INDEMNITY INSURANCE PLAN FEATURES

Transcription

1 INDEMNITY INSURANCE PLAN FEATURES Group Limited Benefit SB

2 HIGHLIGHTS Plan Specifics No pre-existing condition limitation. Mental health and substance abuse disorders covered the same as any other sickness. Guarantee issue. No health questions. Voluntary payroll deduction group plan. Various eligibility waiting periods are available. Benefits may be assigned to providers. Pays in addition to any other insurance. Work-related accidents and sicknesses are not covered. Eligible for pre-tax treatment under Section 125, except Short -Term Disability Income Insurance. Premium rates are guaranteed for the first 12 months of coverage. Thereafter, premium rates are subject to change. Minimum requirements: Employee must be actively at work. Company must have and maintain at least 51 eligible employees. 10 enrolled lives required at initial enrollment and at renewal. Administration Employee missed premium provision (for non-monthly groups) due to insufficient paycheck. Various pay cycles. COBRA services available through TPA. Various billing formats. Plastic ID cards. Account management. Toll-free, English/Spanish customer service. Enrollment Quality enrollment guides and collateral materials. Dedicated implementation team. Telephone enrollment available using specialized benefits counselors. Web-based enrollment available through TPA. Paper enrollment available. Foundation One Security Foundation One Security provides a benefits plan with many options for employers where a traditional health plan is not practical, available, or affordable. Our limited benefit health indemnity plans help those without insurance gain affordable access to basic health services. American Fidelity Assurance Company (AFA) American Fidelity Assurance Company is a third-generation, familyowned organization providing insurance products and financial services to education employees, trade association members and companies throughout the United States and across the globe. Since 1982, American Fidelity has been rated A+ (Superior) 1 by A.M. Best Company one of the nation s leading insurance company rating services because of American Fidelity s strong financial condition and operating performance. Because of American Fidelity s fiscal strength and financial security, the company has been rated A (Excellent) 2 with Weiss Ratings. This places American Fidelity on the list of Weiss Recommended Companies, an elite group of life, health and annuity companies. American Fidelity s rating represents the top 2.8 percent of insurance companies. American Fidelity is founded on and driven by the principle of serving our customers and protecting their investment. We continue to grow steadily through calculated growth and conservative investment practices. Health Plan Not Subject to PPACA The health indemnity plans described in this brochure are considered excepted benefits under the Health Insurance Portability and Accountability Act (HIPAA) and, as such, are not currently subject to the mandated benefits of the Patient Protection and Affordable Care Act (PPACA). It is important to know that excepted benefits do not count as creditable coverage, and certificates of prior (creditable) coverage will not be issued upon termination of indemnity coverage under any of the AFA policy forms. However, AFA voluntarily incorporated HIPAA special enrollment provisions in policy form series G-505.SA and G-513.SA (which are not included in policy form series G-501B). Networks MultiPlan PPO national provider network.* CVS/Caremark national pharmacy network.* *The PPO and pharmacy networks and related network discounts are not part of the fully-insured health indemnity benefits provided by AFA. 1 (March 25, 2011). (A+ is the 2nd out of 16 with 1 being the highest.) 2 Weiss Ratings Guide to Life and Annuity Insurers, Spring (A is the 2nd out of 16 with 1 being the highest.) SB Page 2 of 12

