Detail (a) Eligibility Adjustments This section recaps the eligibility changes that were received and processed since the last billing statement was prepared, and details retroactive premium charges and credits. We recommend that you check this section carefully each month to ensure that all eligibility changes you requested were processed accurately. However, remember that new enrollments and eligibility changes received after the 5 th of the month will most likely be reflected on your next billing statement. (b) Manual Adjustment Detail This section identifies any manual adjustment that was made to your Total Amount Due. A reason and a brief description of the adjustment are provided, along with the amount of the adjustment. (c) Membership Detail The Membership Detail section lists all of the subscribers enrolled on your group coverage for the current billing period. This listing is usually in alphabetical order by the subscriber s last name. User's Guide to the Group Billing Statement The following pages provide a field-by-field explanation of the group billing statement. It will help you read and understand your monthly statement. 5

6 USER'S GUIDE TO THE GROUP BILLING STATEMENT Section C2: COVER PAGE TOP HALF - This section provides a recap of the prior and current month s billing amounts/totals. Ref Field Name Description 1 Prior Bill Amount The total amount due for the previous billing. 2 Amount Paid The total premium payment applied toward the prior month s billing. 3 Prior Balance Due Premium discrepancy amount (debit or credit) after last month s billing was reconciled. 4 Eligibility Adjustment Subtotal This amount represents the net total (debit or credit) for all retroactive membership changes processed after the last month s billing was prepared. 5 Manual Adjustment Subtotal An amount will only appear here if a manual adjustment is processed (e.g., reinstatement fees) 6 Membership Detail Subtotal This amount represents the net premium total for the "current billing period only". 7 Total Amount Due The sum of the prior balance due, eligibility adjustment, manual adjustment and the membership detail. LOWER HALF - This section includes pertinent address and billing information. When mailing your payment, it is important to write the amount of your check in the field Enter Amount Paid. (Field 14) Ref Field Name Description 8 Group Information The group s name and billing address. 9 Bill Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes. 10 Invoice Number A unique invoice number will appear on your group billing statement each time a bill is issued for your group. 11 Billing Period The period of time for which you are being billed. 12 Date Billed The calendar date that your billing was generated. 13 Total Due The total premium due. 14 Enter Amount Paid The amount that you are remitting to GGL. 15 GGL Address Greater Georgia Life s remittance address. 16 Sys For internal use only. 17 Desk For internal use only. 18 Bill Entity The primary group number that consolidates all suffixes under one group number for billing purposes. 19 MBS Number For internal use only. 20 Due Date The date by which your premium payment should be received by Greater Georgia Life. 6

7 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) COVER PAGE Invoice Number A Billing Entity No. GAA042C001 1 Prior Bill Amount $ Amount Paid Prior Balance Due $ Eligibility Adjustment Subtotal Manual Adjustment Subtotal Membership Detail Subtotal Total Amount Due $ Please Return this Page With Your Check Please Fold Here for Mailing GREATER GEORGIA LIFE P.O. BOX ATLANTA, GA FAMILY TREE ENTERPRISES 9 Bill Entity No.: GAA042C OXNARD ST. WOODLAND, GA Invoice Number: A 11 Billing Period: To Date Billed: Total Due: $ Enter Amount Paid,,. 15 Make Check Payable To: GREATER GEORGIA LIFE P.O. BOX ATLANTA, GA BILL MBS SYS DESK ENTITY NUMBER Due Date GAA042C001 LSG

8 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C3: PRODUCT SUMMARY The Product Summary section provides a detailed breakdown of the total amount due for each group/product. It displays the contract counts for all contract types, the current month s charges, current volume, any retroactive adjustments and the rate for each product. This gives you the opportunity to quickly determine the monthly charge for each of your products. Ref Field Name Description 1 Billing Entity Name The group s name. 2 Billing Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes. 3 Invoice No. A unique invoice number will appear on your group billing statement each time a bill is issued for your group. 4 Page No. The page number of the bill. 5 Group Contact The first and last name of the person that Greater Georgia Life contacts when billing or reconcilement issues need to be resolved. 6 Personal Service The name of the personal service representative assigned to administer your account. Representative 7 Desk No. The desk number of the personal service representative (this is not an extension number). 8 Telephone The phone number of the personal service representative. 9 Billing Period The period of time for which you are being billed. 10 Date Billed The calendar date that your billing was generated. 11 Payment Due Date The date your premium payment is to be received by Greater Georgia Life. 12 Group/Product Contract Type Your group numbers/product names with the appropriate contract type codes within each product. 13 Current Count The subscriber counts within each contract type. 14 Current Volume Current total volume for all products billed. 15 Billing Charges The premium charges being billed, by contract type, for the current month only. 16 Retro The premium charges being billed, by contract type, for retroactive changes only. 17 Total The total of all current month s premium plus retroactive amounts being billed. 18 Rate The rate for your group will be displayed by group suffix for each contract type. 19 Total The total for each group suffix, by the number of subscribers, current month charges, retroactive charges and the total premium due. 20 Subtotal/All Products The subtotal for all products. 21 Legend Description of all contract types. Note:The subtotal shown for current billing charges will also appear by the membership detail subtotal on the cover page. The subtotal shown for retroactive charges also appears by the eligibility adjustment subtotal on the cover page. 8

