A Voluntary Personal Accident Insurance Program designed for the Eligible Employees of Unity Health System

Transcription

1 A Voluntary Personal Accident Insurance Program designed for the Eligible Employees of Unity Health System IMPORTANT NOTICE: The Program provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical, major medical or sickness coverage.

2 AFFORDABLE ACCIDENT INSURANCE PROGRAM ( the Program ) Accidents are the fifth leading cause of death for people of all ages.* Today alone, over 250 people will die in accidents in the U.S.* Unfortunately, many families may be financially unprepared for this unexpected loss. Examine your long-term financial needs and those of your family. A serious Injury or the accidental death of a wage earner can have an economic impact, even in two-income families. Benefits from personal accident insurance may help your family meet the obligations of home mortgage payments, college education costs, retirement savings, and care for children and elderly family members. American International Life Assurance Company of New York Personal Accident Insurance -- high-limit accidental death and dismemberment insurance at a cost you can afford -- is an important step in preparing for your future, as well as your family's. Here's why you should enroll now: ACCIDENT PROTECTION - benefits are provided for covered losses resulting from accidental injuries, as described herein. FLEXIBLE PLANNING - you select the amount of coverage you need. See The Coverage Options and Amounts of Insurance below for complete details. AFFORDABLE COST - the cost of this coverage may be lower than that of an individual policy. WORLDWIDE COVERAGE - coverage is in force twenty-four hours a day, on or off the job, anywhere in the world. GUARANTEED ACCEPTANCE - coverage is provided to all eligible persons. PAYROLL DEDUCTIONS - contributions will be made through convenient payroll deductions. FIRST DOLLAR BENEFITS - benefits under the Program are payable in addition to any other insurance you may have at the time of the accident. * Injury Facts, 2004 Edition

3 ELIGIBILITY The following persons are eligible to participate in the Program: Class I All active Employees of Unity Health Systems who meet the following requirements: (1) working a minimum of 20 hours per week. (2) has not filed an *Opt-Out Election with the Employer. *Opt-Out Election means the Employee has chosen to receive an enhanced hourly rate rather than participate in certain benefits under the Employer s welfare Benefits Plan. An Opt-Out is irrevocable, however the Employer may in its sole discretion allow an employee who has previously filed an Opt-Out Election to become a participant at any time as if the Opt-Out Election was never filed (providing the Employee satisfies all other eligibility criteria at that time). With respect to the voluntary coverage, a change in coverage due to a change in the Insured s class, Annual Salary, or election of Principal Sum amount will become effective on date of the change. A change in coverage applies only with respect to accidents that occur on or after the effective date of the change. COVERAGE If you enroll, you are covered 24-hours a day, 365 days a year against covered accidents occurring in the course of business or pleasure. Coverage is provided for Injuries caused by accidents that occur on or off the job, at home, while traveling by plane, train, automobile, or any other public or private air, land or water conveyance (except as limited by the EXCLUSIONS). BENEFITS Accidental Death, Dismemberment and Paralysis Benefits When Injury directly results in loss of life within 365 days, the Program will pay in one payment the Principal Sum applicable to the person suffering the loss. When Injury directly results in any of the following losses within 365 days of the accident causing the loss, the Program will pay in one payment the indicated percentage of the Principal Sum for: Loss of Life Loss of two or more members Loss of speech and hearing in both ears Loss of one member Loss of speech or hearing in both ears Loss of hearing in one ear Loss of thumb and index finger of the same hand Quadriplegia Paraplegia Hemiplegia Uniplegia Loss Due to Coma The Principal Sum The Principal Sum The Principal Sum One-Half the Principal Sum One-Half the Principal Sum One-Quarter the Principal Sum One-Quarter the Principal Sum The Principal Sum Three-Quarters the Principal Sum Sixty-six and two-thirds the Principal Sum One-Half the Principal Sum 1% Per Month Loss means hand, foot or eye. Loss means: with regard to hand or foot, actual severance through or above the wrist or ankle joints; with regard to eye, entire and irrecoverable loss of sight in that eye; with regard to speech and hearing, entire and irrecoverable loss of the ability to speak and/or hear in that ear; with regard to thumb and index finger, actual severance through or above the metacarpophalangeal joints; with regard to Quadriplegia, complete and irreversible paralysis of both upper and lower limbs; with regard to Paraplegia, the complete and irreversible paralysis of both lower limbs; with regard to Hemiplegia, the complete and irreversible paralysis of the upper and lower limbs on one side of the body; and with regard to Uniplegia, the complete and irreversible paralysis of one limb. Only one benefit, the largest to which you are entitled, is payable for all losses resulting from one accident.

