PacifiCare Senior Supplement Plan F (VI) Group Health Insurance Certificate

Transcription

1 PacifiCare Senior Supplement Plan F (VI) Group Health Insurance Certificate PacifiCare Life and Health Insurance Company (the Company ) hereby delivers to the Group Policyholder a Policy providing insurance for certain eligible Covered Persons. The Certificate describes the benefits and provisions of the insurance provided by the Policy. You may receive the benefits specified in the Certificate if You are eligible for insurance under the provisions of the Policy. The Certificate is not a contract of insurance and only summarizes the primary provisions of the Policy. The Certificate supersedes and replaces any similar certificate that the Company previously issued to You. The Certificate is valid only if it includes Your Schedule of Benefits. PacifiCare Life and Health Insurance Company Susan L. Berkel, President This is not a Medicare supplement plan. This is an Employer Group Retiree Plan and may provide coverages that are different from a Medicare supplement plan. PacifiCare Life and Health Insurance Company 3100 Lake Center Drive Santa Ana, California GHC-RET-FP

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3 Table of Contents Sections Certificate Provisions Page Number Important Notice Administrators General Provisions General Definitions Eligibility, Enrollment and Effective Dates for Personal Insurance Termination of Coverage General Benefit Provisions Medicare Eligible Expenses Exclusions and Limitations Claims and Claims Procedures for Insurance Coordination of Benefits Statement of ERISA Rights California Appeal Rights GHC-RET-TOC 1

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5 Important Notice to Persons on Medicare This is not a Medicare supplement insurance plan The Policy under which You are insured is an employer group retiree plan. The benefits provided under the Policy may differ from benefits that are provided under an Individual Medicare supplement plan. Some of the benefits provided under the Policy may be the same as benefits provided under an Individual Medicare supplement plan. The Policy may provide coverage not provided under an Individual Medicare supplement plan depending on the coverage purchased by the Employer. The Policy will not pay benefits for services, supplies or treatment that is paid under Medicare. Because this is an employer group retiree policy,you are not precluded from having coverage under the Policy and an Individual Medicare supplement policy. Having duplicate coverages will not increase the amount of the benefit paid to You. Benefits under Medicare and all health insurance coverage plans You have will never exceed 100% of the amount You were charged for a service. Therefore, it is important that You read this Certificate carefully to determine the benefits it provides. The Company recommends that You check the coverage in all the Health Insurance Policies You already have. For more information about Medicare and Medicare supplement insurance, review the Guide to Health Insurance for People with Medicare produced by the Federal Government. You may obtain a copy of this publication from the Company s plan Administrator. For help in understanding Your health insurance, contact Your state insurance department or state senior insurance counseling program. GHC-RET-NOTICE 3

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7 Administrators Certain provisions of the Certificate are administered by one or more of the Company s Administrators. They are as follows: For payment of claims, eligibility, and benefits verification: PacifiCare Health Plan Administrators Attn: Senior Supplement Plan P.O. Box 6072 Cypress, California GHC-RET-AD 5

8 General Provisions ARBITRATION. If any Insured Person has a dispute, disagreement or claim against the Company, or any employee or agent of the Company, which has not been resolved or settled after exhaustion of the Company s grievance procedures, then the dispute or disagreement shall be resolved by arbitration. The provision shall be applicable to claims or controversies arising under the Policy. Arbitration shall be conducted in accordance with the Commercial Rules of Arbitration of the American Arbitration Association. The decision of the arbitrator(s) shall be binding upon the parties for all purposes and judgment upon the award granted by the arbitrator(s) may be entered in any court having jurisdiction thereof. CERTIFICATE. The Group Policyholder will receive individual Certificates for delivery to each Insured Person. These Certificates summarize the benefits provided by the Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CLERICAL ERROR. Clerical error does not invalidate insurance otherwise validly in force, nor continue insurance otherwise validly terminated. Neither the passage of time nor the payment of premiums for a person who is not eligible for insurance under the terms of the Policy makes this insurance valid for such person. In this event, the Company s only liability is the proper refund of unearned premiums. If a premium adjustment requires the refund of unearned premium, the maximum refund is the 6-month period preceding the date the Company receives proof of the adjustment. The Company can request such information while the Policy is in force and for 12 months after the Policy ends. CONFORMITY TO STATE AND FEDERAL LAW. The Company amends any provision of the Policy that conflicts with state or federal law on the Policy Effective Date to the minimum requirements of the law. EMPLOYER NOT OUR AGENT. The Employer is not an agent of the Company. PROVIDER AS INDEPENDENT AGENT. The Company does not undertake to directly furnish any health care service under the Policy. The obligations of the Company under the Policy are limited to the payment for health care service provided to Covered Persons by Providers who are independent agents. MEDICAL RECORDS. The Company shall have access to medical and treatment records of Covered Persons to determine benefits, process claims, utilization review, quality assurance, financial audit, or for any other purpose reasonably related to the Policy benefits. Each Covered Person shall complete and submit to the Company such additional consents, releases and other documents as may be requested by the Company in order to determine or provide benefits under the Policy. The Company reserves the right to reject or suspend a claim based on lack of supporting medical information or records. RECOVERY OF PAYMENTS. The Company reserves the right to deduct from any benefits properly payable under the Policy the amount of any payment which has been made: 1. in error; 2. pursuant to a misstatement contained in a claim; 3. pursuant to a misstatement made to obtain coverage under the Policy within 2 years after the date such coverage commences; 4. with respect to an ineligible person; 5. pursuant to a Claim for which benefits are recoverable under any policy or act of law provided for coverage for occupational injury or disease to the extent that such benefits are recoverable. This provision shall not be deemed to require the Company to pay benefits under the Policy in any such instance. GHC-RET-GP 6

