YOUR GROUP INSURANCE PLAN BENEFITS UNIVERSITY CORPORATION AT MONTEREY BAY

Transcription

1 YOUR GROUP INSURANCE PLAN BENEFITS UNIVERSITY CORPORATION AT MONTEREY BAY

2 The enclosed certificate is intended to explain the benefits provided by the Plan. It does not constitute the Policy Contract. Your rights and benefits are determined in accordance with the provisions of the Policy, and your insurance is effective only if you are eligible for insurance and remain insured in accordance with its terms / /A /0001/Q11127/ /0000/PRINT DATE: 11/13/08

3 CERTIFICATE OF COVERAGE The Guardian 7 Hanover Square New York, New York CGP-3-R-STK-90-3 B

4

5 TABLE OF CONTENTS

6 TABLE OF CONTENTS (CONT.)

7 COMPLAINT NOTICE CGP-3-CADISC-91 B

8

9 GENERAL PROVISIONS employee. employer. employer. employee. CGP-3-R-GENPRO-90 B Limitation of Authority CGP-3-R-LOA-90 B Incontestability employer. employer s employer CGP-3-R-INCY-96 B Dental Claims Provisions,

10 Dental Claims Provisions (Cont.) injury sickness injury covered dependents, sickness injury sickness CGP-3-R-AHC-90 B

11 Coordination Between Continuation Sections CGP-3-R-COC-87 B An Important Notice About Continuation Rights CGP-3-R-NCC-87 B

12 YOUR CONTINUATION RIGHTS Federal Continuation Rights

13 Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-1 B CGP-3-R-COBRA-96-2 B

14 Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-3 B

15 Federal Continuation Rights (Cont.)

16 Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-4 B Uniformed Services Continuation Rights. CGP-3-R-COBRA-96-4 B

17 ELIGIBILITY FOR DENTAL COVERAGE B Employee Coverage employee.. employee employees full-time employee,, ;. CGP-3-EC B Employee full-time full-time full-time CGP-3-EC B full-time employees. employees, employees

18 Employee Coverage (Cont.) CGP-3-EC B eligible dependents Dependent Coverage B CGP-3-DEP B CGP-3-DEP B ,

19 Dependent Coverage (Cont.) CGP-3-DEP B CGP-3-DEP B , initial dependents eligibility date eligibility date, enrollment period,

20 Dependent Coverage (Cont.) dependents enrollment period initial initial dependents, newly acquired dependent acquired dependent, newly CGP-3-DEP B hospital CGP-3-DEP B CGP-3-DEP B eligible dependents;

21 Dependent Coverage (Cont.) s, employees employees employee s eligible dependent. CGP-3-DEP B

22 DENTAL HIGHLIGHTS.

23 DENTAL EXPENSE INSURANCE CGP-3-DNTL-90-1 B DentalGuard Preferred - This Plan s Dental Preferred Provider Organization dentists covered person covered person s covered person person s, covered person covered covered person,. CGP-3-DENT-PPO-A B

24 Covered Charges dentist s dentists covered person device prosthetic appliance orthodontic treatment CGP-3-DNTL-90-3 B Pre-Treatment Review covered person s dentist orthodontic treatment, covered person s dentist. covered person s covered person person dentist,.. covered CGP-3-DNTL-90-4 B

25 Benefits From Other Sources, employer s employer, employer s employer. CGP-3-DNTL-90-5 B The Benefit Provision - Qualifying For Benefits charges benefit year benefit year year, covered person covered charges covered benefit Covered charges covered person s covered person s covered charges covered person covered charges benefit year. covered charges benefit year. covered person CGP-3-DNTL-92-7 B covered charges covered charges

26 The Benefit Provision - Qualifying For Benefits (Cont.) appliance covered person covered person s. benefit year CGP-3-DNTL-92-8 B year. year.. benefit year benefit year covered charges benefit benefit CGP-3-DNTL-90-9 B CGP-3-DRATE-90 B

27 After This Insurance Ends prosthetic device, orthodontic treatment CGP-3-DNTL B Special Limitations treatment ; ; orthodontic. injury s CGP-3-DNTL B covered person. prosthetic device. employer covered person covered person benefit year, s benefit year, s CGP-3-DNTL B

28 Exclusions appliance prosthetic device orthodontic treatment. prosthetic devices. prosthetic devices appliance prosthetic device covered person s injury appliance appliance prosthetic device. covered person s employer, CGP-3-DNTL B

29 List of Covered Dental Services dentist. CGP-3-DNTL B Group I - Preventive Dental Services (Non-Orthodontic) persons covered covered persons covered persons

30 Group I - Preventive Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL B Group II - Basic Dental Services (Non-Orthodontic)

31 Group II - Basic Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL B

32 Group II - Basic Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL B Group III - Major Dental Services (Non-Orthodontic) injury,

33 Group III - Major Dental Services (Cont.) (Non-Orthodontic) dentist CGP-3-DNTL B Group IV - Orthodontic Services orthodontic treatment. orthodontic treatment appliances appliance, CGP-3-DNTL B

34 DISCOUNT - THIS IS NOT INSURANCE Discounts on Dental Services Not Covered By This Plan B Discounts on Services Not Covered Due To Contractual Provisions B

35 COORDINATION OF BENEFITS Definitions

36 Definitions (Cont.)

37 Definitions (Cont.) CGP-3-R-COB-05 B Order Of Benefit Determination

38 Order Of Benefit Determination (Cont.) CGP-3-R-COB-05 B Effect On The Benefits Of This Plan Right To Receive And Release Needed Information

39 Facility Of Payment Right Of Recovery CGP-3-R-COB-05 B

40 CERTIFICATE AMENDMENT The Guardian CGP-1-A-CAL-PR B

41 GLOSSARY CGP-3-GLOSS-90 B appliance orthodontic treatment CGP-3-GLOSS-90 B prosthetic device. CGP-3-GLOSS-90 B s CGP-3-GLOSS-90 B relatives. covered person s covered person s close CGP-3-GLOSS-90 B s covered dependents. employee CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B employer employer s CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B

42 Glossary (Cont.) employee employer s employer CGP-3-GLOSS.1 B eligible dependents employee dependents, initial dependents. eligible eligible dependents CGP-3-GLOSS-90 B s covered person s injury appliances prosthetic devices CGP-3-GLOSS-90 B eligible dependent initial dependents. CGP-3-GLOSS-90 B active appliance; active appliances. CGP-3-GLOSS-90 B Guardian employer, CGP-3-GLOSS-90 B CGP-3-GLOSS-90 B

43 STATEMENT OF ERISA RIGHTS

44 Statement of Erisa Rights (Cont.) B

45 The Guardian s Responsibilities B B B

46 Group Health Benefits Claims Procedure

47 Group Health Benefits Claims Procedure (Cont.)

48 Group Health Benefits Claims Procedure (Cont.)

49 Group Health Benefits Claims Procedure (Cont.) B

50 Termination of This Group Plan employer employer B

51 YOUR BENEFITS INFORMATION - ANYTIME, ANYWHERE

52 0000/9999/A /0001/Q11127/B/*EOD*