HM Group Supplemental Hospital Indemnity Insurance Definitions

Transcription

1 Key Benefit Administrators, Inc. (KBA) P.O. Box 519 Fort Mill, SC Tel: Fax: hmig.com HM Group Supplemental Hospital Indemnity Insurance Definitions Please note that certain words used in the Policy have specific meanings. Other than references to he, him, his, you, your, yours, we, us or our, the words defined below and capitalized within the text of the Policy have the meanings set forth below. Active Service means that the Covered Person is either: at work on one of the Employee s scheduled work days and is performing his regular duties on a scheduled basis, either at one of the Employer's usual places of business or at some other location to which the Employer's business requires him to travel; on a scheduled holiday, or vacation day or period of employer-approved paid leave of absence, only if the Employee was in Active Service on the preceding scheduled workday; or is able to perform his regular duties and/or normal activities Certificate means the document issued for delivery to the Covered Person that lists the benefits, conditions and limits of the Policy. Child or Children means the Employee s or Spouse s unmarried, natural or step child, unless such child is eligible for medical coverage as a Covered Employee under this Policy and who is either: less than 26 years old; unmarried, under 26 years of age and attends an accredited educational institution as a full-time student; or incapable of self-support because of mental retardation or physical handicap before reaching the limiting age for dependent children. The Company must receive proof of incapacity within 31 days after coverage would otherwise terminate. This insurance will continue for as long as the Covered Employee's insurance stays in force and the child remains incapacitated. Additional proof may be required from time to time but not more often than once a year after the child attains the limiting age for dependent children This term includes a Child who is: living with the Employee in a parent child relationship; adopted by, placed for adoption with or is party in a suit for adoption by the Employee; or required to be provided coverage by the Covered Person or his Spouse under the terms of a Qualified Medical Child Support Order (QMCSO). A QMCSO will also include a judgment, decree or order issued by a court of competent jurisdiction or through an administrative process established under, and having the force and effect of state law and which satisfies the QMCSO requirements of ERISA. Company or we, us, our, means HM Life Insurance Company, domiciled in Pennsylvania. Covered Person means an Employee or Dependent for whom an enrollment form has been accepted by us, the required premium has been paid when due and for whom coverage under this Policy remains in force. If Employee is shown in the Schedule of Benefits, we insure the Employee. Dependents are only covered if either Spouse or Children is shown in the Schedule of Benefits. If Spouse is shown in the Schedule of Benefits, we insure the Spouse. If Children is shown in the Schedule of Benefits, we insure the Children. If both Spouse and Children are shown in the Schedule of Benefits, we insure the Spouse and the Children. Dependent or Dependents means the Employee's Spouse and Child or Children. Page 1 of 6

2 Eligibility Waiting Period means the period of time that must lapse before an Employee or Dependent is eligible for this insurance. It will be extended by the number of days the Employee is not in Active Service. We will not pay benefits during the Eligibility Waiting Period. Employee means a full-time employee of the Policyholder who works an average of 15 hours per week and who meets all of the requirements for one of the Covered Classes shown below. Class 1 All employees of the Policyholder who are officers Class 2 All employees of the Policyholder who are managers or supervisors Class 3 All employees of the Policyholder at location Class 4 All other employees of the Policyholder Provide Evidence of Insurability means an Employee and a Dependent or Covered Person must: complete and sign our enrollment health and medical history form; sign our form authorizing us to obtain information about his health and other insurance coverage; provide any additional reasonable information about his insurability that we request; and undergo a physical examination and testing at our request He, him or his means an individual, male or female. Home Health Care Agency means an agency that: provides mainly skilled nursing and other therapeutic services; is associated with a professional group that makes policy and includes at least one Physician, Doctor or graduate registered nurse (R.N.); has 24-hour supervision by or under the supervision of Physician, Doctor or a graduate registered nurse (R.N.); keeps complete medical records on each Covered Person; has a full-time administrator; is licensed pursuant to applicable law; and charges for its services Home Health Care means continued care and treatment provided by a Home Health Care Agency. The care and treatment must be prescribed in writing by the attending Physician or Doctor, and must be an alternative to staying in the Hospital or Skilled Nursing Facility. This term does not include Out-patient Care. Hospice Care means a program that: provides care to a Terminally Ill person; charges for its services; Page 2 of 6