9 Such deduction may be made against any Claim for benefits under the Policy by an Insured Person or by any of his or her covered Dependents if such payment is made with respect to such Insured Person or any person covered or asserting coverage as a Dependent of such Insured Person. DISCHARGE OF LIABILITY. Any payment made in accordance with the provisions of the Policy shall fully discharge the liability of the Company to the extent of such payment. RIGHT TO RECEIVE INFORMATION. The Group Policyholder shall provide the Company with the information necessary to administer coverage under the Policy. Payroll and any other records of an Insured Person relating to coverage under the Policy shall be open for review by the Company at any reasonable time. The Company may request that information needed to compute the premium be furnished at least once each year. TIME EFFECTIVE. Whenever an effective date of coverage or termination date of coverage is specified by the Policy, such commencement of coverage will be effective as of 12:00 a.m. of that date. WAIVER OF RIGHTS. The Company s failure to enforce any provision of the Policy does not affect Our right to enforce any provision at a later date, and does not affect the Company s right to enforce any other provision of the Policy. GHC-RET-GP General Definitions Certain words or phrases, when used in the Certificate, have only the meanings shown below. These words or phrases when defined appear capitalized. Whenever a personal pronoun in the masculine gender appears in the text, it also includes the feminine, unless the context clearly indicates the contrary. ACCIDENT means an acute Injury that happens suddenly, unexpectedly and without design of the person injured. An accident does not include any activity which ordinarily would not injure a person in good health. ADMINISTRATOR means an appropriately licensed organization with whom the Company has contracted to perform administration services. Applicable administrators are identified under the Administrators section of the Certificate. BENEFIT PERIOD means the period of time used to measure inpatient benefits. A Benefit Period begins on the first day of a Medicare covered inpatient Hospital stay and ends when the Covered Person has been out of a Hospital or Skilled Nursing Facility for sixty (60) consecutive days (including the day of discharge). CALENDAR YEAR means January 1, 12:00 a.m. to December 31, 11:59 p.m. of the same year. CALENDAR YEAR DEDUCTIBLE means the amount of Covered Expense shown on the Schedule of Benefits that a Covered Person is responsible for paying each Calendar Year before benefits are payable under the Policy. Covered Expenses that a Covered Person has to pay due to any additional Deductibles or any Copayments will not be applied toward satisfying the Calendar Year Deductible. CLAIM means notification in a form acceptable to the Company that a Covered Service has been rendered or furnished to a Covered Person. This notification must set forth in full the details of such Covered Service as required by the Company. GHC-RET-DEF 7

10 General Definitions (cont d.) COINSURANCE means that portion of the Covered Expense that is not payable as a benefit due to the Percentage Payable being less than 100%. Coinsurance does not include any Deductible. Coinsurance does not include any amounts payable by the Covered Person which are not considered as Covered Expense under the Policy. CONFINED means that a Covered Person is: 1. restricted to staying in a Hospital, at home or elsewhere because of Injury or Sickness; and 2. unable to carry on any substantial part of the Covered Person s normal activities. COVERED EXPENSE means an expense that: 1. is incurred for a Medicare Eligible Expense provided to a Covered Person while that Covered Person is insured under the Policy and does not exceed the Medicare allowable amount; or 2. is incurred for a non-medicare Eligible Expense that: (a) has been specifically added to the coverage provided by the Policy through a rider amendment to the policy; (b) is provided to a Covered Person while that Covered Person is insured under the Policy; and (c) does not exceed the lesser of billed charges or Usual and Customary Charges; and 3. does not exceed the smallest of any Policy maximum that may apply to the Covered Expense. COVERED PERSON means the Insured Person or the Dependent(s) of the Insured Person who are insured under the Policy. CREDITABLE COVERAGE means coverage under any of the following: 1. a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employer Retirement Income Security Act of 1974; 2. a group health benefit plan provided by a health insurance carrier or health maintenance organization; 3. an individual health insurance policy or evidence of coverage; 4. Part A or Part B of Title XVIII of the Social Security Act (Medicare); 5. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928; 6. Chapter 55 of Title 10, United States Code; 7. a medical care program of the Indian Health Service or of a tribal organization; 8. a state or political subdivision health benefits risk pool; 9. a health plan offered under Chapter 89 of Title 5, United States Code; 10. a public health plan (as defined in federal regulations); or 11. a health benefit plan under Section 5(e) of the Peace Corps Act. Creditable Coverage does not include coverage consisting solely of the following: 1. coverage only for accidents, or disability income insurance, or any combination thereof; 2. liability insurance, or coverage issued as a supplement to liability insurance; 3. workers compensation or similar insurance; 4. automobile medical payment insurance; 5. credit-only insurance; 6. coverage for on-site medical clinics; or 7. other similar insurance coverage specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Creditable Coverage does not include any of the following, if offered separately: 1. limited scope dental or vision benefits; GHC-RET-DEF 8

