THE EPIC LIFE INSURANCE COMPANY

Transcription

1 THE EPIC LIFE INSURANCE COMPANY VISION BENEFITS ENDORSEMENT FOR WSE SUPPLEMENTAL DENTAL, HOSPITAL INDEMNITY AND ACCIDENTAL DEATH AND DISMEMBERMENT CERTIFICATE In consideration of the premiums charged by EPIC and paid by the group policyholder to EPIC for the coverages issued under the group insurance policy under which EPIC issued the EPIC Certificate of Insurance to which this endorsement is attached that certificate and group insurance policy are amended by EPIC as follows: The following subsection is added to Section IV Benefit Provisions : D. Vision Expense Benefit The benefits under this subsection are administrated by Davis Vision. 1. Definitions. The following definitions apply to this subsection only: Allowance: the dollar amount payable under the policy for eye examinations, the fitting of eyeglasses, or materials received and/or purchased by a member. Charge: an amount for a vision care service directly provided to you by a vision care provider that is reasonable, as determined by us, when taking into consideration, among other factors (including national sources) determined by us, amounts charged by vision care providers for similar vision care services when provided in the same geographical area. The term area means a county or other geographical area which we determine is appropriate to obtain a representative cross section of such amounts. For example, in some cases the area may be an entire state. In some cases the amount we determine as reasonable may be less than the amount billed. Charges are incurred on the date you receive the vision care service. Each preferred provider is paid at the negotiated rate determined by us in accordance with the applicable contract between us or the provider network shown on your EPIC vision identification card and that preferred provider. Claim Administrator: Davis Vision acting as the vision claim administrator. Their address is as follows: Vision Care Processing Unit P.O. Box 1525 Latham, New York Collection: a specific category of lenses or frames designated by the provider network shown on your vision identification card. Copayment: that portion of the charge for a covered expense which you are required to pay to the vision care provider for a certain vision care service covered under the policy. Copayments are a specific dollar amount. In-Network: when vision care services are provided by a preferred provider. Materials: frames and lenses provided to a member for ophthalmic correction under the terms and conditions of the policy.

2 Non-Preferred Provider: providers of optometric services who have not entered into a contract with the provider network shown on your EPIC vision identification card to provide vision care services. Optometrist: a specialist licensed by the state in which he/she is located to practice optometry and provide services while he/she is acting within the lawful scope of his/her license. Preferred Provider: vision care providers who have entered into a contract with the provider network shown on your EPIC vision identification card to provide eye examinations and/or materials on a scheduled fee basis. The Preferred Provider Directory is available on the Internet at the address shown on your EPIC vision identification card or by request from the Claim Administrator. Please note that preferred providers may change periodically. While the online Preferred Provider Directory is updated frequently, the presence of a provider's name in the listing does not guarantee or mean that that specific provider participates in that network at the same time that a member receives any service from that provider. The member may be required to pay a larger portion of the cost of his/her covered vision care service if he/she sees any vision care provider who is not a preferred provider at the time he/she receives the vision care service. Scheduled Fee: the amount negotiated between a preferred provider and the provider network shown on your EPIC vision identification card as full payment for eye examinations, the fitting of eyeglasses and materials received or purchased by a member. Vision Care Provider: any physician, ophthalmologist, person, institution or other entity licensed by the state in which he/she or it is located to provide vision care services or supplies covered by the policy to you, within the lawful scope of his/her or its license. Vision Care Services: services or materials provided by a licensed physician or optometrist of a member s choice licensed to perform eye exams and eyeglass fitting. 2. Payment of Benefits. We'll pay benefits for charges for covered expenses you incur for covered vision care services described under subsection Covered Expenses. We'll pay benefits up to the allowed amounts shown in the Schedule of Benefits for charges incurred in connection with covered vision care services, subject to all terms, conditions and provisions of the policy. Covered expenses must be incurred while you are covered under the policy. 3. Schedule of Benefits. If covered expenses are not available through the preferred providers, non-preferred providers will be reimbursed at the same percentage level of reimbursement as preferred providers. This does not apply to a member who chooses to receive services from providers other than preferred providers for the member s own convenience. You and your covered dependents may use either a preferred or non-preferred provider for covered expenses. If a preferred provider is used, you will only be billed for the difference between the applicable copayment, if any, shown below and the difference between the allowance and scheduled fee, if applicable, for the covered expense. Use of a non-preferred provider may result in additional charges. Non-preferred providers may bill you for the difference between the allowance shown below and the provider s actual charge for the vision care service.

