LIMITED BENEFIT HOSPITAL MEDICAL-SURGICAL EXPENSE COVERAGE - FORM TX OUTLINE OF COVERAGE

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1 FORTIS INSURANCE COMPANY 501 West Michigan Milwaukee, WI A Stock Company LIMITED BENEFIT HOSPITAL MEDICAL-SURGICAL EXPENSE COVERAGE - FORM TX OUTLINE OF COVERAGE THE POLICY DESCRIBED IN THIS OUTLINE PROVIDES LIMITED BENEFITS ONLY WHICH ARE LESS THAN THE MINIMUM STANDARDS FOR BENEFITS FOR HOSPITAL, MEDICAL AND SURGICAL EXPENSE COVERAGE AS PRESCRIBED BY THE INSURANCE REGULATORY AUTHORITY OF YOUR STATE. READ YOUR POLICY CAREFULLY: This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! You may call FORTIS' toll-free telephone number for information about your policy or to make a complaint at LIMITED BENEFIT HEALTH COVERAGE: This policy is designed to provide, to covered persons, limited coverage for basic hospital, medical, and surgical expenses incurred as a result of medically necessary care for a covered illness (including complications of pregnancy) or injury. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgery, anesthesia, in-hospital medical services, and out of hospital care subject to any deductibles, coinsurance, copayments or other limitations of the policy. AUTHORIZATION REQUIREMENT: To be eligible to receive the maximum benefits available under this policy, read the Health Care Review provision of your policy carefully. Failure to follow the Health Care Review provision could result in covered charges being reduced by 25% to a maximum of $1,000. This policy provides a lifetime maximum benefit for each covered person. The amount of the benefit will equal covered charges incurred by the covered person during the calendar year, reduced by any copayment and any Medical Deductible, multiplied by the Rate of Payment. When the Maximum Family Medical Deductible has been met, the Medical Deductible will be deemed to have been met by all family members covered under the policy for that calendar year. If there is other insurance which provides benefits for Covered Medical Services, benefits under this policy will be pro-rated. The Medical Deductible* is $. The Rate of Payment is % Network/ % Out-of- Network to a maximum of $. * There is a separate $1,000 Out-of-Network Deductible which is in addition to the plan Medical Deductible. If the plan Medical Deductible is less than $1,000, the Out-of-Network Deductible will be in an amount that is equal to the Medical Deductible. A covered charge is an allowable charge, as determined by us, that is: 1) for services or supplies provided by a health care practitioner, facility or supplier; 2) for services or supplies that are FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

2 medically necessary; 3) incurred by a covered person while insured under the policy for a covered illness or injury, or for a Covered Wellness Service; 4) for services or supplies listed in the Covered Medical Services or Covered Prescription Drug Benefits sections of this outline; and 5) not listed in the Exclusions section of this outline. In determining whether or how much of a covered charge is allowable, we will consider the following factors: 1) the actual charge; 2) relative value scales which include difficulty, work risk and materials used; 3) regional geographic factors for your area or a comparable area; and 4) the rate we negotiate with the provider of service. COVERED MEDICAL SERVICES: Covered Hospital Services: 1) daily room and board up to the semi-private room rate; 2) confinement in a critical care unit; 3) all other inpatient or outpatient treatment provided by a hospital; and 4) treatment provided by an ambulatory surgical center. For treatment of breast cancer, benefits are payable for a minimum of 48 hours of inpatient care following a mastectomy and a minimum of 24 hours of inpatient care following a lymph node dissection unless you and your health care practitioner determine that a shorter period of inpatient care is appropriate. Covered Health Care Practitioner Services: 1) health care practitioner services; 2) surgery; and 3) anesthesia services. X-ray and laboratory services. Professional ground or air ambulance services to the nearest hospital that can provide emergency treatment for the illness or injury. Other types of transportation will not be covered. Supplies and durable medical equipment for the lesser of the rental or purchase price, limited to the following: 1) basic prosthetic devices; 2) splints, trusses, crutches and orthopaedic braces; 3) oxygen and equipment for the administration of oxygen; 4) one standard non-motorized wheelchair and/or basic hospital bed; 5) one newborn phototherapy light and/or one apnea monitor; and 7) other durable medical equipment or supplies that we determine to be covered. Repair, replacement or duplicates are not covered. Home health care services provided