Critical Illness Insurance Frequently Asked Questions

Transcription

1 Critical Illness Insurance Frequently Asked Questions The Aflac coverage described is subject to plan limitations, exclusions, definitions, and provisions. For detailed information, please see the plan brochure, as this booklet is intended to provide a general summary of the coverage. This overview is subject to the terms, conditions, and limitations of the plan. Aflac group Critical Illness provides a lump sum benefit upon the diagnosis of not only one covered illness, but for each covered illness. Cancer, heart attack, stroke or renal failure that requires dialysis are all life-changing events. Medical coverage helps pay providers, but what about the out-of-pocket medical expenses? What about the expenses associated with the life changes that can follow a critical illness? A stroke can leave you paralyzed will medical insurance, life insurance or disability pay for the construction of a wheelchair access ramp on your home? What about job retraining? Aflac group Critical Illness insurance provides a lump sum benefit payment to help you with out-of-pocket medical expenses and the costs associated with a covered critical illness. What is the First Occurrence Benefit? After the waiting period, a lump sum benefit is payable upon initial diagnosis of a covered critical illness. What is the Additional Occurrence Benefit? If you collect full benefits for a critical illness under the plan and later are diagnosed with one of the remaining covered critical illnesses, then we will pay the full benefit amount for each additional illness. Occurrences must be separated by at least six months (or for cancer at least six months treatment- free). What is the Recurrence Benefit? If you collect full benefits for a covered condition and are later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months (or for cancer at least 12 months treatment-free). Cancer that has spread (metastasized), even though there is a new tumor, will not be considered an additional occurrence unless you have gone treatment-free for 12 months. What is the Health Screening Benefit? After the waiting period, you may receive $50 for any one covered health screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the critical illness benefit payable under the plan. There is no limit to the number of years you can receive the Health Screening Benefit; it will be payable as long as coverage remains in force. This benefit is only payable for health screening tests performed for preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. Who gets the Health Screening Benefit? The covered employee and covered spouse. The benefit is not paid for dependent children. Will the Health Screening Benefit pay in addition to my major medical insurance? Yes.

2 What is the waiting period? The plan contains a 30-day waiting period. This means that no benefits are payable for anyone who has been diagnosed before your coverage has been in force 30 days from the effective date. If you are first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss starting after 12 months from the effective date; or, you can elect to void the coverage and receive a full refund of premium. What is considered a critical illness that pays 100% of benefit? Cancer (Internal or Invasive) Heart Attack Major Organ Transplant Stroke End-Stage Renal Failure Coronary Artery Bypass Surgery (CABS*) Mitral Valve Replacement or Repair Aortic Valve Replacement or Repair Surgical Treatment of Abdominal Aortic Aneurysm *Benefits from the Heart Event Rider and certificate will not exceed 100% of the maximum applicable benefit. When you purchase the Heart Event Rider, the 25% CABS partial benefit in your certificate is increased to 100%. That means the CABS benefit in the Heart Event Rider, combined with the benefit in your certificate, equal 100% of the maximum benefit not 125%. What is the benefit for carcinoma in situ? 25% of the cancer benefit is paid for carcinoma in situ. Carcinoma in Situ is defined as cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue. Payment of this benefit will reduce the benefit for cancer by 25%. What is the Occupational HIV benefit? This benefit pays the applicable maximum benefit amount for the initial positive diagnosis of occupational human immunodeficiency virus (HIV), as a result of a covered injury. The benefit is paid at 100%. What is Coronary Artery Bypass Surgery, Coronary Artery Bypass Graft Surgery or Bypass Surgery? Surgical procedures performed to relieve angina and reduce the risk of death from coronary artery disease. Benefit is paid at 100%. What is Mitral Valve Replacement or Repair? A cardiac surgery procedure in which a patient s mitral value is repaired or replaced by a different valve. Benefit is paid at 100% What is Aortic Valve Replacement or Repair? A cardiac surgery procedure in which a patient s aortic valve is repaired or replaced by a different valve. Benefit is paid at 100% What is Surgical Treatment of Abdominal Aortic Aneurysm? Surgery to prevent aneurysm rupture. Benefit is paid at 100%.

