American Heritage Life Insurance Company. A Cancer and Specified Disease Insurance Illustration

Transcription

1 A Cancer and Specified Disease Insurance Illustration Name: Sample F Client Age: 54 Application Signature State: Arkansas Case Name: Agent Name: Policy: Type of Coverage: Benefit Level: Optional Riders: Cancer/Specified Disease Enhancement Rider (CER1) Intensive Care Rider (ICR2) Earl Webb Cancer/Specified Disease (CP10AR) Family Option B 2 units 3 units Premium Payment Mode: Monthly Premium by Policy and Rider: Cancer/Specified Disease $25.82 Cancer/Specified Disease Enhancement Rider $20.80 Intensive Care Rider $5.99 Total Modal Premium: $52.61 Allstate Workplace Division is the marketing name for American Heritage Life Insurance Company, a wholly-owned subsidiary of the Allstate Corporation, Home Office: Northbrook, Illinois. All products are underwritten by American Heritage Life Insurance Company. Home Office: Jacksonville, Florida. This illustration highlights some features of the policy and riders, but is not the insurance contract. Only the actual policy and rider provisions control. The policy and riders set forth, in detail, the rights and obligations of both the insured and the insurance company American Heritage Life Insurance Company. Page 1 of 6 pages

2 In addition to cancer, this policy also covers Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis, Rabies, Tetanus, Typhoid Fever, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever, Epidemic Cerebrospinal Meningitis, Undulant Fever, Sickle Cell Anemia, Rocky Mountain Spotted Fever, Smallpox, Addison's Disease, Hansen's Disease, Tularemia, Bubonic Plague. Benefits Hospital Confinement Each day a covered person is admitted to and confined as an inpatient in a hospital. Maximum 70 days per each period of continuous confinement. Surgery Surgeon's fee not to exceed amount shown in the Schedule of Operations in the policy. Outpatient surgery is paid at 150% of surgical benefit. Maximum Benefit Payable $200/day $3,000/maximum depends on surgery Second Surgical Opinion Actual charges up to $200. Must be incurred after diagnosis and before surgery. $200 Anesthesia Actual charges up to 25% of the amount paid for surgery when surgery is performed. The maximum benefit paid for skin cancer is $100. Ambulatory Surgical Center Actual charges up to $250/day, when surgery is performed at an ambulatory surgical center. Radiation Therapy, Radio-Active Isotopes Therapy, Chemotherapy, or Immunotherapy Actual charges up to maximum shown per 12 month period beginning with the first day of benefit under this provision. New or Experimental Treatment Actual charges when the attending physician judges such treatment necessary and no other generally accepted treatment produces superior results in the opinion of the attending physician. Maximum shown per 12 month period beginning the first day of treatment under this provision. Inpatient Drugs and Medicine Actual in-hospital charges up to $10/day. Blood, Plasma and Platelets Actual charges up to maximum shown per 12 month period beginning with the first day of benefits under this provision for blood, plasma, platelets and transfusions (including administration charges); processing and procurement costs; cross matching. Blood replaced by donors is not covered. Physician's Attendance Actual charges up to maximum shown while hospital confined. Limited to one visit/day by one doctor. Private Duty Nursing Service Actual charges up to while hospital confined. 25% of surgical or $100 if Skin Cancer $250/day $10,000/12 mo. $10,000/12 mo. $10/day $10,000/12 mo. $30/day Page 2 of 6 pages

3 Home Nursing Actual charges up to for private nursing care and attendance by a nurse at home. Must be required and authorized by the attending physician and must begin within 14 days after confinement as an inpatient in a hospital. Limited to the number of days that the Hospital Confinement benefit is paid. Skin Cancer Actual charges for removal of skin cancer up to maximum shown when a physician who is not a pathologist diagnoses it. If more than one skin cancer is removed at the same time, the maximum benefit payable is the amount shown for each additional skin cancer removed. Skin cancers diagnosed by a pathologist are eligible for other policy benefits. Prosthesis Actual charges up to maximum shown per prosthetic device requiring surgical implantation. Limited to $2,000 per covered person, per amputation. Ambulance Actual charges up to maximum shown per continuous confinement for transportation by a licensed ambulance service or hospital owned ambulance. Hospice Care (Freestanding Hospice Care Center or Home Care) One of the following is paid if a covered person has been diagnosed by a physician as terminally ill and the attending physician has approved services. Payable only if services or admission occurs within 14 days after a period of inpatient hospital confinement. 1. Actual charges up to for confinement in a licensed free standing hospice care center. Benefits payable for hospice centers that are designated areas of hospitals will be paid the same as inpatient hospital confinement. Or 2. Actual charges up to $100/visit, limited to 1 visit/day, for home care services by a hospice care team. Home care services are hospice services provided in the patient's home. Food services or meals other than dietary counseling, services related to well-baby care, services provided by volunteers or support for the family after the death of the covered person are not covered. Government or Charity Hospital in lieu of all other benefits in the policy when confined to a hospital operated by the U.S. Government or a hospital that does not charge for the services it provides. Non-Local Transportation Actual cost of round trip coach fare by common carrier or $0.40/mile up to 700 miles for round trip personal vehicle transportation allowance for round trips exceeding 70 miles. Outpatient Lodging Actual cost, up to maximum shown, of single room in a motel, hotel, or other accommodations acceptable to AHL. Covered person must be receiving radiation or chemotherapy treatment on an outpatient basis. Limited to maximum of $4,000 per 12 month period beginning with the first day of benefit under this provision. Outpatient treatment must be received at a treatment facility more than 100 miles from the covered person's home. Must be authorized by the attending physician and cannot be obtained locally. Maximum Benefit Payable $120 for first removal/ $60 each additional removal $2,000 $200 Airfare Page 3 of 6 pages

