American Heritage Life Insurance Company

Transcription

1 Benefits Specified Critical Illness Benefit Primary insured: $25,000 The policy pays the following benefits for covered illnesses subject to the conditions below along with the Exclusions and Limitations provision. We pay this benefit if the insured is diagnosed for the first time ever with one of the illnesses shown below if: 1. the date of diagnosis is after the effective date of coverage; and 2. the date of diagnosis is while insured; and 3. the illness is not excluded by name or specific description; or 4. it is determined, as the result of an autopsy, that the insured died as the result of one of the specified critical illnesses listed below. The illnesses covered under the policy are shown in the following chart. The amount payable for each illness is the percentage multiplied by the basic benefit amount. The percentage of the basic benefit amount payable for each illness is shown beside the illness. The maximum total percentage of the basic benefit amount payable per category of illnesses is shown in the last column of the chart below. Category Number Percentage of the Basic Benefit Amount Maximum Total Percentage of Basic Benefit Amount for Category Illness 1 Heart Attack 100% 1 Stroke 100% 1 Heart Transplant 100% 100% 1 Coronary Artery By-Pass Surgery 25% 2 Major Organ Transplant (excluding heart transplant) 100% 2 End Stage Renal Failure 100% 100% 2 Paralysis (not as a result of stroke) 100% 2 Alzheimer's Disease 25% This benefit provides coverage only for the illnesses shown in the chart shown above. It does not cover any other disease, sickness or incapacity, unless specifically stated. The insured can only receive benefits for an illness shown in the chart above one time, unless the Optional Recurrence Benefit is included. Page 3 of this illustration contains an example of possible benefit payments. Page 2 of 6 pages

2 The insured's coverage remains in force until 100% of the Basic Benefit Amount has been paid within each of Category 1 or Category 2, separately. Once that occurs, no additional benefits for any illness associated with that category are payable for that insured. If the insured receives a percentage of the basic benefit amount for one illness within a category, and then becomes eligible for benefits for another illness within the same category, the percentage of the basic benefit amount the insured will receive for the subsequent illness is the lesser of: the percentage of the basic benefit amount shown in the table for that illness; or 100% minus the percentage of basic benefit amount the insured received for the previous illness(es). All covered illnesses must be diagnosed by a physician. Emergency situations that occur while the insured is outside the United States will be reviewed and considered for approval by a United States physician on foreign soil or when the insured returns to the United States. EXAMPLE OF BENEFIT PAYMENT: An insured has Coronary Artery By-Pass Surgery. Later, he has a Heart Transplant. Under this scenario, the insured is paid 25% of his/her Basic Benefit Amount for the Coronary Artery By-Pass Surgery. He/she will then receive 75% of the Basic Benefit Amount for the Heart Transplant which is the balance of the Basic Benefit Amount for Category #1. He/She would not be eligible for any other benefit payments for illnesses in Category #1. Should the insured subsequently be diagnosed with Alzheimer's Disease, he/she would receive 25% of the Basic Benefit Amount for that condition since it is in Category #2, and would remain eligible for 75% of the Basic Benefit Amount if subsequently diagnosed with any of the remaining illnesses in Category 2. Page 3 of 6 pages

3 OPTIONAL CRITICAL ILLNESS CANCER BENEFIT Primary insured: $25,000 We pay this benefit if the insured is diagnosed with a new form or type of invasive cancer or carcinoma in situ, as defined in the policy, subject to all of the following: there is a clear and definitive diagnosis by either a pathological or clinical method, the date of diagnosis is after the effective date of coverage and while the optional benefit is in force, and the illness is not excluded by name or specific description in the policy; or it is determined, as the result of an autopsy, that the insured died as the result of one of the specified critical illnesses listed below. The illnesses covered by this benefit are shown in the following chart. The amount payable for each illness is the percentage shown below for each illness multiplied by the basic benefit amount. The maximum total percentage of the basic benefit amount payable for Category 3 of illnesses is shown in the last column of the chart below. Category Number Percentage of the Basic Benefit Amount Maximum Total Percentage of Basic Benefit Amount for Category Illness 3 Invasive Cancer 100% 3 Carcinoma in Situ 25% 100% The insured's coverage remains in force until 100% of the basic benefit amount has been paid within Category 3. Once that occurs, no additional benefits for any illness associated with Category 3 are payable for that insured. If the insured receives a percentage of the basic benefit amount for one illness within Category 3, and then becomes eligible for benefits for another illness within the same category, the percentage of the basic benefit amount the insured receives for the subsequent illness is the lesser of: the percentage of the basic benefit amount shown in the table above for that illness; or 100% minus the percentage of basic benefit amount the insured received for the previous illness(es). This benefit provides coverage only for the illnesses shown in the chart shown above. It does not cover any other disease, sickness or incapacity. The insured can only receive benefits one time for an illness shown in the chart above once. OPTIONAL RECURRENCE BENEFIT 25% of Previously Paid Category 1 & 2 We will pay this benefit if any insured is diagnosed more than once with the same specified critical illness listed in Category 1 or 2 for which a benefit was previously paid if: 1. there is more than 18 months between each diagnosis; and 2. the insured did not receive treatment during the 18 month period (treatment does not include medications and follow-up visits to the insured's physician); and 3. the subsequent date of diagnosis is while coverage is in force; and 4. the specified critical illness is not excluded by the policy. We will pay an amount equal to 25% of the specified critical illness basic benefit amount previously paid for that specified critical illness. We will pay no more than one recurrence benefit per previously paid specified critical illness under each of Category 1 and 2. Page 4 of 6 pages