3 What is Angiojet Clot Busting? A procedure used to clear blood clots from coronary arteries before angioplasty and stenting. Benefit is paid at 10%. What is Balloon Angioplasty or Balloon Valvuloplasty? A procedure used to open a clogged blood vessel. Benefit is paid at 10% What is Laser Angioplasty? A laser tip is used to burn/break down plaque in the clogged blood vessel. Benefit is paid at 10%. What is Arethectomy? A procedure used to open blocked coronary arteries or clear bypass grafts by using a device on the end of a catheter to cut or share away atherosclerotic plaque. Benefit is paid at 10%. What is Stent Implantation? A stainless steel mesh is implanted in a narrowed part of an artery to keep it propped open. Benefit is paid at 10%. What is Cardiac Catheterization (also called Heart Catheterization)? A diagnostic and occasionally therapeutic procedure that allows a comprehensive examination of the heart and surrounding blood vessels. Benefit is paid at 10%. What is Automatic Implantable (or internal) Cardioverter Defibrillator (AICD)? The initial placement of the AICD used for treating irregular heartbeats. Benefit paid at 10%. What is a Pacemaker? Pacemakers send electrical signals to make the heart beat when the heart s natural pacemaker is not working properly. Can I cover my spouse? Yes. What is the benefit for my spouse? 50% of the employee benefit. Can I cover my children? Yes. How do you define children? Your or your spouse s natural children, step-children, foster children, legally adopted children or children placed for adoption who are under age 26. Newborn adopted or natural children are automatically covered from the moment of birth. Adopted children are covered from the date of petition or from the date of placement in your home. If you desire uninterrupted coverage for a newborn or adopted child, you must notify us in writing within 31 days of the child s birth, the date of placement in your home or the date the petition is filed for adoption of a child. Coverage for newborn or adopted children will be in effect through the 31st day following the date of such event. Upon notification, we will advise you of any additional premium due. However, if other children are already covered, it is not necessary for you to notify us of the birth of a child or the date the petition is filed for adoption of a child, and an additional premium payment is not be required. Coverage on dependent children will terminate on the child s 26th birthday. However, if any child is incapable of self-sustaining employment due to mental or physical handicap and is dependent on his

4 parent(s) for support, the above age 26 shall not apply. Proof of such incapacity and dependency must be furnished to us within 31 days following such 26th birthday. Is there a cost to cover children? No. Children are covered at 50% of the primary insured at no additional cost. What is the benefit for my children? 50% of the employee benefit. Can I cover my parents? No. What is considered a pre-existing condition? A sickness or physical condition which, within the 12 month period prior to the effective date resulted in medical advice or treatment being received by any covered person. What is the effective date? If you enroll during open enrollment, your effective date will be August 1, New hires through the year are effective one month following effective date for core benefits. Who is the benefit paid to? Aflac pays benefits directly to you (unless you choose otherwise). Will the benefit be paid to the provider? Aflac pays benefits directly to you (unless you choose otherwise). How is a claim filed? Claim form can be downloaded from aflacgroupinsurance.com. Or, contact your Aflac associate Terry Burnett at or terry_burnett@us.aflac.com. What does guaranteed-issue mean and what is the benefit amount? During initial enrollment and for new hires thereafter, an employee has a guaranteed-issue amount of $30,000 and $15,000 for spouse. Employees and spouses must meet the eligibility requirements for coverage. What if I want more than $30,000? You will be required to answer underwriting questions. While a yes response will result in declination of a higher benefit amount, it will not prevent a person from being issued the guaranteed-issue amount. Do I have to enroll in the $30,000 benefit or am I guaranteed-- issue for up to $30,000? You can enroll and receive guaranteed-issue from $5,000 to $30,000 during this initial enrollment or eligibility as a new hire. Can I be cancelled for using the benefits? No. Will my rate increase with age? No, unless you choose to increase the benefit amount. Can my benefit be increased? Yes, during open enrollment each year.

5 Is the Aflac Critical Illness plan portable? Yes, with certain stipulations. A portability packet must be requested within 30 days of your terminating employment. Contact for portability packet is Is there information on the web? Yes, visit aflac.com/kumc anytime! Is deduction pre-tax or after-tax? After-tax. How do I determine my rate? During open enrollment, rates will be shown with the web enrollment process. Following enrollment for new hires throughout the year, rate sheets will be provided. When is the best time to enroll? During this initial rollout so you can make the most of the guaranteedissue offer. For a new hire, it s best to enroll upon eligibility. What is the enrollment period? May 15 June 15. Can new hires be enrolled during the year? Yes. Will new hires have guaranteed-issue? Yes. How do I enroll? Visit aflac.com/kumc and simply link to the enrollment site! Do I have to answer health questions? Only if you are applying for more than $30,000 (or $15,000 for your spouse). Can I enroll my spouse in more benefit than me? No, spouse coverage is 50% of the employee benefit. What does actively at work mean? On the effective date of coverage, you must be performing a full normal workday the regular duties of employment for Kansas University Medical Center. What does successor insured mean? If the insured dies while covered under the plan, the surviving spouse shall become the insured if such spouse is an insured person. If there is no surviving spouse covered under the plan, then the plan shall terminate on the next premium due date. Do I have to be enrolled in the Kansas University Medical Center health insurance to enroll in the Critical Illness plan? No. Can my medical care be by a family member? No a doctor, physician or pathologist does not include an insured or a family member. Can I be treated outside the United States? No benefits will be paid for diagnosis or treatment received outside of the United States.