by a home health care agency. Home health care services are limited to a maximum of 160 hours each calendar year for home health care visits by a statelicensed nurse, respiratory therapist, and services included in a preauthorized health care practitioners plan of treatment. Hospice care services provided in either an inpatient, outpatient or home setting. A state-licensed hospice must be Medicare certified and/or accredited by the Joint Commission on Accreditation of Healthcare Organization (JCAHO). Hospice care includes two visits for counseling services for you and one visit for bereavement counseling for you after an insured's death. Skilled nursing facility services up to 30 days each calendar year. Covered services in a statelicensed skilled nursing facility include room and board, nursing and ancillary services. Subacute care provided in a hospital or state-licensed subacute facility is covered under this provision. Rehabilitation services include the following: 1) inpatient rehabilitation services, up to 180 days per calendar year; and 2) outpatient rehabilitation services, up to $3,000 per calendar year. Rehabilitation services are not covered when we determine measurable progress toward expected outcomes has stabilized or is inconsistent. Rehabilitation services do not include treatment for conditions related to vertebrae, disc, spine, back, neck and adjacent tissues or temporomandibular joint (TMJ) and craniomandibular joint (CMJ) dysfunction. Vertebrae, disc, spine, back and neck: Outpatient diagnosis and treatment for these conditions are limited to $750 each calendar year. This includes massage, accupuncture, biofeedback, manipulation and electrical stimulation. The maximum does not apply to inpatient stays, surgery, anesthesia, laboratory tests, x-rays, magnetic resonance images (MRI) or electromyelograms. FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

3 Temporomandibular joint (TMJ) and craniomandibular joint (CMJ) dysfunction: Benefits for nonsurgical and nondiagnostic treatment are limited to a maximum lifetime benefit of $1,000. Covered charges for nonsurgical and nondiagnostic treatment are limited to diagnostic examinations, diagnostic x-rays, injection of muscle relaxants, therapeutic drug injections, physical therapy, diathermy and ultrasound therapy. Covered Charges for surgical and diagnostic treatment are not subject to this maximum. Services for surgical treatment must be authorized by us prior to the surgery. Organ transplants: Benefits will be reduced by 50% for any organ, tissue or cellular transplants not reviewed by us prior to transplantation evaluation, testing or donor search. The maximum lifetime transplant benefit is $250,000 for each transplant, combined transplants, and sequential transplants. The maximum lifetime transplant benefit includes all related expenses from 14 days before transplant until 365 days after transplant. The maximum benefit for potential donor and donor expenses is $10,000 for each transplant, to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid. All benefits paid for covered donor expenses will be applied to the maximum lifetime transplant benefit. This limit does not apply to kidney and cornea transplants. Covered transplants include: 1) heart, 2) lung, 3) combined heart/lung, 4) combined kidney/pancreas, and 5) liver. Covered charges for marrow reconstitution and support include all chemotherapy, the harvesting, and the reinfusion of the marrow or blood precursor cells. We will not pay for: 1) multiple organ, tissue and cellular transplants during one operative session, except for a heart/lung, double lung or simultaneous kidney/pancreas transplants; 2) any non-human (including animal or mechanical) organ transplant; 3) transplants approved for a specific medical condition, but applied to another condition; 4) the purchase price of an organ or tissue that is sold rather than donated; or 5) any transplants not listed above. All transplant related claims still apply to the lifetime maximum benefit. Covered wellness services: Benefits include those services based on the published recommendations of the U.S. Preventive Services Task Force and include: 1) an annual mammogram for female insureds age 35 years or older; 2) an annual exam for the detection of prostate cancer and an annual prostate-specific antigen test for male insureds 50 years of age or older and asymptomatic or male insureds age 40 or older with a family history of prostate cancer or another prostate cancer risk factor; 3) child immunizations from birth through age 6 for diphtheria, haemophilus influenzae b, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella and any other immunization required by law; and 4) a screening test for hearing loss for a child from birth through the date the child is 30 days old (includes medically necessary diagnostic