4 Eligibility American Heritage Life Insurance Company Family Plan coverage may include the employee/member, their spouse or domestic partner and dependent children as defined in the policy. Individual and Spouse coverage includes the employee/member and their spouse or domestic partner as defined in the policy. Individual and Children coverage includes the employee/member and eligible children as defined in the policy. Individual coverage includes the employee/member only. Termination of Coverage The insured s coverage under the policy ends on the earliest of: the date the policy is canceled; or the last day of the period for which any required premium payments were made; or the last day the insured is in active employment, except as provided under the Temporarily Not Working provision; or the date the insured is no longer in an eligible class; or the date the insured s class is no longer eligible; or the date each insured has received the maximum total percentage of the basic benefit amount for each critical illness category, including the Optional Recurrence Benefit, if applicable. If your spouse is a covered person, the spouse s coverage ends upon valid decree of divorce or your death. If your domestic partner is a covered person, the domestic partner s coverage ends upon termination of the domestic partnership or your death. Coverage for your child will end on the issue day of the month that follows when the child reaches age 26 or otherwise does not meet the requirements of an eligible dependent. If the insured's coverage terminates for reasons other than non-payment of premium, or if coverage of a spouse terminates due to divorce or the insured's death, or if coverage of a child terminates due to the child reaching age 26, the insured will be eligible for portability coverage. This means the insured may continue the same benefits he/she had under the group policy, subject to the conditions defined in the policy, as long as premiums are paid directly to American Heritage Life Insurance Company. Continuation of Coverage (COBRA) Since this plan is employer-sponsored, it is subject to the same federal COBRA continuation requirements that apply to medical plans. In general, this allows the insured to continue insurance under the group policy for 18 months after employment terminates. If the insured s dependent should lose coverage due to his/her death or divorce, or their attainment of the limiting age for dependent eligibility, the coverage may be continued for up to 36 months. If the group policy is terminated by the employer before the end of the COBRA continuation period, the insured will be entitled to exercise the Portability Privilege. Portability Privilege If a covered person s coverage terminates for reasons other than non-payment of premium, such covered person will be eligible for portability coverage. This means the covered person may continue the same benefits he or she had under the group policy, subject to the conditions defined in the policy, as long as premiums are paid directly to American Heritage Life Insurance Company. Exclusions and Limitations We do not pay benefits under the policy for an illness due to or resulting from (directly or indirectly): 1. any act of war, whether or not declared, participation in a riot, insurrection or rebellion; or 2. intentionally self-inflicted injuries; or 3. injury incurred while engaging in an illegal occupation or committing or attempting to commit a felony; or 4. attempted suicide, while sane or insane; or 5. any injury sustained while under the influence of alcohol, narcotics or any other controlled substance or drug unless administered upon the advice of a physician; or 6. participation in any form of aeronautics except as a fare paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports; or 7. alcohol abuse or alcoholism, drug addiction or dependence upon any controlled substance. Page 5 of 6 pages

5 Pre-Existing Condition American Heritage Life Insurance Company If an insured has a pre-existing condition, we do not pay any benefit due to, or caused by, a pre-existing condition, as defined, during the 12 month period beginning on the date that person became insured. A Pre- Existing Condition is a disease or physical condition for which symptoms existed within the 12 month period prior to the effective date of coverage; or medical advice or treatment was recommended or received from a member of the medical profession within the 12 month period prior to the effective date of coverage. The exception to the above would be for follow-up care for breast cancer. Routine follow-up care for a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care or treatment unless evidence of breast cancer is found during, or as the result of, the follow-up care. A preexisting condition can exist even though a diagnosis has not yet been made. Claims for benefits under the policy not satisfying all the criteria for diagnosis are subject to review by an independent physician consultant. This illustration highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the insured and insurance company. The policy is a Limited Benefit Critical Illness Policy. The policy and certificate are not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer s Guide, available from American Heritage Life Insurance Company. Subject to COBRA Continuation of Coverage. Page 6 of 6 pages