6 Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands.

7 Accident Advantage Plus Insurance Frequently Asked Questions The Aflac coverage described is subject to plan limitations, exclusions, definitions, and provisions. For detailed information, please see the plan brochure, as this booklet is intended to provide a general summary of the coverage. This overview is subject to the terms, conditions, and limitations of the plan. The Aflac Accident insurance plan provides benefits to help cover the costs associated with unexpected bills. You don t budget for accidents if you re like most people. When a covered accident occurs, the last things on your mind are the charges that could be accumulating: the ambulance ride, use of the emergency room, surgery and anesthesia, stitches, casts, wheelchairs, crutches, bandages. What is the Medical Fees Benefit? We will pay up to the amount shown for X-rays and doctor services when, because of a covered accident, you are injured and those injuries cause you to receive initial treatment from a doctor within 72 hours after the accident. If you do not exhaust the maximum benefit paid during the initial treatment, we will pay the remainder of this benefit for treatment received due to injuries from a covered accident and for each covered accident up to one year after the accident date. The benefit pays $125 for the employee and covered spouse and $75 for covered children. Is there an Emergency Room Treatment Benefit? Yes. The benefit pays $200 for injuries received in a covered accident if the insured receives treatment in a hospital emergency room and within 72 hours of a covered accident. The benefit is payable once per 24-hour period and only once per covered accident. Will both the Medical Fees Benefit and Emergency Room Benefit be paid? Aflac will not pay the Accident Emergency Room Treatment Benefit and the Medical Fees Benefit for the same covered accident. The highest eligible benefit amount will be paid. Is there an Emergency Room Observation Benefit? The benefit pays $100 if an insured receives treatment in a hospital emergency room and is held in a hospital for observation for at least 24 hours and receives initial treatment within 72 hours of the accident. This benefit is payable only once per 24- hour period and only once per covered accident. This benefit is payable in addition to the Accident Emergency Room Treatment Benefit. Is there a Hospital Admission Benefit? Yes. A $1,000 benefit is payable if, because of a covered accident, the insured is injured, requires hospital confinement and is confined to a hospital for at least 24 hours within 6 months after the accident date. This benefit is payable once per calendar year and does not apply to observation unit, emergency room or outpatient surgery or treatment. Is there a Hospital Confinement Benefit? Yes. The benefit pays $200 per day when, because of a covered accident, the insured is injured and the injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date. The maximum period for hospital confinement for the same injury is 365 days. The benefit is payable once per hospital confinement event if the confinement

8 is caused by more than one accidental injury. The benefit is not payable for emergency room treatment or outpatient surgery or treatment Is there an Intensive Care Benefit? Yes. The benefit pays $400 per day when, because of a covered accident, the insured is injured, and those injuries cause confinement to a hospital intensive care unit. The maximum period for the Hospital Intensive Care Benefit for the same injury is 30 days. The benefit is payable in addition to the Hospital Confinement Benefit. Is there a Rehabilitation Unit Benefit? Yes. $75 per day Is payable for injuries received in a covered accident if insured is admitted for a hospital confinement, transferred to a bed in a rehabilitation unit for treatment and incurs a charge. This benefit is limited to 30 days per period of hospital confinement and to a calendar year maximum of 60 days. The Rehabilitation Unit Benefit is not payable for the same days as the Accident Hospital Confinement Benefit. The highest eligible benefit will be payable. What are Major Injuries? Fractures and dislocations (diagnosed and treated within 90 days). What are Specific Injuries? Ruptured Disc Tendons/Ligament Torn Knee Cartilage Eye Injury Concussion Coma (lasting 30 days or more) Emergency Dental Work (as result of an accident) Burn (treatment within 72 hours and based on percent of body surface burned) Second-Degree Burns, Third-Degree Burns First-Degree burns are not covered. Lacerations (if there are multiple lacerations, the benefit is payable for the largest single laceration requiring stitches) What are Additional Benefits? Emergency Room Treatment and Emergency Room Observation Major Diagnostic Testing and Post Traumatic Stress Disorder (PTSD) Diagnosis Ambulance (both air and ground within 90 days after covered accident) Blood/Plasma (within 90 days following a covered accident) Appliances Internal Injuries (resulting in open abdominal or thoracic surgery) Accident Follow-Up Treatment (must receive initial treatment within 72 hours of accident and follow-up treatment must begin within 30 days of the covered accident or discharge from hospital) Transportation, Family Lodging Benefit, and Rehabilitation Unit Benefit Exploratory Surgery (without repair, i.e. arthroscopy) Prosthesis (hearing aids, wigs, or dental aids, including but not limited to false teeth are not covered)