4 Family Member Lodging and Transportation Covered person must be confined in a non-local hospital for specialized treatment. Lodging. Actual cost of a single room in a motel, hotel, etc. up to 60 days per continuous confinement. Transportation. Actual cost of round trip coach fare on common carrier, or $0.40/mile up to 700 miles personal vehicle allowance for round trips exceeding 70 miles. Not paid if personal vehicle mileage is paid under non-local transportation benefit unless family member lives in a city or town other than the covered person's home. Extended Benefits If continuous hospital confinement lasts more than 70 days, the policy pays the actual hospital charges up to maximum shown. Begins on the 71st day until discharge. Paid in addition to any other benefits paid prior to the 71st day, and paid in lieu of all other benefits after the 70th day. Extended Care Facility Actual charges up to. Confinement period is limited to the number of days of previous continuous hospital confinement. Confinement must begin within 14 days after hospital confinement and must be at the direction of the attending physician. Physical or Speech Therapy Actual charges up to $25/day for restoration of normal body function. Waiver of Premium Premiums that become due after insured is disabled for 90 days are waived as long as the insured remains disabled. Disability must be a direct result of cancer first diagnosed after the 30 day waiting period. Maximum Benefit Payable Airfare $200/day $25/day Yes Page 4 of 6 pages

5 Cancer/Specified Disease Enhancement Rider Cancer Enhancement Rider (CER1) provides the following: Hospital Confinement Benefit The hospital confinement benefit pays $200 per day for each day a covered person is confined as an inpatient in a hospital. The maximum number of days payable is 70 days for each period of continuous hospital confinement. Radiation Therapy, Radio-Active Isotopes Therapy, Chemotherapy, and Immunotherapy Benefit This benefit increases the radiation therapy, radio-active isotopes therapy, chemotherapy, and immunotherapy benefit in your policy by $10,000 per 12 month period. This benefit is only payable after the limit per 12 month period in the policy has been reached. This benefit then pays actual charges up to $10,000 in that 12 month benefit period. Blood, Plasma, and Platelets Benefit This benefit increases the blood, plasma, and platelets benefit in the policy by $10,000 per 12 month period. This benefit is only payable after the limit per 12 month period in the policy has been reached. This benefit then pays actual charges up to $10,000 in that 12 month benefit period. Intensive Care Rider $300 ($150 at ages 70 and above) for each day of confinement in a hospital intensive care unit. Begins with the first day of admission and pays up to 45 days. For time periods less than a day (24 hours), a prorata share of the daily benefit is paid. Benefit reduces to 50% at age 70. Actual charges for ambulance transportation to a hospital for admission to an intensive care unit for a covered confinement; this benefit is not paid if the base policy covers the ambulance. This optional rider is not disease specific and pays a benefit for covered confinement in a hospital intensive care unit for any covered illness or accident from the very first day of confinement. No benefits are paid if confinement is due to an attempted suicide or intentional self-inflicted injury; intoxication or being under the influence of drugs not prescribed by a physician; or alcoholism or drug addiction. Benefits are not paid under this rider for continuous hospital intensive care unit confinements that occur during hospitalization that begins before the rider date. Children born within 10 months of the rider date are not covered for any continuous confinement benefit that occurs or begins during the first 30 days of such child's life. Page 5 of 6 pages

6 Renewability American Heritage Life Insurance Company The policy is guaranteed renewable for life, subject to change in premiums by class. All premiums may change on a class basis. A notice is mailed in advance of any change. Family Plan coverage may include you, your spouse and dependent children as defined in the policy. Coverage for dependent children terminates on the policy anniversary next following the date on which the child is no longer eligible, which is the earlier of when the child marries or reaches age 21 (25 if a full-time student at an educational institution of higher learning beyond high school). Coverage for the insured s spouse ends upon valid decree of divorce. Waiting Period, Exclusions And Limitations The policy and riders contain a 30-day waiting period that begins on the effective date. No benefits are payable for any covered person who has cancer or a specified disease diagnosed before coverage has been in force 30 days from the effective date, except should a covered person have cancer or a specified disease first diagnosed after you sign the application and before the end of the waiting period, benefits for treatment of that cancer or specified disease will apply only to loss commencing after 2 years from the effective date of the policy; or at your option, you may elect to void the policy from the beginning and receive a full refund of premium, in accordance with the Notice of 30 Day Right to Examine Policy provision. The policy does not pay for any loss except for losses due directly from cancer or specified disease. Diagnosis must be submitted to support each claim. Treatment must be received in the United States or its territories. This brochure 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. This Is A Limited Benefit Cancer Policy With Optional Riders The policy and riders are not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer s Guide, available from American Heritage Life Insurance Company. Rider Termination All riders terminate after the grace period when the premium is not paid, or if the base policy terminates, or when a request to terminate is received. CLR1 and CPR1 terminate when a benefit is paid on all covered persons. CFR1 terminates when the benefit is paid or upon the death of the primary insured. Rider Renewability These riders are guaranteed renewable for life, subject to change in premium by class. Rider Premiums Premiums may change on a class basis. A notice is mailed in advance of any change. A grace period will be granted for the payment of each premium after the first. Coverage remains in force during the grace period. Family Plan coverage may include you, your spouse and your unmarried dependent children, as defined in the base policy. The Exceptions and Other Limitations provision of the base policy apply to all riders. The benefits in all riders are subject to all terms, conditions and provisions of the base policy. All terms defined and used in the base policy apply to all riders. Page 6 of 6 pages