follow-up care to the screening test for a child from birth through age 24 months). The maximum benefit payable per calendar year is $500. This maximum will not apply to routine mammograms, routine pap smears, routine annual prostate specific antigen (PSA) tests, the annual exam for detection of prostate cancer, child screening test and diagnostic follow up care for hearing loss and child immunizations. Benefits for child immunizations are payable at 100%. Benefits for the child screening test and diagnostic follow up for hearing loss are exempt from the Deductible. Care and treatment of diabetes for an Insured who has been diagnosed with: insulin dependent or non-insulin dependent diabetes; elevated blood glucose levels induced by pregnancy; or another medical condition associated with elevated blood glucose levels for the following services and supplies: a) Diabetes equipment and supplies as follows: 1) blood glucose monitors, including monitors for use by or adapted for the legally blind; 2) test strips for use with a corresponding glucose monitor; 3) lancet devices; 4) visual reading strips and urine testing strips and tablets which test for glucose, ketones and protein; 5) insulin analog preparations; 6) injection aids, including devices used to assist with insulin injections and needleless systems; 7) biohazard disposal containers; 8) insulin pumps, both external and implantable and associated appurtenances, FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

4 which include: insulin infusion devices; batteries; skin preparation items; adhesive supplies; infusion sets; insulin cartridges; durable and disposable devices to assist in the injection of insulin; and other required disposable supplies; 9) repairs and necessary maintenance of insulin pumps not otherwise provided for under a manufacturer's warranty or purchase agreement and rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump; 10) medications available without a prescription for controlling the blood sugar level; 11) podiatric appliances, including up to two pairs of therapeutic footwear per year, for the prevention of complications associated with diabetes; 12) glucagon emergency kits; 13) other treatment and monitoring equipment, approved by the United States Food and Drug Administration, if medically necessary and deemed appropriate by the treating Health Care Practitioner through a written order. b) immunizations for influenza and pneumococcus. c) Diabetes self-management for which a Health Care Practitioner has written an order for the Insured or for the caretaker of an Insured as follows: 1) a diabetes self-management training program recognized by the American Diabetes Association; 2) diabetes selfmanagement training given by a multidisciplinary team, the non-doctor members of which are coordinated by a Certified Diabetes Educator, who is certified by the National Certification Board for Diabetes Educators, or a person who has completed at least 24 hours of continuing education that meets guidelines established by the Texas Board of Health and includes a combination of diabetes-related educational principles and behavioral strategies; such team consisting of at least a dietician and nurse educator and possibly including a pharmacist or a social worker; provided that all team members, except a social worker, must have recent didactic and experiential preparation in diabetes clinical and educational issues, as determined by the team member s licensing agency, in consultation with the commissioner of public health, unless the member s licensing agency, in consultation with the commissioner of public health, determines that the core educational preparation for the member s license includes the skills the member needs to provide diabetes self-management training; 3) diabetes self- management training given by a Certified Diabetes Educator, certified by the National Certification Board for Diabetes Educators; or 4) diabetes self-management training in which one or more of the following components are provided: the nutrition counseling component provided by a licensed dietician, for which the licensed dietician shall be paid, the pharmaceutical component provided by a pharmacist, for which the pharmacist shall be paid, any component of training provided by a physician assistant or registered nurse, for which the physician assistant or registered nurse shall be paid, except for providing a nutrition counseling or pharmaceutical component unless a licensed dietician or pharmacist is unavailable to provide that component; or any component of the training provided by a doctor of medicine; provided however that a person may not provide a component of diabetes self-management training unless the subject matter of the component is within the scope of the person s practice and the person meets the education requirements, as determined by the person s licensing agency, in consultation with the commissioner of public health. For the purposes of the self-management training, a "caretaker" means a family member or significant other of the Insured who is responsible for ensuring that an Insured, who is not able to manage his or her diabetes, due to age or infirmity, is properly managed, including oversight of diet, administration of medications and use of equipment and supplies. Self-management training will include: 1) the development of an individualized management plan created for and in collaboration with the Insured; and 2) medical nutritional counseling and instructions on the proper use of diabetes FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

5 equipment and supplies. Self-management training will be provided to the Insured or to a caretaker for the Insured upon: 1) the initial diagnosis of diabetes; 2) a written order of a Health Care Practitioner indicating that a significant change in the Insured's symptoms or condition requires changes in the Insured's regime; or 3) a written order of a Health Care Practitioner that periodic or episodic continuing education is warranted by the development of new techniques and treatment for diabetes. Injectable drugs which require a written prescription are covered, except insulin which is covered under the covered prescription drug benefit. Reconstructive surgery in connection with a mastectomy. The following services and supplies are Covered Expenses: a) reconstruction of the breast on which the mastectomy is performed; b) surgery and reconstruction of the other breast to produce symmetrical appearance; and c) prostheses and services and other supplies necessary for any physical complication, including lymphedemas, at all stages of the mastectomy. Reconstructive surgery to improve the function of, or attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections or disease due to craniofacial abnormalities of a dependent child under 18 years of age Parenteral (intravenous infusion) therapy includes total parenteral nutrition and other fluids, blood and blood products, and medications requiring a written prescription. Dental injury: Benefits are payable for an injury resulting from an accidental blow to the mouth causing trauma to sound teeth, the gums or supporting structures of the teeth. Treatment must begin within 90 days of the injury and be completed within 365 days of the injury. Complications of Pregnancy include: conditions requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from, adversely affected by or caused by pregnancy, such as acute nephritis, nephrosis cardiac decompensation, missed abortion, spontaneous miscarriage occurring during a period of gestation in which a viable birth is not possible, termination of ectopic pregnancy, non-elective cesarean section and similar medical and surgical conditions of comparable severity. Complications of pregnancy do not include false labor, occasional spotting, health care practitioner prescribed rest during pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy. Sterilization: Benefits are payable to a maximum lifetime benefit of $500 after you have been insured under this plan for 365 days. Removal of tonsils and adenoids are payable after you have been insured under this plan for 90* days except for emergency treatment. Surgical treatment for hernia (except strangulated or incarcerated), varicose veins and hemorrhoids are payable after you have been insured under this plan for 180* days except for emergency treatment. *The day limitation will be waived if other health insurance with reasonably similar benefits was shown on the application and was in force until the effective date of this policy. World-wide coverage will be provided for services received outside the United States if services would be covered when provided in the United States. Telemedicine services: Benefits for treatment rendered through the use of interactive audio, video, or FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

6 other electronic media to deliver health care including the use of the electronic media for diagnosis, consultation, treatment, transfer of medical data and medial education. No benefits are payable for service performed using a telephone or facsimile machine. Mental Illness and Substance Abuse (you have these benefits only if Rider 2843-TX is included with your policy): Benefits are payable at 50% up to a calendar year maximum of $2,500 for inpatient treatment and $500 for outpatient treatment. The maximum benefit payable for each outpatient visit is $50. The combined maximum benefit for all inpatient and outpatient treatment in any calendar year is $2,500. PRESCRIPTION DRUG BENEFITS: Benefits are payable for a 30 consecutive day supply for each prescription or up to a 90 consecutive day supply for mail order prescriptions for the following: 1) Legend drugs and medicines, that by Federal law, can only be obtained with a prescription; 2) Injectable insulin; and 3) disposable insulin syringes, and disposable blood/urine, glucose/acetone testing agents or lancets. If you do not use a network pharmacy or do not present your ID card at a network pharmacy, you will have to pay the pharmacy in full and file a claim for reimbursement. Reimbursement will be at the negotiated network rate minus any applicable prescription drug deductible, copayment, coinsurance and/or ancillary charge. Prescription Drug Deductible $ Generic Copayment $ Brand Name Copayment $ Prescription Drug Exclusions In addition to the exclusions section listed below, we will also not pay benefits for any of the following: 1) Replacement of lost, stolen, destroyed or damaged prescriptions; 2) Drugs or devices used directly or indirectly to promote conception. 3) Immunization agents, biological sera, blood, blood plasma or its derivatives; 4) Drugs containing nicotine or its derivatives; 5) Injectable drugs which we do not authorize to be paid under this benefit; 6) More than we determine is an average quantity of medication required to treat an immediate condition or symptom on an "as needed" basis; or 7) Over-the-counter medications that can be obtained without a prescription; drugs which we determine have an over-the-counter equivalent; or compounded medications not containing at least one legend ingredient. PREEXISTING CONDITIONS LIMITATION: We will not pay benefits for covered charges incurred due to a pre-existing condition until you have been insured under this policy for 12 months. After this 12 month period, benefits will be paid for a pre-existing condition on the same basis as any other condition, unless the condition has been specifically excluded from coverage. This Preexisting Condition Limitation will not apply to an Insured who was continuously covered for an aggregate period of 18 months by Creditable Coverage that was in effect up to a date not more than 63 days before the effective date of coverage herein (excluding any waiting period) and whose most recent Creditable Coverage was under a group health plan, government plan or church plan. If there has been more than a 63-day gap in coverage, this Preexisting Condition Limitation will be credited for the time an Insured (whose most recent Creditable Coverage was under a group health plan, government plan or church plan) was previously covered under Creditable Coverage if the previous coverage was in effect at any time during the 18 months preceding the effective date of the coverage herein. EXCLUSIONS: We will not pay benefits for any of the following: 1) Illness or injury eligible for benefits under Workers' Compensation, Employers' Liability or similar laws, even when you do not file a claim for benefits. 2) Illness or injury contributed to or caused by: (a) war or act of war (declared or undeclared); FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

7 (b) active duty in the military service of any country; (c) commission of a felony, crime or illegal act; (d) participation in a riot; (e) an insured over age 19 being under the influence of illegal narcotics or non-prescribed controlled substances; or (f) attempted suicide or intentionally self-inflicted injury. 3) Charges that are payable or reimbursable by: (a) a plan or program of any governmental agency (except Medicaid), or (b) Medicare Part A or Part B (where permitted by law). If you do not enroll in Medicare we will estimate benefits. 4) Routine hearing care, routine vision care, vision therapy, surgery to correct vision, routine foot care, or foot orthotics. 5) Cosmetic services including treatment primarily designed to change or improve appearance, self-esteem or body image and/or relieve or prevent social, emotional or psychological distress except for a congenital defect or birth abnormality of a newborn or adopted child or as otherwise stated in the Covered Medical Services section. 6) Not covered services, complications of an excluded or not covered service, or charges for which you are not liable. 7) Charges by a health care practitioner or a medical provider who is an immediate family member. Immediate family members are you, your spouse, your children, brothers, sisters, parents, their spouses and anyone with whom legal guardianship has been established. 8) Custodial care. 9) Growth hormone stimulation treatment including drugs or hormones. 10) Dental care not related to a dental injury. 11) Any treatment for correction of malocclusion, protrusion, hypoplasia or hyperplasia of the jaws. 12) Charges for educational testing or training, vocational or work hardening programs, transitional living, or services provided through a school system. 13) Infertility. 