3 is licensed pursuant to applicable law; is provided by a staff of Physicians, one of whom must be on call at all times; provides 24-hour nursing services by or under the supervision of a graduate registered nurse (R.N.); and has a full-time administrator Hospital means an institution that: is a licensed pursuant to applicable law; it is primarily and continuously engaged in providing medical care and treatment to sick and injured persons; is managed under the supervision of a staff of legally licensed Physicians or Doctors; provides 24-hour nursing services by, or under the supervision of, a graduate registered nurse (R.N.); has medical, diagnostic and treatment facilities with major surgical facilities on its premises, or available on a prearranged basis; and charges for its services The term Hospital does not include: a clinic, facility or unit of a Hospital for convalescent or custodial care; or a clinic, facility or unit of a Hospital for care of the aged; or a clinic, facility or unit of a Hospital for Out-Patient Care; or a unit of a Hospital for care of a Terminal Illness, rehabilitation, residential treatment or skilled nursing; or a Hospital Emergency Department, a Hospice, a Rehabilitation Facility, a Residential Treatment Facility, a Skilled Nursing Facility or a Home Health Care Agency Hospital Emergency Department means a distinct part of a Hospital that provides Emergency Care. An Emergency Department does not include an Out-patient department of a Hospital. Intensive Care Unit means: a specifically designated area of the Hospital that provides the highest level of medical care and is restricted to patients who are critically ill or injured, and who require intensive comprehensive observation and care; is separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement; is permanently equipped with special lifesaving equipment for the care of the critically ill or injured; is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit on a twenty four hour basis; and has a Physician or Doctor assigned to the unit on a full-time basis Page 3 of 6

4 A Hospital Intensive Care Unit includes a Hospital s cardiac care unit; critical care unit, intensive therapy unit, intensive treatment unit, neonatal intensive care unit and neuro intensive care unit. A Hospital Intensive Care unit does not include care provided in a Hospital s step down unit; such as a: progressive care unit; sub-acute intensive care unit; intermediate care unit; private monitored room; surgical recovery room; or observation unit Hospital Confinement means a confinement in a Hospital ordered by a Physician or Doctor for at least 24 consecutive hours when room and board, and general nursing care are provided at a per diem charge made by the Hospital. Separate periods of Hospital Confinement due to the same medical condition will be treated as one period of Hospital Confinement unless separated by at least 90 days or a Covered Employee returns to Active Service for 30 or more days between such periods of Confinement. In-Patient means a Covered Person who is confined for 24 continuous hours in a Hospital, Rehabilitation Facility, Residential Treatment Facility or Skilled Nursing Facility, and who incurred room and board charges. The requirement that a person can be charged for room and board does not apply to confinement in a Veteran's Administration Hospital or Federal Government Hospital in such case the term "In-patient" shall mean a Covered Person who is required to be confined for the period of time determined by applicable law governing such facility. Open Enrollment Period means a period of time, during which an Employee may apply for insurance. Out-Patient means a Covered Person who receives services, supplies or treatment while not confined as an In-patient in a Hospital, Rehabilitation Facility, Residential Treatment Facility or Skilled Nursing Facility. Out-Patient Care means a service, supply or treatment received by a Covered Person while not confined as an In-patient in a Hospital, Rehabilitation Facility, Residential Treatment Facility or Skilled Nursing Facility. This includes: charges billed by a Physician or Doctor, or a free standing facility offering medical services, supplies or treatment on an Out-patient basis; and charges for a service, supply or treatment billed by a Hospital s out-patient department This does not include charges billed by a Hospital Emergency Department Care or a Home Health Agency Care. Not Covered means no benefit will be paid by the Policy. Physician or Doctor means a licensed health care provider practicing within the scope of his license, rendering care and treatment to a Covered Person that is appropriate for the condition and locality and, who is not: employed or retained by the Policyholder; living in the Covered Person's household; or a parent, sibling, Spouse or Child of the Covered Person Page 4 of 6