9 Physical Therapy (Must be seen within 72 hours of accident and physical therapy must begin within 30 days of covered accident or discharge from the hospital. Physical therapy must begin within six months after the accident and the benefit is not payable for the same visit that the Accident Follow-Up Treatment Benefit is paid. Must be with a licensed, registered physical therapist.) Is there an Accidental-Death and Dismemberment benefit? Yes. The benefit is payable within 90 days of the covered accident. Can I cover my children? Yes. How do you define children? Your or your spouse s natural children, step-children, foster children, legally adopted children or children placed for adoption, or children placed in your home by a child placement agency (as defined by Kansas Statutes Annotated (K.S.A) and amendments thereto) for the purpose of adoption who are younger than age 26. However, there is an exception to the age-26 limit listed above. This limit will not apply to any child who is incapable of self-sustaining employment due to mental or physical handicap and is dependent on a parent for support. You or your spouse must furnish proof of this incapacity and dependency to the company within 31 days following the child s 26th birthday. Natural newborn children will be covered from the date of birth. Your adopted newborn children will be covered from the moment of birth if a petition for adoption was filed within 31 days of the date of birth. Other adopted children will be covered from the date the petition for adoption was filed. To extend coverage beyond 31 days, you must contact us within the 31-day time period following the child s birth or adoption. If dependent child coverage is already in force, no notice is required. What type of coverage is offered? You may select individual, single parent family, employee/spouse or two parent family. Can I cover my parents? No. What is considered a pre-existing condition? There is no pre-existing condition limitation for the accident coverage. What is the effective date? If you enroll during open enrollment, your effective date will be August 1, New hires through the year are effective one month following effective date for core benefits. Who is the benefit paid to? Aflac pays benefits directly to you (unless you choose otherwise). Will the benefit be paid to the provider? Aflac pays benefits directly to you (unless you choose otherwise). How is a claim filed? Claim form can be downloaded from aflacgroupinsurance.com. Or, contact your Aflac associate Terry Burnett at or terry_burnett@us.aflac.com.

10 What does guaranteed-issue mean and what is the benefit amount? During initial enrollment and for new hires thereafter. Provided the applicants are eligible for coverage. Can I be cancelled for using the benefits? No. Will my rate increase or decrease? Only if you choose to change your type of coverage. Can I change my coverage during the year? Only during open enrollment. Is the Aflac Accident plan portable? Yes, with certain stipulations. A portability packet must be requested within 30 days of your terminating employment. Contact for portability packet is Is there information on the web? Yes, visit aflac.com/kumc anytime! Is deduction pre-tax or after-tax? After-tax. How do I determine my rate? During open enrollment, rates will be shown with the web enrollment process. Following enrollment for new hires throughout the year, rate sheets will be provided. When is the best time to enroll? During this initial rollout so you can make the most of the guaranteedissue offer. For a new hire, it s best to enroll upon eligibility. What is the enrollment period? May 15 June 15. Can new hires be enrolled during the year? Yes. Will new hires have guarantee issue? Yes. How do I enroll? Visit aflac.com/kumc and simply link to the enrollment site! Do I have to answer health questions? No. What does actively at work mean? On the effective date of coverage, you must be performing a full normal workday the regular duties of employment for Kansas University Medical Center. What does successor insured mean? If the insured dies while covered under the plan, the surviving spouse shall become the insured if such spouse is an insured person. If there is no surviving spouse covered under the plan, then the plan shall terminate on the next premium due date. Do I have to be enrolled in the Kansas University Medical Center health insurance to enroll in the Accident Plan? No.

11 Can I be treated or diagnosed with an injury by a family member? No a doctor or physician does not include you or a member of your immediate family. Does this plan pay in addition to any other coverage I have? Yes. Can I be treated outside the United States? No benefits will be paid for diagnosis or treatment received outside of the United States. Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands.