We respectfully submit the above Rider for your review and approval. It is new and does not replace any like forms previously filed with your state.

Transcription

1 Filing at a Glance Company: Fidelity Security Life Insurance Company Refractive Surgery {and Loss of SERFF Tr Num: FDLT State: Wisconsin Sight} Benefit Rider TOI: H20G Group Health - Vision SERFF Status: Closed State Tr Num: Sub-TOI: H20G.000 Health - Vision Co Tr Num: R State Status: Filing Type: Form Co Status: Reviewer(s): Marcia Zimmer Authors: Jennifer Glaser, Ronni Disposition Date: 01/23/2007 Jones, Debbie Oestreich Date Submitted: 01/03/2007 Disposition Status: Approved Implementation Date Requested: On Approval Implementation Date: General Information Project Name: R Project Number: R Requested Filing Mode: Review & Approval Explanation for Combination/Other: Submission Type: New Submission Overall Rate Impact: Filing Status Changed: 01/23/2007 State Status Changed: Corresponding Filing Tracking Number: Status of Filing in Domicile: Pending Date Approved in Domicile: Domicile Status Comments: Filing submitted simultaneously with our domicile state of Missouri. Market Type: Group Group Market Size: Small and Large Group Market Type: Deemer Date: Filing Description: RE: Fidelity Security Life Insurance Company NAIC #71870 FEIN # Group Health R We respectfully submit the above Rider for your review and approval. It is new and does not replace any like forms previously filed with your state.

2 The above Rider will be offered as a supplemental benefit, to be used with any Group Health product approved in your state. This Rider provides a limited indemnity benefit payable once per insured person for specific surgical procedures that are performed to correct errors of refraction. This Rider may also provide a Loss of Sight benefit, if an insured person suffers permanent and irrecoverable loss of sight in one or both eyes due to an injury. Coverage is elected at the Policyholder/Participating Organization level and covers all eligible members/employees and their dependents. This product is solicited via one-on-one or direct mail basis. Variable information is indicated by brackets { }. The variable will not be adjusted to be less favorable than your state allows. If you have questions or need additional information, please do not hesitate to contact me at (extension 143) or me at jglaser@fslins.com. Sincerely, Jennifer Glaser Senior Contract Analyst Company and Contact Filing Contact Information Jennifer Glaser, Sr. Contract Analyst jglaser@fslins.com 3130 Broadway (800) [Phone] Kansas City, MO (816) [FAX] Filing Company Information

3 Fidelity Security Life Insurance Company CoCode: State of Domicile: Missouri 3130 Broadway Group Code: 451 Company Type: Life & Health Kansas City, MO Group Name: State ID Number: (800) ext. [Phone] FEIN Number:

4 Filing Fees Fee Required? Retaliatory? Fee Explanation: Per Company: No No No

5 Correspondence Summary Dispositions Status Created By Created On Date Submitted Approved Marcia Zimmer 01/23/ /23/2007

6 Disposition Disposition Date: 01/23/2007 Implementation Date: Status: Approved Comment: Rate data does NOT apply to filing.

7 Item Type Item Name Item Status Public Access Supporting Document Certification of Compliance Approved Yes Form Benefit Rider Approved Yes

8 Form Schedule Lead Form Number: R Review Form Form Type Form Name Action Action Specific Readability Attachment Status Number Data Approved R Other Benefit Rider Initial 50 r02916.pdf

9 F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri Phone A STOCK COMPANY (Herein Called the Company ) REFRACTIVE SURGERY {AND LOSS OF SIGHT} BENEFIT RIDER This Rider amends the Policy/Certificate to which it is attached. The following refractive surgical benefits are added: DEFINITIONS {Injury means a bodily Injury sustained directly and independently of all other causes resulting in a covered loss under this Rider.} LASEK (Laser Assisted Epithelium Keratomileusis) means a slight variation of the traditional LASIK procedure as described below. This surgical procedure utilizes a trephine to create an epithelial flap (as opposed to the deeper stromal flap with LASIK) and an alcohol solution to preserve the epithelial cells. Once the epithelial flap is created and lifted, the treatment proceeds as for traditional PRK, with light smoothing at its conclusion. The epithelial flap is then repositioned with a small spatula. LASIK (Laser Assisted In-Situ Keratomileusis) means a surgical procedure involving the use of a computer-controlled excimer laser to reshape the cornea (epithelium) without invading the adjacent cell layers. An automated microkeratome is used to shave off a thin, hinged layer of the cornea that is lifted, and the exposed surface is reshaped using the laser. After altering the cornea curvature, the flap is replaced and is adhered without stitches. In IntraLase Initiated LASIK, a special laser is used instead of a blade to create the flap. In Custom Wavefront or Wavefront-Guided LASIK procedures, a 3-dimensional measurement of how the eye processes images is used to guide the laser in re-shaping the front part of the eye (cornea). PRK (Photorefractive Keratectomy) means a surgical procedure involving removal of the surface layer of the cornea by gentle scraping and use of a computer-controlled excimer laser to reshape the stroma. Physician means an Ophthalmologist or Optometrist licensed under applicable state law to perform the surgical procedures for which benefits are payable under this Rider, and who is acting within the lawful scope of his or her license to render such service. A Physician cannot be the {Insured, Insured Person, Member, Employee, Covered Person} or a member of the {Insured s, Insured Person s, Member s, Employee s, Covered Person s} Immediate Family. "Immediate Family" means the {Insured, Insured Person, Member, Employee, Covered Person} or the {Insured s, Insured Person s, Member s, Employee s, Covered Person s} spouse, parent, child, grandparent, brother, sister, in-law or any person residing with the {Insured, Insured Person, Member, Employee, Covered Person}. Refractive Surgery means a surgical procedure which permanently alters the focusing power of the eye(s) in order to change refractive errors. BENEFITS Refractive Surgery Benefit. The Company will pay a one-time surgical indemnity benefit of {$100 - $1,000} (per {Insured, Insured Person, Member, Employee, Covered Person}) for one of the following refractive surgical procedures to one or both eyes: LASIK (including Custom Wavefront, Wavefront-Guided or IntraLase initiated LASIK), LASEK or PRK, if performed by a Physician on {a}{an} {Insured, Insured Person, Member, Employee, Covered Person} while covered under this Rider, subject to the Exclusions provision. R {###}