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7 Benefits Specified Critical Illness Benefit Primary insured: $10,000 The policy pays the following benefits for covered illnesses subject to the conditions below along with the Exclusions and Limitations provision. We pay this benefit if the insured is diagnosed for the first time ever with one of the illnesses shown below if: 1. the date of diagnosis is after the effective date of coverage; and 2. the date of diagnosis is while insured; and 3. the illness is not excluded by name or specific description; or 4. it is determined, as the result of an autopsy, that the insured died as the result of one of the specified critical illnesses listed below. The illnesses covered under the policy are shown in the following chart. The amount payable for each illness is the percentage multiplied by the basic benefit amount. The percentage of the basic benefit amount payable for each illness is shown beside the illness. The maximum total percentage of the basic benefit amount payable per category of illnesses is shown in the last column of the chart below. Category Number Percentage of the Basic Benefit Amount Maximum Total Percentage of Basic Benefit Amount for Category Illness 1 Heart Attack 100% 1 Stroke 100% 1 Heart Transplant 100% 100% 1 Coronary Artery By-Pass Surgery 25% 2 Major Organ Transplant (excluding heart transplant) 100% 2 End Stage Renal Failure 100% 100% 2 Paralysis (not as a result of stroke) 100% 2 Alzheimer's Disease 25% This benefit provides coverage only for the illnesses shown in the chart shown above. It does not cover any other disease, sickness or incapacity, unless specifically stated. The insured can only receive benefits for an illness shown in the chart above one time, unless the Optional Recurrence Benefit is included. Page 3 of this illustration contains an example of possible benefit payments. Page 2 of 6 pages

8 The insured's coverage remains in force until 100% of the Basic Benefit Amount has been paid within each of Category 1 or Category 2, separately. Once that occurs, no additional benefits for any illness associated with that category are payable for that insured. If the insured receives a percentage of the basic benefit amount for one illness within a category, and then becomes eligible for benefits for another illness within the same category, the percentage of the basic benefit amount the insured will receive for the subsequent illness is the lesser of: the percentage of the basic benefit amount shown in the table for that illness; or 100% minus the percentage of basic benefit amount the insured received for the previous illness(es). All covered illnesses must be diagnosed by a physician. Emergency situations that occur while the insured is outside the United States will be reviewed and considered for approval by a United States physician on foreign soil or when the insured returns to the United States. EXAMPLE OF BENEFIT PAYMENT: An insured has Coronary Artery By-Pass Surgery. Later, he has a Heart Transplant. Under this scenario, the insured is paid 25% of his/her Basic Benefit Amount for the Coronary Artery By-Pass Surgery. He/she will then receive 75% of the Basic Benefit Amount for the Heart Transplant which is the balance of the Basic Benefit Amount for Category #1. He/She would not be eligible for any other benefit payments for illnesses in Category #1. Should the insured subsequently be diagnosed with Alzheimer's Disease, he/she would receive 25% of the Basic Benefit Amount for that condition since it is in Category #2, and would remain eligible for 75% of the Basic Benefit Amount if subsequently diagnosed with any of the remaining illnesses in Category 2. Page 3 of 6 pages

9 OPTIONAL CRITICAL ILLNESS CANCER BENEFIT Primary insured: $10,000 We pay this benefit if the insured is diagnosed with a new form or type of invasive cancer or carcinoma in situ, as defined in the policy, subject to all of the following: there is a clear and definitive diagnosis by either a pathological or clinical method, the date of diagnosis is after the effective date of coverage and while the optional benefit is in force, and the illness is not excluded by name or specific description in the policy; or it is determined, as the result of an autopsy, that the insured died as the result of one of the specified critical illnesses listed below. The illnesses covered by this benefit are shown in the following chart. The amount payable for each illness is the percentage shown below for each illness multiplied by the basic benefit amount. The maximum total percentage of the basic benefit amount payable for Category 3 of illnesses is shown in the last column of the chart below. Category Number Percentage of the Basic Benefit Amount Maximum Total Percentage of Basic Benefit Amount for Category Illness 3 Invasive Cancer 100% 3 Carcinoma in Situ 25% 100% The insured's coverage remains in force until 100% of the basic benefit amount has been paid within Category 3. Once that occurs, no additional benefits for any illness associated with Category 3 are payable for that insured. If the insured receives a percentage of the basic benefit amount for one illness within Category 3, and then becomes eligible for benefits for another illness within the same category, the percentage of the basic benefit amount the insured receives for the subsequent illness is the lesser of: the percentage of the basic benefit amount shown in the table above for that illness; or 100% minus the percentage of basic benefit amount the insured received for the previous illness(es). This benefit provides coverage only for the illnesses shown in the chart shown above. It does not cover any other disease, sickness or incapacity. The insured can only receive benefits one time for an illness shown in the chart above once. OPTIONAL RECURRENCE BENEFIT 25% of Previously Paid Category 1 & 2 We will pay this benefit if any insured is diagnosed more than once with the same specified critical illness listed in Category 1 or 2 for which a benefit was previously paid if: 1. there is more than 18 months between each diagnosis; and 2. the insured did not receive treatment during the 18 month period (treatment does not include medications and follow-up visits to the insured's physician); and 3. the subsequent date of diagnosis is while coverage is in force; and 4. the specified critical illness is not excluded by the policy. We will pay an amount equal to 25% of the specified critical illness basic benefit amount previously paid for that specified critical illness. We will pay no more than one recurrence benefit per previously paid specified critical illness under each of Category 1 and 2. Page 4 of 6 pages