3 a. Frequency of Use: One complete set of spectacle lenses or contact lenses (in lieu of eyeglasses), as determined by the Claim Administrator, every 12 months and frames every 24 months b. In-Network Benefits: Copayment (1) Lenses (Spectacle or Contact) $25.00 Collection contact lenses are not covered under the policy. Contact lenses other than collection contact lenses will be paid up to a maximum allowance of $ The balance, if any, is your responsibility. Evaluation, fitting and follow-up adjustments for non-collection standard contact lenses and all collection contact lenses will be payable under the policy. Evaluation, fitting and follow-up adjustments for non-collection specialty contact lenses will be paid up to a maximum allowance of $ The balance, if any, is your responsibility. (2) Frames Fashion $0 Designer $20.00 Premier $40.00 Frames other than collection frames will be paid up to a maximum allowance of $ The balance, if any, is your responsibility. c. Out-of-Network Benefits: You may use the vision care provider of your choice for covered vision care services. However, if you use a non-preferred provider, benefits will be paid up to the allowance shown below. The balance of the charge is your responsibility. Allowance (1) Lenses Single Vision $25.00 Bifocal $35.00 Trifocal $45.00 Lenticular $60.00 Contact Elective $75.00 Medically Necessary $ (2) Frames $30.00 d. Low Vision Benefit: You may use the vision care provider of your choice for covered low vision services. However, benefits shall be paid as stated below. The balance of the charge is your responsibility. (1) Comprehensive Evaluation: Once every five years (includes four followup visits)

4 (2) Maximum per Evaluation: $ (3) Maximum per Follow-up Visit: $ (4) Low Vision Aids Maximum per Aid: $ Lifetime Maximum for all Aids: $1, Covered Expenses. The following vision care services are covered expenses. All vision care services must be ordered by a physician or optometrist. If the treatment, service or material is not listed in this subsection, that treatment, service or material is not covered and benefits are not payable under the policy. a. Fitting of Eyeglasses. If vision correction is recommended by a vision care provider, we ll pay benefits for charges for the fitting of eyeglasses and follow-up adjustments. b. Materials. The following materials are payable under the policy as stated below. (1) Glass or plastic lenses, in single vision, bifocal, trifocal or lenticular prescriptions. The following types of lenses are also included: (a) (b) (c) (d) (e) Prescription sunglasses with grey glass #3 lenses; Oversized lenses; Fashion and gradient tinting of plastic lenses; Cataract lenses; Contact lenses. Lenses are subject to the frequency of use shown in section a. of the Schedule of Benefits. Lenses from a preferred provider are subject to the copayment shown in paragraph 3. b. (1). Benefits for lenses from a non-preferred provider are payable up to the allowance shown in paragraph. c. (1) or the actual charge for the lenses, whichever is less. You are responsible for any amount in excess of the allowance. (2) Frames. Frames from a preferred provider are subject to the copayment shown in paragraph 3. b. (2). Benefits for frames from a non-preferred provider are payable up to the allowance shown in paragraph 3. c. (2) or the actual charge for the frames, whichever is less. You are responsible for any amount in excess of the allowance. (3) Medically necessary contact lenses subject to the Claim Administrator s prior approval. Contact lenses may be medically necessary when the use of contract lenses, in lieu of eyeglasses, will result in significantly better visual acuity and/or improved binocular function, including avoidance of diplopia or suppression. Contact lenses may be determined as medically necessary in the treatment of the following conditions: (a) keratoconus; (b) anisometropia; (c) corneal disorders; (d) pathological myopia; (e) aniseikonia; (f) post-traumatic disorders; (g) aphakia; (h) aniridia; and (i) irregular astigmatism.