4 Injury means bodily injury caused by an accident occurring while the Policy is in force as to the person whose injury is the basis of claim and resulting directly and independently of all other causes in a covered loss. EXCLUSIONS No coverage shall be provided under the Policy and no payment shall be made for any loss resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks 1. suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally selfinflicted Injury. 2. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Covered Person is: a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or c. riding as a passenger in an aircraft owned, leased or operated by the Policyholder or the Covered Person's employer. 3. declared or undeclared war, or any act of declared or undeclared war. 4. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Covered Person is not covered due to his or her active duty status will be refunded.) 5. the Covered Person being under the influence of drugs unless taken under the advice of and as specified by a Physician. 6. sickness, disease or infections of any kind, except bacterial infections due to accidental ingestion of contaminated substances or pyogenic infections which result from an injury. THE COVERAGE OPTIONS AND AMOUNTS OF INSURANCE PRINCIPAL SUM Employee Only Coverage You may choose one of the following amounts of insurance: $50,000, $100,000, $250,000, $500,000 or $1,000,000 THE COST OF INSURANCE The rate per Employee is $.014 per $1,000 per month.

5 HOW TO ENROLL 1) Select the Principal Sum amount which best fits your needs. 2) Complete the Unity Health System s Enrollment Form. Be sure to indicate the amount desired. 3) Return the Enrollment Form to your Human Resources Department. You should retain a copy as evidence of enrollment. Everyone must complete an Enrollment Form. If you decide not to participate, please check the appropriate box on the form, sign the form and return it to your Human Resources Department. PLEASE RETAIN THIS BOOKLET WITH YOUR VALUABLE PAPERS. THIS INSURANCE IS IN FORCE ONLY IF THE UNITY HEALTH SYSTEM S ENROLLMENT FORM IS COMPLETED, YOU HAVE AUTHORIZED PAYROLL DEDUCTIONS OF PREMIUM, AND YOUR PREMIUM IS ACTUALLY RECEIVED BY THE INSURER. BENEFICIARY Unless you name a specific beneficiary under the Policy, your beneficiary for accidental death will be that person or those persons designated by you under Unity Health System's group life insurance policy as shown on Unity Health System s records kept on that policy. Benefit payments made for all other losses will be made to (or on behalf of) you. ADDITIONAL BENEFIT HIGHLIGHTS (see the attached Certificate for complete details of each benefit including any applicable limitations regarding amounts payable thereunder) CONVERSION PRIVILEGE Provides an accidental death and dismemberment conversion option to covered persons when their coverage ends (prior to age 79) because they are no longer eligible for coverage under the Program. Conversion may be obtained from Human Resources. EMERGENCY EVACUATION BENEFIT Pays benefits for covered emergency evacuation expenses if a covered person suffers an Injury or emergency sickness while he or she is at least 100 miles from home and the Injury or emergency sickness results in a medically necessary emergency evacuation, up to a maximum of $50,000. FELONIOUS ASSAULT BENEFIT - PERCENTAGE OF PRINCIPAL SUM Pays an additional benefit equal to 10% of a covered person s principal sum to a maximum of $50,000 if a covered person suffers a specified covered loss as a result of a felonious assault. OCCUPATIONAL HIV/ HEPATITIS BENEFIT Pays a monthly benefit up of $3,000, if you test positive for Human Immunodeficiency Virus (HIV) or Hepatitis within 365 days of the date of a covered occupational incident causing the condition for a period of 60 consecutive months. The benefit is payable if, within 72 hours of the covered occupational incident you 1) report it to the Company and the Policyholder in writing; and 2) undergo a Food and Drug Administration (FDA) approved preliminary screening test for HIV or Hepatitis which indicates negativity with respect to the presence of any antibodies or antigens to such disease.