11 2. long term care, nursing home care, home health care, community-based care, or any combination thereof; 3. Medicare supplemental health insurance; 4. coverage supplemental to coverage under Chapter 55 of Title 10, United States Code; or 5. similar supplemental coverage provided to coverage under a group health plan. Creditable Coverage does not include either of the following, if offered as independent, noncoordinated benefits: 1. coverage only for a specified disease or illness; or 2. Hospital indemnity or fixed indemnity insurance. CUSTODIAL CARE means those personal services required to assist the Covered Person in meeting the requirements of daily living. Custodial Care includes, without limitation, assistance in walking, getting in or out of bed, bathing, dressing, feeding, using the lavatory, preparation of special diets, and supervision of medical schedules. Custodial Care does not require the continuing attention of trained medical or paramedical personnel. DEDUCTIBLE means the amount of Covered Expense a Covered Person must pay before benefits become payable under the Policy. DEPENDENT means a person who is the Insured Person s: 1. Spouse/Domestic Partner who is not legally separated from the Insured Person; 2. unmarried child younger than 19 years of age; 3. unmarried child younger than 23 years of age and a full-time student at an accredited college or university; or 4. unmarried child meeting all of the following conditions: a. totally and permanently disabled and unable to earn a living (proof of such disability must be submitted to the Company within 30 days of the date coverage would have ended due to the child s age); b. dependent on the Insured Person for principal economic support. The term child includes the Insured Person s unmarried: 1. natural child, including a newborn child; and 2. adopted child, including a child the Insured Person is seeking to adopt. The term full-time student status means enrollment in an accredited school as a full-time student as defined in the rules of the school. Child also includes an Insured Person s stepchild if the child is dependent on the Insured Person for principal economic support. The term Dependent does not include any person serving in the armed forces of any country. DOMESTIC PARTNER means, per California law, a registered domestic partner is established between two same-sex adults age 18 and older whom: (1) share a common residence; (2) are not married to, or in domestic partnership with, another adult; (3) are not related by blood; and (4) have filed a Declaration of Domestic Partnership with the California Secretary of State. DURABLE MEDICAL EQUIPMENT means items or appliances that: 1. are able to withstand repeated use; 2. are designed to serve a medical purpose; 3. generally are not useful to a Covered Person in the absence of a medical condition, Injury or Sickness; 4. are not disposable; 5. are not customarily found in a Physician s office; 6. are needed for functional rather than cosmetic reasons; and 7. are appropriate for use in the home. Equipment must be Medically Necessary and prescribed by a Physician for use in the home, such as oxygen equipment, standard wheelchairs, GHC-RET-DEF 9

12 General Definitions (cont d.) and hospital beds. This term does not include charges for the repair or maintenance of such equipment. The Company will determine if the item is Medically Necessary in accordance with the Medicare laws, regulations and guidelines. EFFECTIVE DATE means, with respect to any Covered Person, the date such Covered Person is first insured under the Policy. ELIGIBLE RETIREE means a retired employee of the Group Policyholder who is age 65 or older and who is covered under both Parts A and B of Medicare. EMERGENCY means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could reasonably be expected to result in: 1. placing the patient s health in serious jeopardy; 2. serious impairment to bodily functions; or 3. serious Injury to or dysfunction of any bodily organ or part. EMPLOYER means the Group Policyholder and/or any employer approved by the Company for participation in the coverage provided by the Policy. EXCLUSIONS mean those health care services not covered under the Policy. EXPERIMENTAL OR INVESTIGATIONAL TREATMENT PROCEDURES AND ITEMS mean any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies that are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the Sickness, Injury or condition at issue, unless a procedure is an organ or tissue transplant determined by the Company pursuant to Medicare guidelines to not be experimental. FULL-TIME EMPLOYEE means an employee of the Employer: 1. whose employment with the Employer is the employee s principal occupation; and 2. who is regularly scheduled to work at such occupation at least the minimum number of hours shown in the Policy Information Page. GROUP POLICYHOLDER means the person, partnership, corporation or trust as shown on the Policy Information Page of the Policy. HOME HEALTH AGENCY means a Medicarecertified agency that provides intermittent Skilled Nursing Care and other therapeutic services in the Covered Person s home when Medically Necessary, when the Covered Person is confined to his or her home, and when authorized by the Covered Person s treating Physician. HOSPICE CARE means treatment providing pain relief, symptom management and supportive care and counseling during the terminal phase of a Sickness by a Medicareapproved Hospice. Hospice Care is provided when the Covered Person is judged to have six (6) months of life expectancy or less and no longer elects to pursue aggressive medical treatment for the terminal Sickness. HOSPITAL means a general acute care hospital licensed by the state and certified by Medicare. HOSPITAL SERVICES mean services for covered inpatient, outpatient, Emergency, diagnostic and therapeutic services performed by a Hospital on an inpatient or outpatient basis which are directed or authorized by the Covered Person s treating Physician. Hospital Services do not include services received from custodial care facilities such as convalescent nursing homes, rest facilities, or facilities for the aged. Hospital services must be either Medically Necessary Medicare Eligible Expenses as determined by Medicare or covered under a rider to the Policy and be Medically Necessary as determined by the Company. GHC-RET-DEF 10