5 You or your attending vision care provider must send a completed request to the Claim Administrator for medically necessary contact lenses before the lenses are dispensed. If the required approval is not obtained, benefits are not payable under the policy for such lenses and the entire charge will be your responsibility. This limitation will not apply if it is shown that is was not reasonably possible to submit the request for approval. If approved by the Claim Administrator: (1) medically necessary contact lenses provided by a preferred provider are not subject to any copayment, and benefits include the charges for evaluation, fitting and follow-up; and (2) medically necessary contact lenses provided by a nonpreferred provider will be payable up to the allowance shown in Section c. (1) of the Schedule of Benefits. Any amount due over the allowance for such lenses is your responsibility. b. Low Vision Program. We ll pay benefits for charges for up to the allowance shown in paragraph 3. d.. Covered expenses include: (1) Comprehensive low vision evaluation in addition to a comprehensive eye examination when the comprehensive eye examination indicates a need for such an evaluation; (2) Follow-up visits; (3) Low vision aids. This program is available both in and out of network and is subject to prior approval. You or your attending physician must send a completed request to the Claim Administrator prior to the initial evaluation. Once approved, you are eligible for comprehensive low vision evaluation and follow-up visits up to the maximums stated in paragraph 3. d. (1), (2), and (3). Low vision aids will be provided as prescribed up to the maximum per aid, subject to the lifetime maximum for all aids shown in paragraph 3. d. (4). Any amount due over the allowances above for an evaluation, follow-up visits or aids is your responsibility. If the required approval is not obtained, benefits are not payable under the policy for any such evaluation, follow-up visits or aids and the entire charge will be your responsibility. 5. GENERAL EXCLUSIONS. The following aren't covered under the policy. The policy provides no benefits for: a. Vision care services not recommended by a vision care provider. b. Eye examinations. c. Vision care services provided in connection with special procedures such as orthoptics and visual training. d. Lenses which do not provide vision correction. e. Charges for the replacement of lost or stolen lenses or frames within 24 months of service. f. Vision care services for any injury or illness arising out of, or in the course of, any activity for pay, profit or gain. This exclusion applies regardless of whether benefits under workers compensation or similar laws have been claimed, paid,

6 waived or compromised or whether you re covered under worker s compensation insurance. g. Vision care services furnished by the U.S. Veterans Administration, except for such vision care services which under the policy we are the primary payor and the U.S. Veterans Administration is the secondary payor under applicable federal law. h. Vision care services furnished by any federal or state agency or a local political subdivision when the member is not liable for the costs in the absence of insurance, unless coverage under the policy is required by any state or federal law. i. Vision care services covered by Medicare, if a member has or is eligible for Medicare, to the extent benefits are or would be available from Medicare. j. Vision care services for any injury or illness caused by: (a) atomic or thermonuclear explosion or resulting radiation; or (b) any type of military action, friendly or hostile. k. Vision care services in connection with any illness or injury caused by your: (a) engaging in an illegal occupation; or (b) commission of, or attempt to commit a felony; or (c) self-inflicted injury. l. Medical treatment provided outside of the United States or Canada. m. Vision care services provided by practitioners who do not meet the definition of vision care provider. n. Vision care services provided when your coverage was not effective under the policy. This includes vision care services provided either prior to your effective date of coverage or after his/her coverage terminated under the policy. (See section WHEN COVERAGE ENDS ). o. Vision care services for which you have no legal obligation to pay. p. That portion of the amount billed for a vision care service covered under the policy that exceeds our determination of the charge for such vision care service. q. Comprehensive low vision evaluations, subsequent follow-up visits following such evaluation or low vision aids for which prior notification was not sent to the Claim Administrator. r. Medically necessary contact lenses prescribed for you for which prior notification was not approved by the Claim Administrator. s. Eye refractive surgery. Under Section VI Exclusions paragraph I. shall be replaced by the following: I. Preparation, fitting or purchase of eyeglasses or contact lenses, or eye refractive surgery, except as specifically stated in the policy; vision therapy, including orthoptic therapy and pleoptic therapy.

7 Under Section XI. General Provisions, subsection H. Proof of Claim, paragraph 1, the heading shall be changed to the following: 1. Health, Dental and Vision. This endorsement shall be effective beginning with the date for which the appropriate premium shall have been paid to and accepted by EPIC. It shall continue in force under the same provisions as govern the policy. All other terms, provisions and conditions of the entire policy remain unchanged except as stated above. IN WITNESS WHEREOF, The EPIC Life Insurance Company has executed this endorsement. THE EPIC LIFE INSURANCE COMPANY Michael F. Hamerlik, President