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11 {Loss of Sight Benefit. If {a}{an} {Insured, Insured Person, Member, Employee, Covered Person} suffers a permanent and irrecoverable loss of sight in one or both eyes due to an Injury that is sustained directly and independently of all other causes within {90-365} days from the accident date, the Company will pay a benefit of {$100 - $1000}. The Injury and loss of sight must occur while the {Insured, Insured Person, Member, Employee, Covered Person} is covered under this Rider.} EXCLUSIONS Refractive Surgery Vision Benefit Exclusions Benefits are not payable for any of the following: 1. {Routine vision examinations or corrective vision materials, including corrective eyeglasses, fittings, lenses, frames or contact lenses; or} 2. {Medical or surgical procedures, services or treatments: a. {not specifically covered under this Rider;} b. {provided free of charge in the absence of insurance;} c. {payable under any Workers Compensation law, or similar statutory authority;} d. {payable under any governmental plan or program whether Federal, state or subdivisions thereof.}} {Loss of Sight Benefit Exclusions Benefits are not payable for loss of sight caused directly or indirectly by any of the following: 1. {attempted suicide or intentionally self-inflicted Injury, while sane or insane (while sane in Colorado and Missouri);} 2. {sickness, including any medical or surgical treatment of sickness;} 3. {infections, except pyogenic infections resulting from Injury;} 4. {participation in a riot or insurrection. For purposes of this exclusion, participation means to take an active part in common with others; riot means any use or threat to use force or violence or disturbance by three or more persons without authority of law;} 5. {in the service of the Armed Forces of any country or organization;} 6. {war or act of war, whether declared or undeclared;} 7. {commission or attempted commission of a felony or misdemeanor;} 8. {voluntary use of any alcohol, drug or narcotic or inhalation of any kind of gas, unless prescribed by a doctor and taken according to the prescribed dosage;} 9. {any Injury that occurs while {a}{an} {Insured, Insured Person, Member, Employee, Covered Person} has been determined to be intoxicated: a. by judicial or administrative judgment or order; b. by evidence of an alcohol concentration in the {Insured s, Insured Person s, Member s, Employee s, Covered Person s} blood, breath or urine which equals or exceeds the limits set by applicable motor vehicle laws; or c. by other evidence demonstrating the {Insured, Insured Person, Member, Employee, Covered Person} was under the influence of any alcohol, narcotic, barbiturate or hallucinatory drug, unless the same was administered on the advice of a Physician and was taken according to the prescribed dosage; and the use of such substance was a proximate cause of the Injury;} 10. {travel or flight in any aircraft except, as a fare paying passenger of a commercial airline flying on regularly scheduled routes between definitely established airports;} 11. {on the job Injury that is covered under Workers Compensation law or similar statutory authority;} or 12. {participation in any activity in which {a}{an} {Insured, Insured Person, Member, Employee, Covered Person} purposely exposes the {Insured, Insured Person, Member, Employee, Covered Person} to an increased risk of bodily Injury. These activities include, but are not limited to: a. belaying and repelling rock climbing; b. flying ultra-light aircraft; c. hang-gliding, skydiving, scuba diving, para-sailing; d. motorized vehicle stunt driving, racing, jumping, drag racing and demolition; e. bungee jumping; or f. any sport for exhibition purposes.}} 2

12 This Rider takes effect on the {later of the} effective date {of the {Policy}{/}{Certificate} to which it is attached} {or {Month Day, Year}} {shown in the Certificate Schedule}. This Rider terminates concurrently with the {Policy}{/}{Certificate} to which it is attached. It is subject to all the definitions, limitations, exclusions and conditions of the {Policy}{/}{Certificate} except as stated. FIDELITY SECURITY LIFE INSURANCE COMPANY President Secretary 3

13 Rate Information Rate data does NOT apply to filing.

14 Supporting Document Schedules Review Status: Satisfied -Name: Certification of Compliance Approved 01/23/2007 Comments: Please see the attached form. Attachment: WI - Certification of Compliance.pdf

15 TO: Office of the Commissioner of Insurance State of Wisconsin 12 East Wilson Street Madison, Wisconsin CERTIFICATE OF COMPLIANCE I, Martha E. Madden, an officer of Fidelity Security Life Insurance Company hereby certify that I have authority to bind and obligate the company by the filing of this (these) form(s). I further certify that, to the best of my information, knowledge and belief: 1. the accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance; 2. the form(s) does (do) not contain any inconsistent, ambiguous or misleading clauses; 3. the form(s) does (do) not contain specifications or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s); 4. the only variations from a form currently on file with the Commissioner of Insurance and the only unconventional policy provisions are clearly marked or otherwise indicated on pages of the attached form(s) or in an attachment; and 5. the attached form(s) is (are) in final printed format or typed facsimile and is (are) exactly as will be offered for issuance or delivery in the State of Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material. Individual responsible for this filing: Martha E. Madden Vice President and General Counsel January 3, 2007 Date Name: Title: Jennifer Glaser Senior Contracts Analyst Address: P. O. Box , 3130 Broadway, Kansas City, MO Phone Number , ext. 143 Date: January 3, 2007