13 INJURY means bodily injury due to an Accident occurring while a Covered Person is insured under the terms and conditions of the Policy. INPATIENT means being registered as an inpatient in a Hospital or a Facility upon the recommendation of a Provider, and incurring charges for room and board. INPATIENT SERVICES mean those Covered Services provided to a Covered Person in a Hospital or Skilled Nursing Facility bed that is not in the Outpatient department of such institution. INSURANCE MONTH means that period of time: 1. beginning at 12:00 a.m. Standard Time at the Group Policyholder s principal location on the first day of any calendar month; and 2. ending at 11:59 p.m. on the last day of the same calendar month. INSURED PERSON means the Retiree for whom coverage is in effect as provided by the Policy. LATE ENROLLEE means a Person or a Dependent who enrolls for coverage under the Policy other than during: 1. the 31-day period following the date the Person or the Dependent becomes eligible for coverage; or 2. a Special Enrollment Period. MEDICARE means Hospital Insurance Plan (Part A) and the supplementary Medical Insurance Plan (Part B) provided under Title XVIII of the Social Security Act, as amended. MEDICARE ELIGIBLE EXPENSE means expenses of the kind covered by Medicare, to the extent recognized as reasonable and Medically Necessary by Medicare. Payment of benefits under the Policy for Medicare Eligible Expenses will be based on the same payment conditions and determinations of medical necessity as are applicable under Medicare. MENTAL ILLNESS OR MENTAL HEALTH means a psychological or mental condition that has an emotional or psychological origin and that is diagnosed by a Physician or a licensed clinical psychologist as a condition listed in the Diagnostic and Statistics Manual IV. Illnesses that are considered severe disorders of the brain including, but not limited to, schizophrenia, schizoaffective disorder, bipolar and delusional depression and pervasive developmental disorder are considered Mental Illnesses for the purposes of the Policy. Any loss for Mental Illness must begin while the Policy is in force. OPEN ENROLLMENT PERIOD means a period of time as specified in the application of the Group Policyholder and approved by the Company during which Persons may enroll themselves and their Dependents under the Policy. The Open Enrollment Period, if any, is shown on the Policy Information Page. PART A means the Hospital Insurance Benefits for the Aged portion of Medicare. PART B means the Supplementary Medical Insurance for the Aged portion of Medicare. PART B EXCESS CHARGES mean the difference between Medicare s approved amount for Part B services and the actual charges up to the amount of charge limitations set by either Medicare or state law. PERCENTAGE PAYABLE means the benefits payable under the Policy which are a percentage of the Covered Expense in excess of all Deductibles and Copayments. The Percentage Payable for each type of Covered Service is set forth in the Schedule of Benefits. PERSONAL INSURANCE means the group health insurance provided by the Policy on Insured Persons. POLICY means the Group Health Insurance Policy issued by the Company to the Group Policyholder. POLICY ANNIVERSARY means the annual date stated as the Policy Anniversary on the Policy Information Page of the Policy. POLICY EFFECTIVE DATE means the date stated as the Policy Effective Date on the Policy Information Page of the Policy. GHC-RET-DEF 11

14 General Definitions (cont'd.) POLICY MAXIMUM means the maximum amount of benefits payable under the Policy for all Covered Expenses incurred by a Covered Person while insured under the Policy. The Policy Maximum is shown on the Schedule of Benefits. No further benefits will be paid after a Covered Person reaches the Policy Maximum, and such Covered Person will no longer be insured under the Policy. PROVIDER means a duly licensed or certified practitioner of the healing arts, who is practicing within the scope of his or her license. REPLACED PLAN means a similar health benefits policy or plan that was issued to the Group Policyholder and which the Policy replaced. RETIREE means a retired employee of the Group Policyholder. SEMI-PRIVATE ROOM RATE means the most common charge for a two-bed room in a Hospital, Facility, or Skilled Nursing Facility, as determined by the Company. SICKNESS means a physical illness, disease or Complication of Pregnancy, but does not include Mental Illness. The term Sickness, when applied to the Insured Person or the Insured Person s covered Spouse/Domestic Partner, will include pregnancy and resulting childbirth. SKILLED NURSING CARE means skilled nursing service that is Medically Necessary, ordered by the Covered Person s treating Physician, customarily provided by licensed Skilled Nursing Facilities, and above the level of Custodial Care. SKILLED NURSING FACILITY means a skilled nursing facility or skilled nursing unit of a legally operated hospital certified under Titles XVII and XIX of the Social Security Act. SPECIAL ENROLLMENT PERIOD means a period of time, mandated by the Health Insurance Portability and Accountability Act of 1996, where Persons or Dependents who are not insured under the Policy may enroll for coverage as specified in the Special Enrollment provision. SPOUSE means the Insured Person s legally recognized husband or wife under the laws of the state where the Policy is delivered. WE, OUR, US AND COMPANY mean PacifiCare Life and Health Insurance Company. YOU and YOUR mean the Insured Person. SIGNIFICANT BREAK IN COVERAGE means a period of 63 consecutive days during all of which an individual does not have any Creditable Coverage. Waiting periods and HMO affiliation periods during which an individual does not have coverage are not taken into account in determining a Significant Break in Coverage. GHC-RET-DEF 12