6 REHABILITATION BENEFIT Reimburses covered rehabilitation expenses, up to a maximum of $6,000, incurred within two years of and as a result of an accident causing a covered dismemberment or paralysis. REPATRIATION OF REMAINS BENEFIT Pays benefits for covered expenses, up to a maximum of $10,000, to return the covered person s body to his or her home if the covered person suffers a covered loss of life due to Injury or emergency sickness while at least 100 miles from home. SEAT BELT BENEFIT Pays an additional benefit of the lesser of $100,000 or 50% of the covered person's Principal Sum, if a covered person suffers a covered accidental death while operating or riding as a passenger in a private passenger automobile if it is verified that such person was wearing a properly-fastened, original, factory-installed seat belt or, if the covered person is a child, a properly installed and fastened child restraint device as defined by state law. WAIVER OF PREMIUM BENEFIT Waives your premium payments under the Program if you are receiving disability benefits under a disability plan provided through Unity Health System. YOUR EFFECTIVE AND TERMINATION DATES Effective Date: Your coverage will become effective on the latest of: a) the Policy effective date of January 2000 b) the date you become eligible for coverage; c) the date that you enroll for coverage; or d) the date premium is paid when due.

7 IMPORTANT This brochure/certificate provides you with an easy-to-understand summary of the Voluntary Personal Accident Insurance Program of Unity Health System (the Policyholder ) as underwritten by American International Life Assurance Company of New York. (the "Insurance Company") under Policy Number (called the Policy in this brochure/certificate) as well as your Certificate of Insurance. Although it is the present intention of the Policyholder and the Insurance Company to keep the Policy in force indefinitely, the Policy may be terminated on any premium due date by either party by giving 90 days advance written notice to the other party or at any time by mutual written consent of the Insurance Company and the Policyholder. If any conflict should arise between the contents of this brochure/certificate and the Policy or if any point is not covered herein, the terms of the Policy will govern in all cases. Conformity With State Statutes. Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which the Insured resides is hereby amended to conform to the minimum requirements of those statutes. Workers Compensation. The Policy is not in lieu of and does not affect any requirements for coverage by any Workers Compensation Act or similar law. YOUR RIGHTS UNDER ERISA You are entitled to certain rights and protections under the Employee Retirement Income Security Acts of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Examine, without charge, at the Plan Administrator s office, all Plan documents, including insurance contracts and copies of all documents files by the Plan with the U.S. Department of Labor, such as detailed annual reports and descriptions. Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and the other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have your claim reviewed and reconsidered. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file a lawsuit in a federal court. In such case, the court may require the Plan Administrator to provide the materials and pay you up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. IF you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest area office of the U.S. Labor-Management Service Administration, Department of Labor. For the nearest office call

8 Additional ERISA Information Plan Name: Plan Administrator: Unity Health System Voluntary Personal Accident Insurance Plan Unity Health System Identification Number: Plan Number: 515 Type of Plan: Type of Administration: Agent of Legal Service: Welfare Accidental Death and Dismemberment Insured Plan Plan Administrator Plan Year: January 1 through December 31. Funding: Insurance Company: Employer: Insured with only employee contribution. American International Life Assurance Company of New York Participating Organizations on file with the Plan Administrator.