3 PLAN DETAILS Enrollment Different enrollment methods are available. The method that works best for each employer can be determined by the number of eligible employees, work locations, information and payroll systems capabilities, and the services a broker can provide. Ideally, open enrollments are conducted over a 30-day period beginning at least 60 days prior to the group effective date. Enrollment forms and/or data should be received by the administrator no later than two weeks prior to the group effective date. Enrollments of newly-hired employees should be conducted throughout the year. The employee must satisfy any waiting period established by the employer. Following such waiting period, the employee will have 31 days to enroll for the insurance coverage. If the employee chooses not to enroll at this initial enrollment period, the employee must wait until the next open enrollment to enroll. The insurance coverage is not effective on the date of enrollment, and will not become effective until the enrollment process is complete. If an employee voluntarily ends coverage, the employee cannot re-enroll for 24 months. The employee may re-enroll within 31 days immediately following the 24-month waiting period, or during an open enrollment or special enrollment after the 24-month waiting period. Employee and Dependent Eligibility* All actively-at-work employees age 18 or older are eligible. Dependent coverage is available to: A legally married spouse who lives with the eligible employee. Any unmarried natural, adopted or stepchild. Such child must be under age 25, and be dependent on the eligible employee for principal support and maintenance. Please note that this coverage may not be appropriate for anyone eligible for Medicaid. Effective Date Procedures The employer may choose one of the following effective date procedures: First of Month The employee s coverage will take effect on the first day of the month following the enrollment process. This procedure requires that monthly premium be submitted for employees. The administrator will update eligibility and provide benefits on a calendar month basis. Normal Pay Date The employee s coverage will take effect on the first day after the normal pay date for which the first payroll deduction is taken for coverage. Under this procedure, premium must be remitted on a pay cycle basis (weekly or bi-weekly) as deductions are made. The administrator will update eligibility and provide benefits for the 7-day period (weekly) or 14-day period (bi-weekly) following the normal pay date. Coverage Begins The employee must complete the enrollment process, submit premium, and be on active service on the effective date for coverage to become effective. The effective date for dependents will be the same as the employee, unless dependent coverage is added at a later date. With respect to Short Term Disability Income Insurance, if an employee is totally disabled on the date coverage is to begin, the employee s coverage will be delayed until the first of the month or normal pay date following the date the employee ceases to be disabled. With respect to Life Insurance only, if a dependent is totally disabled on the effective date, coverage will be deferred until the first of the month or normal pay date following the date the dependent ceases to be totally disabled. (This provision applies only to Life Insurance for policy forms G-505.SA and G-513.SA). Coverage Ends Coverage will end when the employee no longer qualifies as an eligible insured, when the employee s premium payments are discontinued, or when the group plan ends, whichever occurs first. Coverage on a dependent ends on the earliest of the date that they no longer meet the definition of a dependent, the date that dependent coverage is terminated, or the date that the employee s coverage terminates. *State insurance laws may affect the definition of an eligible dependent. SB Page 3 of 12

4 HEALTH BENEFIT DESCRIPTIONS Benefits are provided on a per covered person basis, and are payable for non-occupational covered accidents and sicknesses. Some benefits are paid according to a schedule and/or a specified dollar amount, and number of days per calendar year. OUTPATIENT BENEFITS Outpatient Benefits are payable for covered services received on an outpatient basis, subject to the benefit limits shown in the HEALTH PLAN BENEFITS table. Physician Office Visit Indemnity Benefit Pays a set dollar amount per visit, for a maximum number of visits per year, for physician services performed during an office visit, including physician services received in an emergency room. Diagnostic X-Ray and Laboratory Indemnity Benefit Pays a set dollar amount per day of testing, for a maximum number of testing days per year, for diagnostic lab tests, screenings, and x-rays, including x-rays or tests received in an emergency room. Wellness Indemnity Benefit Pays a set dollar amount for at least one additional visit under the Outpatient Physician Office Visit Indemnity Benefit each year for child immunizations, well child exam, prostate or pelvic exam, or any other general health check-up. Also pays a set dollar amount for at least one additional testing day under the Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit each year for x-ray, blood chemistry determination, electrocardiogram, urine test, tuberculosis test, prostate-specific antigen (PSA) test, pap smear, or mammogram. Emergency Facility Indemnity Benefit (optional) Pays a set dollar amount per emergency visit, for a maximum number of visits per year. PRESCRIPTION DRUG BENEFIT Pays a set dollar amount per fill or refill of a prescription medication or supply that is dispensed by a pharmacy on an outpatient basis, for a maximum number of prescriptions per year. If a CVS/Caremark network pharmacy is used, negotiated discounts are available for both brand name and generic drugs. A mail-order program* is available for 90-day supplies of maintenance drugs. SUPPLEMENTAL ACCIDENT BENEFIT Pays 100% of inpatient and outpatient covered expenses for covered accidental injuries treated within 90 days of accident, up to the maximum benefit per accident. Pays after all other applicable inpatient or outpatient benefits. SURGERY BENEFITS Surgery Benefits are payable for services in connection with covered surgeries. Surgery Indemnity Benefit Pays a benefit for covered outpatient and inpatient surgeries, according to a surgical schedule. There is no annual maximum of covered surgeries. Anesthesia Indemnity Benefit Pays 20% of the covered Surgery Indemnity Benefit amount, for anesthesia and its administration. Pays in addition to the Surgery Indemnity Benefit. Outpatient Surgical Facility Indemnity Benefit (optional) Pays a set benefit amount when a covered surgery is performed in an outpatient surgical center, or hospital emergency room. Pays in addition to the Surgery Indemnity Benefit and Anesthesia Indemnity Benefit. INPATIENT BENEFITS Inpatient Benefits are payable for covered services provided during a hospital confinement, subject to the benefit limits shown in the HEALTH PLAN BENEFITS table. Daily In-Hospital** Indemnity Benefit Pays a set dollar amount per day of hospital confinement, up to 30 days per confinement. Maximum confinement per calendar year limited to 60 days. This benefit helps cover room and board charges. Miscellaneous Hospital Services and Supplies Indemnity Benefit Pays a set dollar amount for each day that miscellaneous hospital services and supplies are received during confinement, when the Daily In-Hospital Indemnity Benefit is payable. Inpatient Physician Indemnity Benefit Pays a set dollar amount for each day non-surgical inpatient physician services are received, when the Daily In-Hospital Indemnity Benefit is payable. Daily Intensive Care Unit Indemnity Benefit (optional) Pays a set dollar amount per day of confinement in an intensive care unit when the Daily In Hospital Indemnity Benefit is payable. Hospital Admission Indemnity Benefit (optional) Pays a lump-sum benefit for each hospital admission. Pays in addition to all other applicable inpatient benefits. *The CVS/Caremark pharmacy network, and mail-order program are not part of the fully-insured health indemnity benefits provided by AFA. **The term Hospital does not include (a) any institution used as a place for rehabilitation, rest, the aged, education, or training, or (b) a nursing or convalescent home, or (c) an extended care facility for the care of convalescent patients. SB Page 4 of 12