14) Maternity and routine nursery charges unless you have a Maternity Rider. 15) Genetic testing, counseling and services. 16) Charges for sex transformation, and treatment of sexual dysfunction or inadequacy or to enhance sexual performance or desire. 17) Over-the-counter products including vitamins and food supplements, herbal and homeopathic medications. 18) Treatment of "quality of life" or "lifestyle" concerns including but not limited to: smoking cessation; obesity; hair loss; sexual function, dysfunction, inadequacy or desire; or cognitive enhancement. 19) Treatment used to improve memory or to slow the normal process of aging. 20) Mental illness other than due to demonstrable organic brain disease or substance abuse, unless Rider 2843-TX is included with your policy. RENEWABILITY PROVISION: The policy will remain in force at the option of the insured, except for the following reasons: 1) Nonpayment of premiums; 2) Fraud or intentional material misrepresentation made by or with the knowledge of an insured applying for this coverage or filing a claim for benefits; 3) All policies with the same form number are non-renewed in the state in which your policy was issued or the state in which you presently reside; or 4) You are no longer a covered dependent. OPTIONAL RIDERS (Check Optional Coverage Selected) Network Doctor/Hospital Coverage Rider 2849 Yes No This rider provides for a separate out-of-pocket limit for covered charges incurred for treatment incurred by a network provider and for treatment rendered by a non-network provider. Network Doctor's Office Copayment Rider 2856 Yes No This rider provides a network provider office visit benefit in which covered charges incurred for treatment received from a network provider during an office visit will be paid at 100% after the doctor's office copayment is paid. Coverage for non-network physician office visits is also included FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

8 with benefits payable at 70% after the medical deductible has been met. This rider also provides a supplemental outpatient x-ray and laboratory services benefit in which the first $100 of covered charges incurred in a calendar year for outpatient x-ray and lab services are not subject to the medical deductible and are payable at 100%. Traditional Coverage Rider 2847-TX Yes No This rider provides comprehensive medical coverage on a fee-for-service basis (traditional indemnity). An insured has the freedom to select the hospital and doctor of their choice. This option does not include any benefit incentives to obtain services from a network provider. Prescription Drug Services/MSA Rider 2846 Yes No This rider modifies the prescription drug coverage under the base plan to comply with federal regulation when this plan is purchased to accompany an MSA. Accident Medical Expense (AME) Rider 2844 Yes No This rider provides first-dollar coverage in the event of an accident with no up-front deductible or coinsurance to meet for charges incurred within 90 days of an accident. After the selected AME benefit has been used, the emergency room copayment (if applicable), annual deductible and coinsurance will apply. Copayment Rider 2960-TX Yes No This rider provides a network provider office visit benefit in which covered charges incurred for treatment received from a network provider during an office visit will be paid at 100% after the doctor s office copayment is paid for up to a maximum of 2 office visits in a calendar year for each covered person. Visits may not be used for Wellness Services. Treatment received from a nonnetwork physician is covered under the basic policy provisions. This rider also provides a supplemental outpatient x-ray and laboratory services benefit in which the first $100 of covered charges incurred in a calendar year for outpatient x-ray and lab services are not subject to the medical deductible and are payable at 100%. In addition, this rider adds a $500 hospital confinement access fee for each admission, a $250 outpatient facility access fee for each surgical procedure and a 12-month waiting period for wellness services. This waiting period does not apply to routine mammograms, routine pap smears, the annual exam for detection of prostate cancer, annual prostate-specific antigen test, child screening test and diagnostic follow-up care for hearing loss and child immunizations. PREMIUM The initial premium for this policy including the $20 processing fee and all riders applied for is: $. Semi-Annually $ ; Quarterly $ ; C.O.M. $ (Insert the mode wanted.) After the first premium, you have 31 extra days to pay each premium after it is due. The total annual premium for this policy, including the $20 processing fee and all riders applied for is: $. Licensed Agent's Signature Date. FORM TX OUTLINE OF COVERAGE (Rev. 05/03)

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