5 Plan Year or Annual or Annually means a period of twelve consecutive months beginning on the Policy Effective Date and subsequent anniversary dates. Policyholder means the entity shown on the cover page of the Policy. Rehabilitation Confinement means a confinement in a Rehabilitation Facility ordered by a Physician or Doctor for at least 24 consecutive hours when room and board, and general nursing care, are provided at a per diem charge made by the Rehabilitation Facility. Separate periods of Rehabilitation Facility Confinement for the same medical condition will be treated as one period of Rehabilitation Facility Confinement unless separated by at least 90 days or a Covered Employee returns to Active Service for 30 or more days between such periods of Confinement. Rehabilitation Facility means an institution that: provides infirmary-level medical services and provides or arranges with a Hospital in the area for any other medical service that may be required; is staffed by Physicians involved in care and treatment; has a Physician present during the whole treatment day; provides at all times social work and nursing services; provides 24-hour nursing services by or under the supervision of a graduate registered nurse (R.N.); prepares and maintains a written plan of treatment for each patient. The plan must be supervised by a Physician or Doctor; charges for its services; and is licensed pursuant to applicable law A Rehabilitation Facility does not include a Hospital, a Hospital Emergency Department, Out-patient Care, a Hospice, a Residential Treatment Facility, a Skilled Nursing Facility or a Home Health Care Agency. Residential Treatment Confinement means a confinement in a Residential Treatment Facility ordered by a Physician or Doctor for at least 24 consecutive hours when room and board and general nursing care are provided at a per diem charge made by the Residential Treatment Facility. Separate periods of Residential Treatment Facility Confinement due to the same medical condition will be treated as one period of Residential Treatment Facility Confinement unless separated by at least 90 days or a Covered Employee returns to Active Service for 30 or more days between such periods of Confinement. Residential Treatment Facility means an institution that: provides a program for the diagnosis, evaluation and treatment of: mental illness; serious emotional or behavioral disorders; alcoholism; or drug abuse is not mainly a school or a custodial, recreational or training institution; provides infirmary-level medical services and provides or arranges with a Hospital in the area for any other medical service that may be required; Page 5 of 6

6 is supervised full-time by a psychiatrist who is responsible for patient care and is on-site regularly; is staffed by psychiatric Physicians involved in care and treatment; has a psychiatric Physician present during the whole treatment day; provides psychiatric social work and nursing services at all times; provides 24-hour nursing services by or under the supervision of a graduate registered nurse R.N.); prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs the plan must be supervised by a psychiatric Physician or Doctor; charges for its services; and is licensed pursuant to applicable law A Residential Treatment Facility does not include a Hospital, a Hospital Emergency Department, Out-patient Care, a Hospice, a Rehabilitation Facility, a Skilled Nursing Facility or a Home Health Care Agency. Skilled Nursing Confinement means a confinement in a Skilled Nursing Facility ordered by a Physician or Doctor for at least 24 consecutive hours when room and board, and general nursing care, are provided at a per diem charge made by the Skilled Nursing Facility. Separate periods of Skilled Nursing Facility Confinement for the same medical condition will be treated as one period of Skilled Nursing Facility Confinement unless separated by at least 90 days or a Covered Employee returns to Active Service for 30 or more days between such period of Confinement. Skilled Nursing Facility means an institution that it is licensed pursuant to applicable law and provides the following services on an Inpatient basis for a Covered Person convalescing from an accident or sickness; 24-hour nursing services by or under the supervision of Physician, Doctor or a graduate registered nurse (R.N.); physical restoration services to help patients meet a goal of self-care in daily living activities is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for the mentally incompetent, for custodial or educational care, or for care of mental disorders; and charges for its services A Skilled Nursing Facility does not include a Hospital, a Hospital Emergency Department, Out-patient Care, a Hospice, a Rehabilitation Facility, a Residential Treatment Facility or a Home Health Care Agency. Spouse means a Covered Person s partner by marriage or by any union between two adults that is recognized by law in the state where the Policy is issued. Terminally Ill means a medical prognosis of six months or less to live made by a Covered Person s Physician or Doctor. This document is meant to provide a representation of the definitions that apply to the group supplemental hospital indemnity insurance offered by HM. Only the Certificate of Insurance issued to your employer contains the actual definitions that apply should you become insured. Coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HMP- HI 213. MTG-2657 (10/13) Page 6 of 6