9 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) PRODUCT SUMMARY 1 Billing Entity Name: FAMILY TREE ENTERPRISES 3 Invoice No.: A 2 Billing Entity No.: GAA042C001 4 Page No.: 1 5 Group Contact: FRANCES JONES 6 Personal Service Representative: SALLY SMITH 7 Desk No.: Telephone: (800) Billing Period: FROM TO Date Billed: Payment Due Date: Group/Product Current Current Billing Contract Type Count Volume Charges Retro Total Rate GAA042B001 AD&D - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 5 150, *** 19 Total 5 150, GAA0042C001 BASIC LIFE TERM - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 1 30, *** 19 Total 1 30, GAA042F001 LIFE WITH DEP - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 4 120, *** LDEP **** 19 Total 4 120, GAA042L001 LONG TERM DISABILITY - ACTIVE OFFERED BY GREATER GEORGIA LIFE ** ** ** ** , ** , ** ** ** ** ** ** GAA042W001 SHORT TERM DISABILITY - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 5 1, * 19 Total 5 1, Subtotal/ALL Products 310, * Rate per $10 ** Rate per $100 *** Rate per $1000 **** Flat Rate 9

10 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C3: PRODUCT SUMMARY 21 LEGEND S = SUBSCRIBER ONLY 2P = TWO PARTY CONTRACT FAM = FAMILY CONTRACT DEP = ONE DEPENDENT DEPS =TWO OR MORE DEPENDENTS S+DEP = SUBSCRIBER + 1 DEPENDENT (NO SPOUSE) S+DEPS = SUBSCRIBER + 2 OR MORE DEPENDENTS (NO SPOUSE) LSUB = LIFE SUBSCRIBER LSPS = LIFE SPOUSE LCHD = LIFE CHILD LDEP = LIFE SPS AND CHILD(REN) 10

11 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) CALCULATING PREMIUM To calculate the premium due for a particular coverage, please follow the formulas provided below. Please refer to your insurance contract to determine the coverage amounts for your employees. SHORT TERM DISABILITY (*) The cost of weekly income (or short term disability) insurance is calculated based on the actual benefit provided to the employee if that employee becomes disabled. Rates are per $10 of benefit. Use the formula below to calculate the cost of WI/STD coverage. BENEFIT AMOUNT X RATE = PREMIUM $10 EXAMPLE: (STD coverage for John Smith) According to the contract under which he is covered, John's benefit amount will be 60% of his weekly earnings. The maximum benefit allowed under this group plan is $ % of John's weekly earnings : $ Maximum Benefit Amount: $250 Cost of John's coverage: = x.44 = $ LONG TERM DISABILITY INSURANCE (**) Traditional LTD rates are based on a per $100 of monthly covered payroll. However, the payroll rate must be converted to a monthly covered benefit rate and premium is calculated based on monthly benefit. Payroll rate.38 =.633 (benefit rate) Benefit percentage.60 Use this formula to calculate the cost of LTD coverage: MONTHLY BENEFIT X RATE = PREMIUM $100 EXAMPLE: (LTD insurance for Julie Johnson) According to the group contract, this plan will cover a 60% maximum per member's monthly benefit of $5,000 and has a rate of $.38 of monthly covered payroll. Julie's monthly earnings: $3,012 x.60 = 1, (Julie's benefits) Cost of Julie's coverage: 1, = x.633 = $ ** This applies to LTD coverage that was effective prior to June 1,2003. If you have any questions on your LTD premium calculation, please contact your personal service representative. BASIC LIFE/AD&D INSURANCE (***) Life and AD&D rates are per $1,000 of coverage, so premium should be calculated based on the actual benefit amounts provided to each employee. Use the formula listed below to calculate the cost: BENEFIT AMOUNT X RATE = PREMIUM $1,000 EXAMPLE: (Life insurance for John Smith) 25,000 = x.55 = $ ,000 DEPENDENT LIFE INSURANCE (****) Dependent life insurance rates are per family unit. The same rate is charged per family regardless of the actual number of dependents covered. Use the formula below to calculate the cost of dependent life insurance: FAMILY UNIT X RATE = PREMIUM EXAMPLE: (Dependent life insurance for John and Sarah Smith and children) EXAMPLE: (AD&D insurance for John Smith) 25,000 = x.05 = $1.25 1,000 1 Family unit X 1.20 = $

12 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C4: BILLING DETAIL a) ELIGIBILITY ADJUSTMENTS This section of the billing recaps all eligibility changes that were received and processed after the last billing statement was prepared. This section also details all retroactive premium charges. Ref Field Name Description 1 Cert. No. Subscriber s certificate number (generally the employee s social security number). 2 Subscriber Name The name of the subscriber. 3 Dept. No. Employee department number if group requests. 4 Group No. Each of the group numbers that were impacted by the subscriber s eligibility changes. 5 Prod Type Each of the product types that were impacted by the subscriber s eligibility changes. 6 Cont. Type The new contract code resulting from the membership change. 7 No Cvd. Number of members covered. 8 From Date The from date of the change*. 9 To Date The to date of the change*. 10 Mo/Da Indicates the number of months/days affected by the adjustment change. Zeros will be displayed for all changes made during the current billing period. 11 Calc. Rate The rate amount used to calculate retroactive premium (calculation rate) x (number of months/days). 12 Prem. Adj. Premium adjustments resulting from the membership change. The premium adjustment for changes processed as of the current billing period will display with zeros due. Premium amounts for the current billing period are shown in the membership detail section. Premium adjustment amounts shown here represents retroactive premiums only. 13 Code Short description of the membership change processed (See General Terms). 14 Eligibility Adjustment Subtotal The net subtotal of the eligibility adjustments. We recommend that you audit this section of the billing each month to ensure that all eligibility changes requested were processed accurately. * If the change is effective as of the current billing period, the " from" and "to" dates will be the same. If the change is effective retroactive to the current billing period, the effective date will be displayed in the "from date" column. b) MANUAL ADJUSTMENT DETAIL This section identifies any manual adjustment that had to be made to your Total Amount Due. A reason and a brief description of the adjustment are provided, along with the amount of the adjustment. Ref Field Name Description 15 Grp/Suf The group number to which the adjustment has been made. 16 Reason The reason for the adjustment. 17 Description A brief explanation of the adjustment. 18 From Date The from date of the change. 19 To Date The to date of the change. 20 Amount The dollar amount of the adjustment. 21 Manual Adjustment Subtotal The net subtotal of all the manual adjustments. 12

13 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) BILLING DETAIL Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: A Billing Entity No.: GAA042C001 Page No.: 2 Group Contact: FRANCES JONES Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) Billing Period: FROM TO Date Billed: Payment Due Date: ELIGIBILITY ADJUSTMENTS * *Eligibility changes received after the 5 th of the month may be reflected on your next bill Dept Group Prod Cont No. From To Mo/ Calc Prem Cert No. Subscriber Name No. No. Type Type Cvd Date Date Da Rate Adj Code 14 Eligibility Adjustment Subtotal MANUAL ADJUSTMENT DETAIL GRP/SUF Reason Description From Date To Date Amount 21 Manual Adjustment Subtotal 13