5 NETWORK BENEFITS The following network benefits are available with all Foundation One Security plans. PPO NETWORK BENEFIT* Employees and their covered dependents will receive negotiated network discounts from the normal fees charged by network hospitals, physicians, and outpatient x-ray and laboratory providers. PHARMACY NETWORK BENEFIT* Employees and their covered dependents receiving the fullyinsured Prescription Drug Indemnity Benefit will receive negotiated network discounts on prescription drugs from more than 55,000 participating pharmacies in the CVS/Caremark network. Network discounts continue after the benefits have been exhausted. *The PPO, CVS/Caremark pharmacy network, and related network discounts are not part of the fully-insured health indemnity benefits provided by AFA. SB Page 5 of 12

6 LIFEGUARD HEALTH OPTIONS This package of non-insurance benefits and services provides added value when combined with our limited benefit group health indemnity plans. VISION CARE* The EyeMed Vision Care program offers discounts from 15% to 40% on a wide variety of vision services and products from thousands of providers nationwide through leading optical retailers such as Pearle Vision, LensCrafters, Sears Optical, Target Optical, and JCPenney. Most frames, lenses, specialty items such as tints, scratch resistant coatings and ultraviolet protection are available. As a Vision Care participant, there are no limits on the number of times the benefits may be used during the year. Services include: Laser Vision Correction 15% off the retail price or 5% off the promotional price of LASIK or PRK procedures, whichever is the greater discount. Replacement Contact Lenses by Mail EyeMed participants may order replacement contact lenses at competitive prices via the Internet and have them mailed directly to their home. TELEPHONE MEDICAL CONSULTATION* A doctor is not always available to handle non-emergency medical needs. The CallMD program provides four free doctor consultations per enrolled employee (or family) per calendar year. A $35 credit card charge is applied for each consultation over the four provided. Services include: CallMD provides access to a nationwide network of medical doctors available for consultation and, if appropriate, for the prescription of non-narcotic medicines. Enrolled persons have access to doctors for routine medical needs without having to take the time to make an appointment and wait in line at the doctor s office. CallMD maintains all electronic medical records (EMR) in a highly secured, Internet accessible environment and makes this information available to their network doctors prior to a doctor consultation. CallMD is staffed with registered nurses to speak with enrolled persons regarding their medical needs and to arrange consultations with CallMD doctors 24 hours per day, 7 days per week PATIENT ADVOCACY* The Karis Group is a patient advocacy service that helps answer the question, What happens when plan benefits are not enough?. Since 1997, they have focused on helping patients with large outof-pocket balances by mediating between the patient and providers to resolve outstanding bills. Historically, Karis saves patients over 30% on their bills, and is able to get some type of reduction on 3 out of 4 bills on which they work. Services include: Enrolled employees are assisted with out-of-pocket balances exceeding $2,500, after the Foundation One Security plan benefits have been applied. The service is for single medical incidents that require hospitalization. This service links enrolled employees to negotiating professionals who help to resolve large bills with medical providers once a bill has been received. Karis shoulders the load by doing the time consuming work with providers on the member s behalf. COUNSELING SERVICES* LifeGuard Support SM provides unlimited telephone counseling services at no cost to enrolled employees and families. Simply call the toll-free number to access masters-level counselors 24 hours a day, 7 days a week. Services provided: Counselors are available to help you for depression, anxiety, stress, loss, grief, anger management, substance abuse, relationship, parenting challenges, abuse, and many other issues. Benefit features: Immediate access for immediate family Unlimited access and utilization Caller confidentiality maintained Caller satisfaction assessment *LifeGuard Health Options is not part of the fully-insured benefits provided by AFA, and AFA does not contract for these services. Discounts on professional services are not available where prohibited by law. SB Page 6 of 12

7 HEALTH PLAN BENEFITS BUILD A PLAN TO SUIT YOUR NEEDS Treatment for mental health and substance abuse disorders covered the same as any other sickness. This applies under both inpatient and outpatient benefits below. The following table illustrates each benefit and the amounts available. Choose the benefits that would best suit your company s employees, along with appropriate benefit levels. We will help you build a plan to suit your needs. Outpatient Benefits Physician Office Visit Indemnity Benefit (OPOV) Diagnostic X-Ray and Laboratory Indemnity Benefit (DXL) Wellness Indemnity Benefit Emergency Facility Indemnity Benefit $40 to $150 per visit ($5 increments) 3-14 visits per calendar year $50 to $250 per testing day ($25 increments) 2-6 testing days per calendar year 1 to 3 additional visits/testing days under the selected OPOV and DXL benefits $50 to $500 per visit (variable increments) 1-3 visits per calendar year Outpatient Prescription Drug Benefit Prescription Drug Indemnity Benefit Surgery Benefits Surgery Indemnity Benefit (Inpatient or Outpatient) Anesthesia Indemnity Benefit (Inpatient or Outpatient) Outpatient Surgical Facility Indemnity Benefit $10 to $50 per prescription fill ($5 increments) 1-20 prescriptions per calendar year Paid according to surgical schedule described in Certificate of Insurance 20% of covered Surgery Indemnity Benefit amount $100 - $1,500 each day a surgery is performed ($25 increments) Accident Benefit Supplemental Accident Benefit Inpatient Benefits Daily In-Hospital Indemnity Benefit (DIH) Inpatient Physician Indemnity Benefit Miscellaneous Hospital Services and Supplies Indemnity Benefit Daily Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit 100% of covered expenses, up to $100 - $1,600 per accident ($100 increments) $100 - $1,000 per day, up to 30 days per confinement, limited to 60 days of confinement per calendar year ($50 increments) $25 - $100 per day when the DIH Benefit is payable ($25 increments) $50 - $400 per day when the DIH Benefit is payable ($25 increments) $200 - $1,500 per day when the Daily In Hospital Indemnity Benefit is payable (variable increments) $200 - $1,500 per hospital admission (variable increments) SB Page 7 of 12

8 OPTIONAL INSURANCE COVERAGES TERM LIFE INSURANCE/ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE Employee and dependents must be enrolled in Health Indemnity Insurance to elect and remain covered for Life Insurance. The Accidental Death and Dismemberment Insurance benefit applies to the employee only, in an amount equal to the life benefit. (Reduced amount payable for certain stated dismemberment/loss.) Term Life / AD&D Plan Benefit Levels Employee $5,000 - $25,000* (various increments) Spouse $2,500 - $12,500** (various increments) Each Child (over 6 months) $2,500 - $12,500** (various increments) Each Child (age 14 days to 6 months) $500 * For persons age 65 or older, the Death Benefit will be 65% of the amount shown. ** At no time may a covered Dependent s amount of Life Insurance exceed 50% of the Employee s Face Amount. Any necessary reduction in a Dependent s amount of coverage will be effective on the same date that the Employee s Face Amount reduces. DENTAL INSURANCE Employee must be enrolled in Health Indemnity Insurance to elect and remain covered for Dental Insurance benefits. Dependents may be enrolled without being covered under Health Indemnity Insurance. Dental Plan Benefit Levels Calendar Year Deductible Per Person $50 Preventative / Diagnostic Services 80%* Basic Services 80%* Major Restorative Services 50%** Calendar Year Maximum Per Person $500 - $1,500 (various increments) * Based on usual and customary charges. **Major Restorative Services will not be covered until the covered person has been continuously insured under this dental plan (or the dental plan replaced) for 12 consecutive months. SHORT TERM DISABILITY INCOME INSURANCE (where available) A Disability Benefit will be payable in the event an employee is totally disabled due to a covered accident or sickness that begins while insured for this coverage. Coverage is available to the employee only. Employee must be enrolled in Health Indemnity Insurance to elect and remain covered for Short Term Disability Income Insurance. Termination of coverage will have no effect on payment of benefits with respect to a total disability that begins before the policy is terminated. Short Term Disability Income Insurance is not available to the residents of California, New Jersey, New York, and Rhode Island, due to the availability of state-sponsored disability programs in those locations. Short Term Disability Income Plan Benefit Levels Maximum Disability Period (Accident or Sickness) 13 or 26 weeks Elimination Period (Accident or Sickness) 7 or 14 days Benefit Amount 50% of pay, up to $125; $150; or $175 per week Minimum Disability Benefit $50.00 per month Maximum Mental Illness Disability Period Maximum Alcoholism/ Drug Addiction Period 3 months (including hospital confinement) Up to 15 days in any 12-month period DEPENDENT ONLY HEALTH COVERAGE OPTION For many employees, dependent coverage is not an affordable option. Dependent Only Health plans have been developed to provide meaningful benefits for employees dependents. These plans provide the same health benefits as our other plans, for covered dependents, with a Daily In-Hospital Benefit for the employee, of $100 per day, up to 30 days per confinement. This is the only benefit available for the employee on Dependent Only Health plans. Three flexible coverage options are available: Spouse Only; Child(ren) Only; and Spouse and Child(ren). Employers may choose Dependent Only Health coverage instead of our standard health plans when this option better fits the employees needs. Optional insurance coverages (i.e., life, dental, short term disability income) are not available with Dependent Only Health. All policy provisions and exclusions and limitations remain the same for Dependent Only Health coverage. SB Page 8 of 12

9 FREQUENTLY ASKED QUESTIONS Are employers required to make a premium contribution? No. The plan is a voluntary payroll deduction group plan. However, some level of premium contribution can increase participation and enhance an employer s ability to attract and retain employees. Is everyone guaranteed coverage in the plan? Yes. Eligible employees and their eligible dependents are automatically accepted for all Foundation One Security plans. What happens after enrollment? An orderly enrollment enables the administrator to issue and mail the employees Identification Cards and Certificate of Insurance in a timely fashion. Identification cards and member packets for LifeGuard Health Options will be issued separately, but included with the Certificate of Insurance. Can an employee cancel coverage at any time? Yes, unless deductions are being made through a Section 125 Plan. In that event, the timing of the change must comply with Section 125 guidelines. Can employees coverage continue under COBRA? Yes. The administrator will fully administer all aspects of COBRA continuation laws, including mailing COBRA notification correspondence to the employee s home address of record. The plan administrator will also be responsible for collecting premium for COBRA continuation coverage. A separate agreement for the COBRA services must be signed, but there is no additional charge. Can employees go to any doctor or hospital? Yes. There is no restriction of doctors or hospitals in the plan. However, employees will receive an added value of having the MultiPlan PPO network discounts applied towards their charges, when they utilize in-network providers. How does indemnity insurance work? Indemnity insurance coverage is reimbursed at the stated benefit amount, regardless of the provider s fee. When a provider s charge exceeds the plan benefit, the employee is responsible for paying the balance. If the provider s charge is less than the indemnity benefit, the employee will be paid for the difference when a claim is processed, the administrator will send the employee a check with a remark code on the Explanation of Benefits indicating that the check is the payment of indemnity plan benefits that exceeded the amount charged by a provider or pharmacy. How does the Outpatient Prescription Drug Indemnity Benefit work? An employee s best value will come from negotiated network discounts at participating pharmacies in the CVS/Caremark nationwide pharmacy network. There are over 55,000 participating pharmacies across the country. The program provides benefits for both brand name and generic drugs. The employee simply presents his insurance ID card at a participating pharmacy in the CVS/Caremark network. If the plan benefit is less than the cost of the prescription, the employee must pay the difference. If the plan benefit is more than the network discount price, the employee pays nothing, and will receive a check for the difference after the pharmacy submits the claim to the administrator. What happens if an employee s deduction is not enough to cover the insurance premium? Our Normal Pay Date effective date procedure was specifically developed to accommodate pay cycle business. This coverage includes a Missed Premium Provision, which offers employees the opportunity to keep their insurance coverage active during periods when a reduction in hours worked results in a paycheck that does not support the full amount of the payroll deduction premium for their insurance coverage. Here s how it works. In the event an employee s paycheck is not large enough to cover the full amount of the payroll deduction premium for insurance, coverage on the employee and any covered dependents will not end immediately but will, instead, be placed in a suspended status for up to 35 days if their deductions are weekly, or 42 days if deductions are bi-weekly. The employee is not required to make up premium missed during the suspension period, but will have the option of doing so by paying their premium directly to the administrator. If an employee or one of his dependents incurs an eligible claim during the suspension period, such claim will not be considered for payment unless the missed premium is paid. If premium deductions do not begin again by the end of the 35- or 42-day suspension period, the employee s insurance coverage will be terminated as of the end of the last period that was paid. If this happens, the employee will be eligible to re-enroll during the employer s next open enrollment period. The Missed Premium Provision is available only to groups with a Normal Pay Date effective date. Our monthly coverage (First of Month effective date) requires that monthly premium be submitted without interruption to keep coverage in effect. SB Page 9 of 12

10 EXCLUSIONS AND LIMITATIONS The following exclusions and limitations are summarized, and actual wording may vary slightly by policy. Please refer to the group master policy for fully detailed exclusions and limitations. Exclusions and Limitations may be affected by state law. GENERAL EXCLUSIONS AND LIMITATIONS With respect to all of the insured health indemnity, dental, and short term disability income insurance benefits provided under this plan, no benefits will be payable as the result of: 1. Suicide or attempted suicide, while sane or insane; 2. Any intentionally self-inflicted injury or sickness; 3. Participation in a riot, civil commotion, civil disobedience, or unlawful assembly; 4. Committing, attempting to commit, or taking part in, a felony or assault; or engaging in an illegal occupation; 5. Participation in a contest of speed in power-driven vehicles, parachuting, parasailing, bungee jumping, or hang gliding; 6. Air travel; 7. Any accident occurring while the covered person is intoxicated; 8. An act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; 9. Occupational accident or sickness; or 10. Treatment received during a period of time that coverage is not in force. HEALTH INDEMNITY INSURANCE EXCLUSIONS AND LIMITATIONS In addition to the general exclusions and limitations, with respect to Health Indemnity Insurance, no benefits will be payable as the result of: 1. Rest care or rehabilitative care and treatment; 2. Cosmetic surgery or care; 3. Routine examinations, except as provided under the Wellness Indemnity Benefit; 4. Routine newborn care, including routine nursery charges; 5. Voluntary abortion; 6. Pregnancy of a dependent child; 7. Sex changes; 8. Experimental treatments or surgery; 9. The reversal of tubal ligation or vasectomy; 10. Artificial insemination, in vitro fertilization, and test tube fertilization, including related medications; 11. Treatment of exogenous obesity or weight control; or gastric bypass procedure; or any other surgical procedure for control of weight; 12. Venipuncture; 13. Ambulance service; 14. Treatment that is not medically necessary; 15. With respect to a non-emergency hospital admission during which a surgical procedure is performed: confinement, or services or treatment received more than 24 hours prior to admission; 16. Equipment or appliances; 17. Prostheses; 18. Supplies; except as provided under the Miscellaneous Hospital Services and Supplies Indemnity Benefit; 19. Visits made or examinations given while confined to a hospital; except as provided under the Inpatient Physician Indemnity Benefit; 20. Routine eye examinations, or the fitting of glasses or contact lenses; 21. Hearing examinations, or the fitting of hearing aids; 22. Dental examinations or dental care other than that resulting from accidental injury; 23. Benefits that are provided under any other part of the policy; 24. X-rays or laboratory tests while confined to a hospital; 25. X-rays or laboratory tests performed in relationship to dental care, other than expenses resulting from accidental injury; 26. Over-the Counter drugs and medicines; 27. Investigational or experimental drugs; 28. Drugs, medicines or insulin, in whole or in part, used by, administered to, or provided to, a covered person: (a) during an outpatient physician s office visit; (b) during a visit to a hospital emergency room or outpatient surgical facility; or (c) while confined in a hospital, rest home, sanatorium, extended care facility, convalescent hospital, nursing home or similar institution; 29. Immunization agents (shots), biological sera, blood, or blood plasma; or 30. Contraceptive materials, devices or medications. TERM LIFE INSURANCE EXCLUSION With respect to Term Life Insurance, no benefits will be payable as the result of suicide or any attempt thereat, while sane or insane; or any intentionally self-inflicted injury or sickness, unless the covered person has been continuously insured under the policy for two years. ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE EXCLUSIONS AND LIMITATIONS In addition to the general exclusions and limitations, no Accidental Death and Dismemberment Insurance benefits will be payable as the result of: 1. Infection or disease; or 2. Voluntary self-administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a licensed physician. SB Page 10 of 12

11 EXCLUSIONS AND LIMITATIONS DENTAL INSURANCE EXCLUSIONS AND LIMITATIONS In addition to the general exclusions and limitations, with respect to Dental Insurance, no benefits will be payable as the result of: 1. Cosmetic surgery or care; 2. Class B expenses, until the covered person has been continuously insured under this dental plan (or the dental plan this plan replaced) for 12 consecutive months; 3. Treatment started before coverage began; 4. Charges for initial installation for dentures or bridgework to replace teeth extracted prior to when coverage began; 5. Replacement of existing dentures or bridgework less than five years old, or for replacement because of loss or theft; 6. Charges for orthodontics; 7. Charges for services with respect to congenital malformations; 8. Charges for dental care which is covered under any other part of this plan; 9. Charges by anyone other than a dentist; 10. Charges for more than one fluoride treatment, one dental prophylaxis, or one bite-wing x-ray in any six-month period; 11. Charges for more than one complete mouth x-ray in any twoyear period; or 12. Charges which the covered person is not legally required to pay, or charges which would not have been made if no coverage had existed. SHORT TERM DISABILITY INCOME INSURANCE EXCLUSIONS AND LIMITATIONS In addition to the general exclusions and limitations, no Short Term Disability Income Insurance benefits will be paid as the result of: 1. Voluntary abortion; 2. Sex changes; 3. The reversal of tubal ligation or vasectomy; 4. Treatment of exogenous obesity or weight control; gastric bypass procedure; or any other surgical procedure for control of weight; or 5. Cosmetic surgery or care. Additionally, no benefits will be paid: 1. For any period during which the employee is not under the regular care and attendance of a physician; 2. If the employee should fail to follow the medical treatment advice of his/her physician as it pertains to his/her disabling condition; or 3. During any period in which the employee is incarcerated. SB Page 11 of 12

12 Health Indemnity, Term Life/Accidental Death and Dismemberment, Dental, and Short-Term Disability Income Insurance Fully insured by: American Fidelity Assurance Company, Oklahoma City, Oklahoma Administered by: WEB-TPA, Irving, Texas National wholesale marketing by: Foundation One Insurance Services, Ltd., Frisco, Texas This brochure highlights the important features of the proposed group insurance plan. It does not include every benefit, limitation, adjustment, or exclusion provision of the actual contract in detail. The Master Group Policy determines the complete terms of group insurance coverage with regards to Health Indemnity, Dental, Term Life/AD&D, and Short-Term Disability benefits only. This brochure is for the exclusive use of presentation to an employer, and may not be used for employee presentation. This brochure is applicable only to groups effective October 1, 2011, and later. SB Policy Series G-501B, G-505.SA and G-513.SA