15 Eligibility, Enrollment and Effective Dates for Personal Insurance ELIGIBILITY. Only Retirees of the Group Policyholder and the Retirees Dependent Spouse/Domestic Partner are eligible for coverage under the Policy for Retirees. The Retiree or their Dependent Spouse/Domestic Partner must: 1. be age 65 or older; and 2. be covered under Medicare Parts A (Hospital) and B (Medical Insurance). If the eligible Spouse/Domestic Partner is a Dependent of a Full-Time Employee who is covered under another group plan issued to the Employer by PacifiCare, the Dependent will be eligible for coverage under the Retiree Policy if all other eligibility requirements are met. Dependents under the age of 65 will not be insured under the Policy for Retirees. However, the Dependents may be eligible for coverage under a PacifiCare plan issued to the Employer for active employees and Dependents who are under the age of 65. Please contact either PacifiCare or Your former Employer for additional information if You have Dependents under the age of 65. NOTIFICATION OF ELIGIBILITY CHANGE. Any Covered Person who no longer satisfies the eligibility requirements is not covered by the Policy and has no right to any of the benefits described in the Certificate. The Company must be notified within 31 days of any change in the status of any condition that may affect eligibility. EFFECTIVE DATE. The Retiree or their Dependent may be enrolled for coverage under the Policy in one of the four ways described below. Subject to payment of the applicable premium, the Company s receipt of the appropriate enrollment forms and the Delayed Effective Dates provision below, Personal Insurance becomes effective as indicated in this section. 1. Open Enrollment. If a Retiree or Dependent Spouse/Domestic Partner enrolls during an Open Enrollment Period, coverage will become effective on the first day of the Insurance Month following the end of the Open Enrollment Period. 2. Within 31 Days of an Eligibility Date. If a Retiree or Dependent Spouse/Domestic Partner does not enroll during an Open Enrollment Period, but does enroll within 31 days after first becoming eligible for coverage under the Policy, Personal Insurance will become effective on the first day of the Insurance Month following the date of enrollment. 3. Late Enrollment. In the event a Retiree or Dependent Spouse/Domestic Partner who is eligible for coverage under the Policy declines enrollment for coverage during an Open Enrollment Period or within 31 days of becoming eligible, and subsequently requests enrollment, Personal Insurance will become effective on the first day of the Insurance Month following the end of the next Open Enrollment Period after the date on which the Person enrolled, unless the Person is eligible for Special Enrollment. 4. Special Enrollment. A Special Enrollment Period of 31 days is provided for a Retiree or Dependent Spouse/ Domestic Partner to enroll for coverage under the Policy if the Retiree or Dependent Spouse/Domestic Partner: a. had other health insurance coverage at the time he or she was eligible to enroll under the Policy; b. was given the opportunity to enroll; c. certified in writing that having other coverage was the reason for declining enrollment under the Policy; d. was notified that the failure to provide the certification would result in a delay in future coverage under the Policy; and GHC-RET-ELIG-DEP 13

16 Eligibility, Enrollment and Effective Dates for Personal Insurance (cont d.) e. has lost or will lose such other health insurance coverage due to exhaustion of a COBRA continuation provision, a loss of eligibility for the other coverage, or a termination of employer contributions for the other coverage. The Effective Date of coverage for the Person enrolled during this Special Enrollment Period will be the first day of the Insurance Month following the date on which the Person enrolled. GHC-RET-ELIG-DEP Termination of Coverage INDIVIDUAL TERMINATIONS. A Covered Person s coverage will terminate on the earliest of the following: 1. the date the Policy terminates; 2. the date the Covered Person is no longer covered by Medicare Parts A and B; 3. the last day of the Insurance Month in which the Insured Person requests termination; 4. the last day of the last Insurance Month for which premium payment is made on behalf of the Covered Person; 5. the date the Covered Person ceases to be eligible for coverage under the Policy; 6. with respect to any particular insurance benefit, the date that benefit terminates; or 7. the date the Covered Person becomes insured through a foreign state or country s health insurance program. FRAUD OR DECEPTION. At its discretion, the Company may terminate or rescind the Policy or a Covered Person s coverage under the Policy, if the following are true: 1. the Covered Person knowingly provides the Company with fraudulent information upon which the Company relies; and 2. such information materially affects the Covered Person s eligibility for enrollment or benefits under the Policy. In such instance, the Company shall send a written notice of termination or rescission to the Insured Person. The Company will also refund any unearned premium which applies after the date of termination or rescission. FRAUDULENT USE OF IDENTIFICATION CARD. A Covered Person s eligibility for coverage under the Policy shall immediately terminate if the Covered Person permits the use of his or her insurance identification card by any other person. In such instance, the Company shall mail a written notice of termination to the Insured Person. The Company will also refund any unearned premium which applies after the date of termination. GHC-RET-TERM-DEP 14