14 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) c) MEMBERSHIP DETAIL This section of the group billing statement lists all of your subscribers who are enrolled for the billing period in your group plan. Ref Field Name Description 1 Cert. No. Subscriber s certificate number (generally the employee s social security number). 2 Dept. No. This area will remain blank unless your organization utilizes department numbers for billing purposes. 3 Emp. No. This area will remain blank unless your organization utilizes employee numbers for billing purposes. 4 Subscriber The name of the subscriber. Name 5 COBRA End Does not apply to Life benefits. Date 6 Group No. The group number(s) in which the subscriber is enrolled. /Suffix 7 Grp Type Group type associated with the group the subscriber is enrolled in (e.g. A=Active) 8 Prod Type A brief description of the benefit associated with each group suffix. Refer to the General Terms section for a complete list. 9 Cont Type Current contract type for each subscriber (i.e., S=Subscriber Only, FAM=Family) 10 No. Cvd Total number of members currently covered on the subscriber s contract. 11 Volume Product volume per subscriber. 12 Prem. Amt. Premium amount due for the current billing period for each subscriber. 13 Total The total number of subscribers. Subscribers 14 Volume Total The total volume for subscriber products for your group for the current billing period. 15 Membership The premium sub total amount due for the current billing period. Detail Subtotal 16 Total Amount Due The total amount due for any eligibility adjustments, any manual adjustments and all the membership detail. 14

15 USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) BILLING DETAIL Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: A Billing Entity No.: GAA042C001 Page No.: 2 Group Contact: FRANCES JONES Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) MEMBERSHIP DETAIL Billing Period: FROM TO Date Billed: Payment Due Date: Dept Emp. COBRA Group No. Grp Prod Cont No. Prem. Cert No. No. No. Subscriber Name End Date / Suffix Type Type Type Cvd Volume Amt ATON, VIVIAN GAA042B001 A ADD LSUB 30, GAA042F001 A LDEP LSUB 30, GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD , GAA042W001 A STD LSUB ANNT, XAVIER GAA042B001 A ADD LSUB 30, GAA042F001 A LDEP LSUB 30, GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD , GAA042W001 A STD LSUB HOOVER, YVONNE GAA042B001 A ADD LSUB 30, GAA042C001 A LBAS LSUB 30, GAA042L001 A LTD GAA042W001 A STD LSUB MMEL, ZEEK GAA042B001 A ADD LSUB 30, GAA042F001 A LDEP LSUB 30, GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD , GAA042W001 A STD LSUB SMITH, JOE GAA042B001 A ADD LSUB 30, GAA042F001 A LDEP LSUB 30, GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD , GAA042W001 A STD LSUB Volume Total 310, Total Subscribers: 5 15 Membership Detail Subtotal Total Amount Due

16 Section D. ELIGIBILITY D1. New Enrollments (a) Who is eligible to enroll To obtain coverage under your group policy, an employee must meet the eligibility requirements as defined in your policy, reach an eligibility effective date as designated by the group policy probation period, and enroll by completing a Group Insurance Application or Member Enrollment Application Form. General eligibility requirements for coverage under your group policy include (actual eligibility provisions may vary - please refer to your group policy for details): Employees a. Must be full-time active employees working 30 hours or more per week. b. Must have completed the required probationary period. Dependents (Applicable to Life Only) a. Employee must complete the required probationary period. b. Must be a dependent of a member employee who has elected dependent coverage. Dependents include: - Legal spouse (only one spouse may be enrolled at one time) under the age AND not legally separated from the employee. - Unmarried children who are financially dependent upon the employee for support. Children are considered financially dependent if they qualify as dependents for Federal Income Tax purposes - Unmarried children who meet all the other unmarried children criteria AND who are enrolled as full-time students at an accredited secondary school, college or university. Please refer to your group policy for specifics pertaining to your group. - Age restrictions apply. Please see your policy for details. Notes: 1) An unmarried child may include the employee s natural child, stepchild, legally adopted child, and a child under custody pursuant to a court order or legal guardianship. (Note: Copies of the court documents are required.) 2) The term dependent does NOT include any person who: - is eligible as an employee - is a member of the armed forces of any country - is residing outside the United States and Canada (b) Employees who do not wish to enroll If an employee declines coverage, an application marked "refused" or the "Life/Disability Coverage Waiver Authorization Form" needs to be completed. This is necessary to document that the employee was given an opportunity to enroll through the group plan, but elected not to do so at that time. An employee who declines coverage when first eligible or who does not elect coverage for his eligible family members during the initial eligibility period may apply at a later date, but will be subject to medical underwriting. Refer to Section D2 -Late Enrollees for more information. 16

17 Section D: ELIGIBILITY (continued) (c) When may employees enroll Eligible employees may apply for coverage as a new hire within 31 days of employment or within 31 days of any group's specific employee probationary period. If an employee does not enroll for coverage by completing the enrollment application form within 31 days from his or her eligibility date, the employee and dependents become late enrollees and are subject to medical underwriting. Refer to Section D2 - Late Enrollees for more information. (d) How to enroll new employees Eligible employees may enroll by completing the Group Insurance Application or Member Enrollment Application Form. These forms are created to clearly convey information between you and GGL and it's parent and affiliates. Please take a moment to review and verify that all items have been completed accurately. Errors or missing information could cause a delay in processing and the application being returned. Important points to help your employees enroll: New employees should complete enrollment forms when hired. Applications must be submitted within 31 days from an employee s eligibility date, or the employee will be required to apply for coverage as a late enrollee. Having the form completed when the employee is hired will help in meeting the 31-day timeliness requirement in the event that you or the applicant are away from the office when eligibility occurs. Be sure that each employee indicates the exact coverage(s) desired. This is especially important when dependent term life insurance is desired. If the employee pays any portion of the premium for dependent term life insurance, the box for dependent term life insurance must be checked. If the box is not checked, the dependent life coverage will not be effective. Each member must name a primary beneficiary. (1) A primary beneficiary is the person(s) who will receive the death benefit upon the death of the member. If more than one primary beneficiary is named, be sure to indicate the percentage each person is to receive. If percentages are not indicated, the proceeds will be divided equally. (2) If no beneficiary is named or surviving at the member s death, benefits will be paid to the member s estate. (3) When designating children as beneficiaries, note that we cannot make payment to children under the age of 18. If the beneficiary is under 18, we will pay benefits to a court appointed guardian of property (conservator). (4) Use the full first and last name of the beneficiary; do not use initials only for the first name. (5) A member cannot name his/her employer as their beneficiary. (6) A member cannot name himself as beneficiary. However, a member can name his estate or a trust. When naming a trust as beneficiary, we will need both the name and date of the trust. (7) The employee is always the primary beneficiary in a dependent life claim. 17

18 Section D. ELIGIBILITY (continued) (e) Effective date of coverage If an employee applies for coverage when first eligible, the effective date of coverage will be as stipulated in accordance with the Eligibility section of the Group Term Life Insurance Master Application. Example 1: Assume that your Group Term Life Insurance Master Application provides that employees and their dependents become eligible for coverage on the first day of the month following 30 days of employment. Here is how coverage would begin for a new employee hired on August 15: 1. Date of hire 08/15 2. Date probationary period is completed (Hire date plus 09/14 term of probationary period as shown in the Group Policy) 3. Date coverage begins (as specified in your Group 10/01 Policy) 4. First billing period for which premiums must be paid 10/01-10/31 Example 2: Now let us see how coverage and the first premium payment would differ if the employee is hired on August 1 (rather than August 15): 1. Date of hire 08/01 2. Date probationary period is completed 08/31 3. Date coverage begins 09/01 4. First billing period for which premiums must be paid 09/01-09/30 18

19 Section D. ELIGIBILITY (continued) D2. Late Enrollees (a) Who is a late enrollee? Contributory Products (Employee and Employer Paid) Late enrollment rules apply to employees who elected not to apply when first eligible or who did not enroll prior to the expiration of the enrollment probationary period. Additionally, if an employee has existing coverage with GGL and initially declined dependent life coverage for dependents, but later elects to provide coverage for those dependents, a Member Enrollment Change Form and a Medical Questionnaire are required for the dependents. Non-Contributory Products (Employer Paid) Late enrollment rules do not apply. All employees should be enrolled during their initial eligibility period. Coverage will be effective as of the date first eligible. (b) How to enroll late enrollees Late enrollees may apply for coverage by completing the Group Insurance Application or the Member Enrollment Application and a Medical Questionnaire. The Medical Questionnaire is a self-explanatory form with clear instructions. A copy has been enclosed in this manual. Information on the form should be verified by the employee and the group administrator for completeness and accuracy to prevent a delay in processing. Our Underwriting department will review the application and medical questionnaire. For legal and audit purposes, please be sure the original forms are filled out in ink and are signed by the employee and spouse (if applying). The forms should be mailed immediately to the address in Section A Membership. Please note that applications with signatures more than 60 days old will not be accepted. In some instances, additional medical information may be required. The originals of all questionnaires are to be submitted to GGL; duplicates or facsimiles cannot be accepted. If such health evidence is required, GGL will not be liable for any of the costs related to acquiring the additional documents. It will take approximately 30 days to process the application and medical questionnaire. If approved, the effective date of coverage will be the first of the month following approval by our underwriting department. D3. Changes The Member Enrollment Change Form or Request for Change Form provides documentation that a member has made a change in beneficiary, dependent status (adding or deleting dependent life coverage) or a change in name. All of the appropriate sections of the form must be completed, signed and dated by the employee and must include the employee s certificate number and group number(s). Events that might occur after an employee is originally enrolled include the following: - Primary beneficiary dies Submit change form to specify a new primary beneficiary; otherwise, benefits will be paid to the contingent beneficiary, if one was named; if no contingent beneficiary was designated, benefits will be paid to the member s estate. 19

20 Section D. ELIGIBILITY (continued) - Spouse or dependent loses eligibility (divorce, spouse or dependent s death, dependent s attainment of policy s maximum age, dependent s marriage, etc.) Employee submits Member Enrollment Change Form within 31 days of the event for consideration. The effective date of the change will be the date of the event unless otherwise specified in your policy. Note that the loss of eligibility may also qualify the individual for a conversion policy. Refer to Section D6 - Conversions for more information. - Employee wishes to add a new spouse (marriage or change in employment status of spouse.) A Member Enrollment Change Form must be received within 31 days of the event; the coverage effective date will be the first of the month following the event. If not received within 31 days of the event, a Medical Questionnaire will also be required; the effective date of coverage will be the first of the month following medical underwriting approval. - Employee wishes to assign benefits An employee may request an assignment of benefits by submitting an Absolute Assignment of Group Life Insurance Form to GGL (form available from the Life Claims Service Center ). The request must be approved by GGL to be a valid assignment under the policy. To be valid, an assignment must also be absolute and irrevocable. GGL assumes no liability for its sufficiency. D4. Retroactivity Retroactivity is generally defined as any change affecting additions or terminations of a member or members with an effective date prior to the date received by GGL. The processing of all retroactive changes is solely at the discretion of GGL, and the following guidelines are in place: Non-Contributory Products: Retroactive terminations and changes will be processed for effective dates up to six months prior to GGL receipt. Retroactive additions will be added back to the date first eligible. Contributory Products: Retroactive terminations and changes that reduce benefits will be processed for effective dates up to 90 days prior to GGL receipt for billing purposes. Additions and changes that increase benefits must be applied for within 31 days of becoming eligible. Premium will be billed from the date first eligible. Additions and changes that increase benefits that are not applied for within 31 days of becoming eligible will require the submission of a medical questionnaire and will not be effective until the first of the month following underwriting approval. Requests for effective dates other than what would be provided using the above guidelines must be approved by the Underwriting Department. 20

21 Section D. ELIGIBILITY (continued) D5. Employee Terminations Written notification should be received by GGL when loss of eligibility occurs. Written notification may be provided on your group billing statement, a change form, or letter. This information should be provided as soon as the termination occurs and include the term effective date. If termination is due to death of an employee, please write deceased next to the employee s name along with the date of death. D6. Conversions Eligible employees or spouses may apply, without evidence of insurability, for an individual policy of life insurance when they have lost their eligibility to be covered under the group policy for the following reasons: a. termination of the employee s employment b. death of the employee c. loss of eligibility in a class under this policy Consult your group policy for additional reasons that may allow an eligible employee or spouse to apply for an individual policy. Note: Dependent children are not eligible for conversion. The steps to follow if an eligible employee or eligible dependent wishes to exercise his of her conversion option: a. The employer must complete Section I of the Request for Group Life Conversion Information Form. b. The employer forwards the request to the employee to complete Section II of the form and mail to the address at the bottom of the form. c. The employee will then be sent an application for life conversion, along with the rates for a conversion policy. The employee completes the application and returns it, along with appropriate premium, to the address designated on the form. NOTE: IN ORDER TO MEET THE CONVERSION PROVISIONS SET FORTH IN THE POLICY, THE COMPLETED CONVERSION APPLICATION AND APPROPRIATE PREMIUM MUST BE RECEIVED WITHIN 31 DAYS OF TERMINATION OF YOUR LIFE INSURANCE BENEFITS UNDER YOUR GROUP INSURANCE POLICY. 21