10 Eligibility American Heritage Life Insurance Company Family Plan coverage may include the employee/member, their spouse or domestic partner and dependent children as defined in the policy. Individual and Spouse coverage includes the employee/member and their spouse or domestic partner as defined in the policy. Individual and Children coverage includes the employee/member and eligible children as defined in the policy. Individual coverage includes the employee/member only. Termination of Coverage The insured s coverage under the policy ends on the earliest of: the date the policy is canceled; or the last day of the period for which any required premium payments were made; or the last day the insured is in active employment, except as provided under the Temporarily Not Working provision; or the date the insured is no longer in an eligible class; or the date the insured s class is no longer eligible; or the date each insured has received the maximum total percentage of the basic benefit amount for each critical illness category, including the Optional Recurrence Benefit, if applicable. If your spouse is a covered person, the spouse s coverage ends upon valid decree of divorce or your death. If your domestic partner is a covered person, the domestic partner s coverage ends upon termination of the domestic partnership or your death. Coverage for your child will end on the issue day of the month that follows when the child reaches age 26 or otherwise does not meet the requirements of an eligible dependent. If the insured's coverage terminates for reasons other than non-payment of premium, or if coverage of a spouse terminates due to divorce or the insured's death, or if coverage of a child terminates due to the child reaching age 26, the insured will be eligible for portability coverage. This means the insured may continue the same benefits he/she had under the group policy, subject to the conditions defined in the policy, as long as premiums are paid directly to American Heritage Life Insurance Company. Continuation of Coverage (COBRA) Since this plan is employer-sponsored, it is subject to the same federal COBRA continuation requirements that apply to medical plans. In general, this allows the insured to continue insurance under the group policy for 18 months after employment terminates. If the insured s dependent should lose coverage due to his/her death or divorce, or their attainment of the limiting age for dependent eligibility, the coverage may be continued for up to 36 months. If the group policy is terminated by the employer before the end of the COBRA continuation period, the insured will be entitled to exercise the Portability Privilege. Portability Privilege If a covered person s coverage terminates for reasons other than non-payment of premium, such covered person will be eligible for portability coverage. This means the covered person may continue the same benefits he or she had under the group policy, subject to the conditions defined in the policy, as long as premiums are paid directly to American Heritage Life Insurance Company. Exclusions and Limitations We do not pay benefits under the policy for an illness due to or resulting from (directly or indirectly): 1. any act of war, whether or not declared, participation in a riot, insurrection or rebellion; or 2. intentionally self-inflicted injuries; or 3. injury incurred while engaging in an illegal occupation or committing or attempting to commit a felony; or 4. attempted suicide, while sane or insane; or 5. any injury sustained while under the influence of alcohol, narcotics or any other controlled substance or drug unless administered upon the advice of a physician; or 6. participation in any form of aeronautics except as a fare paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports; or 7. alcohol abuse or alcoholism, drug addiction or dependence upon any controlled substance. Page 5 of 6 pages

11 Pre-Existing Condition American Heritage Life Insurance Company If an insured has a pre-existing condition, we do not pay any benefit due to, or caused by, a pre-existing condition, as defined, during the 12 month period beginning on the date that person became insured. A Pre- Existing Condition is a disease or physical condition for which symptoms existed within the 12 month period prior to the effective date of coverage; or medical advice or treatment was recommended or received from a member of the medical profession within the 12 month period prior to the effective date of coverage. The exception to the above would be for follow-up care for breast cancer. Routine follow-up care for a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care or treatment unless evidence of breast cancer is found during, or as the result of, the follow-up care. A preexisting condition can exist even though a diagnosis has not yet been made. Claims for benefits under the policy not satisfying all the criteria for diagnosis are subject to review by an independent physician consultant. This illustration highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the insured and insurance company. The policy is a Limited Benefit Critical Illness Policy. The policy and certificate are not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer s Guide, available from American Heritage Life Insurance Company. Subject to COBRA Continuation of Coverage. Page 6 of 6 pages