17 General Benefit Provisions DEDUCTIBLE TAKE-OVER. If the Policy is replacing a similar policy that had been issued to the Group Policyholder, any portion of any Deductible the Covered Person had satisfied under the Replaced Plan shall apply to the satisfaction of the Covered Person s initial Calendar Year Deductible under the Policy. Proof of deductible satisfaction under the Replaced Plan will be required upon submission of the initial claim for benefits to be payable under the Policy. EFFECT OF CHANGES IN MEDICARE BENEFITS. The benefits provided under the Policy will not duplicate benefits provided under Medicare. Coverage provided for deductible amounts will automatically change to coincide with any applicable changes in Medicare. Premiums may be modified to correspond with any such changes. EMERGENCY SERVICES. If a Covered Person needs Emergency medical services, the Covered person should: 1. Immediately go to the nearest Hospital or Emergency room or call for assistance. 2. Notify, or take reasonable steps to notify the Covered Person s regular Physician as soon as possible to inform the Physician of the treatment rendered. MEDICARE ASSIGNMENT. If a provider of services accepts the assignment method of payment under Medicare, the Company s payment will be limited to the difference between the amount paid by Medicare and the approved charge under Medicare. NON-DUPLICATION OF BENEFITS. Benefits provided under the Policy will not duplicate any benefits paid by Medicare. The combined benefits provided under the Policy and Medicare or other coverage will never exceed 100% of the charges incurred for medical services and supplies. Additionally, if a service is covered under more than one provision of the Policy, benefits will be provided under the provision that provides the greatest benefit but not under both provisions. PAYMENT OF BENEFITS. The Company will pay a benefit under the Policy for the Covered Expense that a Covered Person incurs due to Sickness or Injury when the Covered Expense exceeds the Calendar Year Deductible and any other Deductible that may apply. Benefits will be paid as set forth in the Schedule of Benefits. Benefits will not exceed the Policy Maximum or any other maximums or limits set forth in the Policy. Benefits are subject to the Exclusions and Limitations specified in the Policy. The Definitions and all other terms and conditions of the Policy that may limit or exclude benefits also apply in determining the payment of the benefits. PRESUMPTION OF AVAILABILITY OF MEDICARE BENEFITS. In determining the benefits payable under the Policy, the Covered Person will be presumed to be enrolled in Medicare Parts A and B. Payments of benefits for a Covered Person who is not enrolled in Medicare will be the same as for a Covered Person who is enrolled in Medicare. GHC-RET-BEN-PAYMENTS 15

18 Medicare Eligible Expenses Covered Services A. BASIC BENEFITS The purpose of this benefit is to pay for Part A Medicare Eligible Expenses that are not paid by Medicare. Benefits for Covered Expenses are available only to the extent that the Medicare Eligible Expense has not been paid by Medicare. Coverage is subject to all other limitations and exclusions set forth in the Policy and in the Schedule of Benefits. The Company will pay the following benefits subject to the limits set forth in the Schedule of Benefits: 1. Part A Medicare Eligible Expenses for hospitalization of a Covered Person, to the extent not covered by Medicare, from the 61st day through the 90th day in any Benefit Period. 2. Part A Medicare Eligible Expenses incurred as daily Hospital expenses during a Covered Person s use of Medicare s 60 nonrenewable lifetime inpatient reserve days to the extent these charges are not covered by Medicare. 3. When Medicare stops paying Part A benefits because all hospital inpatient coverage, including lifetime reserve days, have been exhausted, the Company will continue to pay 100% of the amount Medicare was paying for Part A Medicare Eligible Expenses based on the Diagnostic Related Group (DRG) day outlier per diem. These extended benefits are limited to a lifetime maximum benefit of an additional 365 days. 4. Under Medicare Parts A and B, the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells as defined under federal regulations) unless replaced in accordance with federal regulations. 5. The Coinsurance amount of Medicare Eligible Expenses under Medicare Part B regardless of hospital confinement, subject to the Medicare Part B Deductible. B. ADDITIONAL BENEFITS Benefits for Covered Expenses are available only to the extent that the Medicare Eligible Expense has not been paid by Medicare. Coverage is subject to all other limitations and exclusions set forth in the Policy and in the Schedule of Benefits. The Company will pay the following benefits subject to any limits set forth in the Schedule of Benefits: 1. Medicare Part A Deductible. The initial Deductible under Part A of Medicare when Medicare pays for a Covered Person s stay in a hospital. 2. Medicare Part B Deductible. The initial Deductible under Part B of Medicare. 3. Skilled Nursing Facility Care. The actual billed charges up to the Coinsurance amount of Part A Medicare Eligible Expenses. Benefits are limited to the 21st day through the 100th day of the Covered Person s confinement. Payment will be made only for: a. Part A Medicare Eligible Expenses incurred during a Skilled Nursing Facility stay for which Medicare Part A benefits are paid including: i) Semi-private room ii) Meals including special diets iii) Regular nursing services iv) Physical, occupational and speech therapy v) Drugs vi) Medical supplies vii) Use of appliances such as wheelchairs; and GHC-RET-MEE 16

19 b. Skilled Nursing Facility confinements beginning within 30 days after the Covered Person s discharge from a Hospital stay of at least 3 days. 4. Medically Necessary Emergency Care In A Foreign Country. Eighty percent (80%) of the Medicare Eligible Expenses for Medically Necessary Emergency Hospital, Physician and medical care received in a foreign country if the Covered Person lost entitlement to Medicare recovery solely because of a temporary absence from the United States. Benefits will be: GHC-RET-MEE a. limited to charges covered by Medicare if care had been provided in the United States; b. limited to treatment that began during the first sixty (60) consecutive days of a trip outside of the United States; c. subject to a $250 Calendar Year Deductible; and d. limited to a lifetime maximum benefit of fifty thousand dollars ($50,000). 5. Medicare Part B Excess Charges. One Hundred percent (100%) of the difference between the Medicare Eligible Expenses and the actual billed charges. Charges may not exceed charge limitations established by the Medicare program or by state law. With respect to the Covered Services of a Physician, this benefit will supplement, but not duplicate, benefit payments made under Part B of Medicare and the Skilled Nursing Facility Benefit of this Certificate. Medicare Eligible Expenses used to meet the Calendar Year Deductible for Part B, if applicable, will not count as a Covered Service under this benefit. Exclusions and Limitations No benefits will be provided under the Policy for, or in connection with, the following treatments, services or supplies: 1. Any expense or service that is not determined by the Company to be a Medicare Eligible Expense, unless coverage for the expense or service is specifically provided by a Rider to the Policy. 2. Any treatment or service found to be unnecessary by Medicare. 3. Any services or supplies paid for by Medicare. 4. Any treatment, service or supply that is not Medically Necessary. 5. Any treatment, service or supply that is provided before the Covered Person s Effective Date of coverage under the Policy or after the Covered Person s coverage has terminated under the Policy. 6. Any Injury or Sickness that arises out of, or in the course of, any past or present employment, or that is covered under any Workers Compensation law or similar law. 7. Charges for self-inflicted Injury or attempted suicide. 8. Charges incurred as a result of participation in a riot, insurrection or the commission of a felony. 9. Any treatment, confinement, services or supply provided by a government owned or operated Facility, unless the Covered Person is legally required to pay the charges incurred. 10. Any Injury or Sickness resulting from war or any act of war (declared or undeclared). 11. Charges incurred while on active duty with any military, navy or air force of any country or international organization. GHC-RET-EXL 17

20 Exclusions and Limitations (cont d.) 12. Blood and plasma, except that this exclusion will not apply to the first three (3) pints of blood a Covered Person receives in a Calendar Year. 13. Experimental or Investigational Treatment, Procedures and Items. 14. The Medicare Part A Coinsurance for days 366 and over, after the Medicare 365 day lifetime reserve has been used. 15. Preventive Care. 16. At Home Recovery Visits for services provided for short term, at-home assistance with the Activities of Daily Living for a Covered Person who is recovering from a Sickness, Injury or surgery. 17. Prescription Drugs unless specifically provided by rider. 18. Hospice Care. ACTS BEYOND THE COMPANY S CONTROL. In the event of circumstances not reasonably within the control of the Company, such as any major disaster, epidemic, complete or partial destruction of facility, war, riot, or civil insurrection, which result in the unavailability of the facilities or personnel, the Company shall not have any liability or obligation for delay or failure for the provision of medical services and/or treatment of the Covered Person. GHC-RET-EXL Claims and Claims Procedures for Insurance CLAIMS PROCEDURE. These procedures must be followed by Covered Persons to obtain payment of benefits under the Policy. LIMITATION OF LIABILITY. The Company shall not be obligated to pay any benefits under the Policy for any Claims if the proof of loss for such Claim was not submitted within the period provided, unless it is shown that: (a) it was not reasonably possible to have submitted the proof of loss within such period; and (b) the proof of loss was submitted as soon as it was reasonably possible. In no event will the Company be obligated to pay benefits for any Claim if the proof of loss for such Claim is not submitted to the Company within 1 year after the date of loss, except in the case of legal incapacity of the Covered Person. NOTICE OF CLAIM. A written notice of Claim must be furnished to the Company within 60 days after a covered loss occurs or begins, or as soon thereafter as reasonably possible. The Company will, upon receipt of notice of Claim, furnish to the Insured Person such forms as are usually furnished for filing proof of loss. If such forms are not furnished within 15 days after the giving of such notice, the Insured Person shall be deemed to have complied with the requirements of the Policy as to the proof of loss upon submitting within the time fixed in the Policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which a Claim is made. PROOF OF LOSS. Written proof of loss must be furnished to the Company at its office within 90 days after the date of the loss. The Company will not reduce or deny a Claim for failure to furnish such proof within the time required, provided such proof is furnished as soon as reasonably GHC-RET-CLS 18

21 possible. Except in the absence of legal capacity, the Company will not accept proof more than 1 year from the time proof is otherwise required. TIME OF PAYMENT OF CLAIMS. Benefits for incurred medical expenses that are covered under the Policy will be paid upon receipt of a proper Claim by the Company. PAYMENT OF BENEFITS TO INSURED PERSON. All benefits, unless assigned under the Policy, are payable to the Insured Person, whose Injury or Sickness, or whose covered Dependent s Injury or Sickness, is the basis of a Claim. DEATH OR INCAPACITY OF INSURED PERSON. In the event of the Insured Person s death or incapacity and in the absence of written evidence to the Company of the qualification of a guardian for the Insured Person s estate, the Company may, in its sole discretion make any and all payments of benefits under the Policy to the individual or institution that, in the opinion of the Company, is or was providing the Insured Person s care and support. ASSIGNMENTS. Benefits for Covered Expenses may be assigned by the Covered Person to the person or institution rendering the services. No such assignment will bind the Company prior to the payment of the benefits assigned. The Company will not be responsible for determining an assignment s validity. Payment of assigned benefits will be made directly to the assignee unless a written request not to honor the assignment, signed by the Covered Person and the assignee, is received prior to payment. LEGAL ACTIONS. Any Person may not bring legal action for benefits against the Company: 1. Until at least 60 days after proof of loss is sent to the Company as required; or 2. More than 3 years after the time for submitting proof has ended. PHYSICAL EXAMINATIONS. The Company, at its expense, may: 1. Have a Covered Person examined, as often as reasonably necessary, while any Claim is pending; and 2. Have an autopsy made, where allowed by law, if a Claim for benefits is made. GHC-RET-CLS Coordination of Benefits COORDINATION OF BENEFITS. Under certain circumstances, coverage provided by the Policy will be secondary to any other group, medical or health coverage a Covered Person may receive, such as Workers Compensation, automobile medical, no-fault liability insurance or employer group health plan coverage. When a claim is received that involves other parties, the Company will coordinate benefits to be sure that the Covered Person is fully covered but without any duplication of benefits. The following rules will be used to determine which coverage will be primary: 1. A plan without a Coordination of Benefits provision must pay benefits before a plan with such a provision. 2. A plan that covers a person as an employee or retiree must pay benefits before a plan that covers the person as a Dependent. 3. A plan that covers a person as a full-time employee or Dependent of a full-time employee must pay benefits before a plan covering the person as a retiree or as a Dependent of a retiree. 4. If automobile medical, no-fault or liability insurance is available to a Covered Person, then those benefits must be used first. GHC-RET-COB 19

22 Coordination of Benefits (cont d.) RIGHT TO RECEIVE AND RELEASE INFORMATION. For determining the applicability and implementing the terms of this Coordination of Benefits provision or any provision of similar purpose of any other Plan, the Company may release or obtain from any insurance company or other organization or person any information, with respect to any Covered Person, which the Plan deems to be necessary for such purposes. Any Covered Person claiming benefits must furnish information necessary to implement this provision. REIMBURSEMENT OF PAYMENT. Payments made by any organization may be reimbursed by the Company subject to Policy limitations. Such reimbursements will fully discharge the Company s liability under the Policy. RIGHT OF RECOVERY. Whenever payments for Covered Expenses exceed the maximum payment necessary to satisfy the Coordination of Benefits provisions, the Company may recover such excess payments. The term payments for Covered Expenses includes the reasonable cash value of any benefits provided in the form of services. THIRD PARTY LIABILITY AND NON-DUPLICATION OF BENEFITS. This provision applies when: 1. A Covered Person suffers an Injury or Sickness through the act or omission of another person (the Third Party ); and 2. Benefits are paid under the Policy for that Injury or Sickness. The Company is entitled to a refund of all benefits paid. The refund must equal the payment for the Injury or Sickness by the Third Party. The Company may file a lien against the Third Party payment. The Covered Person must complete and return any required forms to the Company upon request. The Covered Person agrees that the Company s rights to reimbursement under the Coordination of Benefits section are the first priority Claim against any Third Party. The Company shall be reimbursed from any recovery before payment of any other existing Claims, including any Claim by the Covered Person for general damages. The Company may collect from the proceeds of any settlement or judgment recovered by the Covered Person, or his or her legal representative, regardless of whether the Covered Person is fully compensated. The Covered Person agrees to cooperate in protecting the interests of the Company. The Covered Person must execute and deliver to the Company any and all liens, assignments or other documents necessary to fully protect the right of the Company, including, but not limited to, the granting of a lien right in any claim or action made or filed on behalf of the Covered Person. The Covered Person s failure to cooperate with the Company may result in such Covered Person s termination under the Policy. The Covered Person shall not settle any Claim, or release any person from liability, without the written consent of the Company, if such release or settlement extinguishes or bars the Company s rights of reimbursement. In the event the Company employs an attorney for the purpose of enforcing any part of this section against a Covered Person, based on the Covered Person s failure to cooperate with the Company, the prevailing party in any legal action or proceeding shall be entitled to reasonable attorneys fees. In lieu of payment as indicated above, the Company, at its option, may choose to be subrogated to the Covered Person s rights to the extent of the benefits received under the Policy. The Company s subrogation right shall include the right to bring suit in the Covered Person s name. The Covered Person shall fully cooperate GHC-RET-COB 20