22 Section E. TERMINATING THE GROUP POLICY Termination of a group from GGL coverage can be initiated by a request from the group or by GGL. If the group requests cancellation of its policy, a letter signed by an authorized representative of the company is required. The letter must include the requested cancellation date and be received at least 30 days prior to the next premium due date. Your group policy will clearly outline all of the above in detail. Example: Next premium due date Letter must be received by GGL or the group must receive GGL's notice of termination no later than Cancellation of the group occurs on If no written notice is given, the policy renews under the same terms and conditions. If premium due for a group is not paid before the end of the grace period, GGL will cancel that policy as of the paid to date of the policy. Upon termination, it is the group s responsibility to notify its employees when GGL coverage is cancelled. 22

23 Section F. LIFE CLAIMS Life claims are processed by a claims unit that specializes in the administration and payment of life related claims. Please submit all Life, AD&D, Waiver of Premium, and Accelerated Death claims to the Life Claims Service Center. Our goal is to process all life claims with complete information within 5-7 days of receipt. For specific details regarding the benefits provided by your policy, please refer to the benefit provisions of your policy. Life Claims Contact Information Topic: Phone: Fax: Claims - Customer Service (800) (770) Mailing Address: Life Claims Service Center P.O. Box Atlanta, GA F1. Life and Dependent Claims Life Claims require the following: Claims Submissions Beneficiary Claim Form Certified copy of death certificate Enrollment Form Any change of beneficiary designation, if applicable Employer provides payroll records for last period worked 23

24 F2. Beneficiary Designations In the event of a claim, the Group Administrator is responsible for providing copies of the enrollment form (with beneficiary information) plus any other beneficiary designation forms that the member completed. Valid beneficiary designations should include a name, social security number, relationship to member and birth date. In addition, the form must be signed and dated by the member. Multiple beneficiaries may be named on the same form. If percentages are not filled in, equal shares will be assumed. Primary and secondary beneficiaries may also be named on the form. If the primary beneficiary is not living at the time of the member's death, the secondary beneficiary will receive the benefit. If no beneficiary is living at time of death, or none is named, the benefit will be paid as shown in the certificate booklet. Standard wording would be..."benefits are payable to the executor or administrator of the estate. If there is no executor or administrator, we may at our option: - (a) pay benefit to the spouse if living; or - (b) if there is no living spouse, pay equal shares of the benefit to your children if living; or - (c) if there are no living children, pay the benefit in equal shares to the direct parents if living." It is important to review the wording in the certificate booklet that applies to your benefits. ABSOLUTE ASSIGNMENT BENEFICIARY DESIGNATIONS are a special type of beneficiary designation that can ONLY be changed if the new owner agrees to the change. They change the ownership of the group life benefit. They are often done for estate planning, taxation issues, and for viatical arrangements. Forms are available from the Life Claims Service Center. Refer to Section A - Contact Information for more information. F3. Accidental Death & Dismemberment (AD&D) Claims (a) Accidental Death Claims require the following: Beneficiary Claim Form Certified copy of death certificate Enrollment form Any change of beneficiary designation if applicable Newspaper clipping and/or police report Employer provides payroll records for last period worked AD&D includes the following benefits in addition to life insurance: Accidental Death - Benefit paid if death is by accidental means. Usually, the benefit equals the life benefit. Dismemberment - Benefit paid due to loss of limbs or vision in the event of an accident. Seatbelt - Additional benefit of 10% of face amount or $25,000 (whichever is less), if accidental death was caused while using an unaltered seat belt. Repatriation - Pays up to an additional $5,000 to return remains of member to a mortuary, if accidental death occurred more than 100 miles from primary residence. Education Benefit - Pays an additional benefit in four equal installments of $3,000 to a maximum of $12,000 for the education of the child of the deceased. Refer to the exclusions section of the Certificate booklet for more information on AD&D exclusions. 24

25 F4. Accelerated Death Benefit (ADB) Claims ADB may be included with the Basic Life. It is not available for AD&D or Dependent Life coverages. This benefit is also referred to as Living Life Benefit (LLB). This provision offers up to 50% of the life benefit when an active member becomes terminally ill* and life expectancy is 12 months or less. Employees can request for less than the maximum, but only one payment will be made during the member's lifetime. *Refer to contract wording for specific definition. (a) Typical steps for an ADB claim: 1. Claim forms completed by group, member and physician: a) "Claim for Personal Accelerated Death Benefit" b) "Accelerated Death Benefit Attending Physician's Statement" 2. Employer provides payroll records for last period worked 3. Submit claim forms to Life Claims Service Center 4. Life Claims Service Center reviews 5. If approved, Life Claims Service Center pays ADB benefit to member 6. Employer should reduce the life benefit by the ADB amount paid (reducing monthly cost to employer) 7. Member may file for waiver of premium benefit on remaining benefit, if not already completed. Refer to Section F5 - Waiver of Premium Claims for more information. 8. Upon death of member, group files death claim a) Employer provides payroll records for last period worked b) Life Claims Service Center pays remaining amount to beneficiary c) Employer terminates member from billing statement Refer to Section H - Claim Forms for a list of forms. 25

26 F5. Waiver of Premium Claims Waiver of Premium (also referred to as "W of P", "Total and Permanent Disability" or "TPD") (WAIVER) is a standard provision of group basic and supplemental life policies throughout the industry. It is not available for AD&D or for dependent life. A member may qualify for WAIVER if he/she becomes totally disabled* before age 60 (65 in certain contracts), and is continuously totally disabled for 6 months. If WAIVER is approved, life coverage remains in force, without premium payments, assuming continuous total disability. Approvals are usually for one year with re-certification required annually. *If a member was totally disabled and under age 60 when coverage terminated, and dies within the first 12 months of continuous total disability, a death benefit may be payable even if premium payments ended. Proof of total disability would be required with the death claim. (a) Waiver of Premium Claims require the following: "Disability Claim" form "Application for Group Life Insurance Disability Benefits" form "Attending Physician's Statement" form Employer provides payroll records for last period worked Refer to Section H - Claim Forms for a list of forms. (b) How to apply for waiver: To apply for WAIVER, the group and member must complete the "Disability Claim" form. The doctor must complete the "Application for Group Life Insurance Disability Benefits" and the "Attending Physician's Statement" form. These forms should be completed no earlier than three months before the end of the WAIVER waiting period. Assuming a nine-month waiting period, proof can be submitted when the member has been continuously totally disabled six months but must be submitted prior to 12 months from the date disability commenced. (c) When waiver is approved: The member and group are notified of approval by letter. The "Re-certification for Waiver of Premium" form is sent with the member's letter that indicates the time frame in which to submit the re-certification assuming continuous total disability. We may request a copy of the Notice of Award for Social Security Disability benefits. Under certain conditions, we may also require an examination by our physician, at our expense, at reasonable intervals. A member cannot be covered under WAIVER and a conversion policy simultaneously. If a member converted when group coverage terminated, the conversion policy must be returned when WAIVER is approved. Conversion premiums are then refunded. (d) When waiver ends: Waiver ceases when any of the following occur: The member is no longer totally disabled. Written proof of continuous disability is not provided when required. The member refuses an examination by our physician when required. The benefit schedule provides for a termination or reduction of benefits at a specific age or retirement. When WAIVER ceases, or coverage is reduced, the conversion privilege is applicable. 26

27 Section G. STD & LTD CLAIMS Short Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling , Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. G1. Short-Term Disability (STD) Claim Claims for weekly disability benefits should be filed using the "Short Term Disability Claim Form". You, as the employer, complete Section II. The employee should complete Section I and the attending doctor completes Section III. Mail or fax the completed claim form to the address below. All disability checks will be mailed directly to your member employee. Please contact the Disability Service Center to report the employee s return to work date. STD Claims Contact Information Topic: Phone: Fax: (770) Claims - Customer Service (800) (800) Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center P.O. Box , Atlanta, GA STD MEMBER CLAIM PROCESS OVERVIEW The administration of Short Term Disability (STD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is totally disabled under the provisions of the disability policy. The claim process begins with the completion of a three-part STD Claim Form, including data from the employee, the employer and the attending physician. Eligibility for benefits is confirmed by the policyholder's Benefit Representative who completes the employer's portion of the form. The claim should be submitted as soon as it becomes evident that the employee will be out of work in excess of the plan's initial elimination period. The claim form may be either faxed or mailed to GGL. Upon receipt of all three parts of the completed claim form and any clinical information (if requested), the Disability Case Manager (DCM) is in a position to evaluate the claim. The DCM works closely with policyholder's Benefit Representatives to obtain physical job descriptions and evaluate any opportunities for modified or light duty work. A claim decision is made within three days of receipt of all required information. The Claim Form with clinical documentation and occupational requirements are taken into consideration when a claim is reviewed. Once a claim is approved, STD benefits are issued to the claimant on a weekly basis. Periodic clinical updates are requested as needed. 27