YOUR GROUP INSURANCE PLAN BENEFITS UNIVERSITY CORPORATION AT MONTEREY BAY
The enclosed certificate is intended to explain the benefits provided by the Plan. It does not constitute the Policy Contract. Your rights and benefits are determined in accordance with the provisions of the Policy, and your insurance is effective only if you are eligible for insurance and remain insured in accordance with its terms. 00337318/00024.0/A /0001/Q11127/99999999/0000/PRINT DATE: 11/13/08
CERTIFICATE OF COVERAGE The Guardian 7 Hanover Square New York, New York 10004 CGP-3-R-STK-90-3 B110.0023
TABLE OF CONTENTS
TABLE OF CONTENTS (CONT.)
COMPLAINT NOTICE CGP-3-CADISC-91 B120.0011
GENERAL PROVISIONS employee. employer. employer. employee. CGP-3-R-GENPRO-90 B160.0012 Limitation of Authority CGP-3-R-LOA-90 B160.0004 Incontestability employer. employer s employer CGP-3-R-INCY-96 B160.0061 Dental Claims Provisions,
Dental Claims Provisions (Cont.) injury sickness injury covered dependents, sickness injury sickness CGP-3-R-AHC-90 B160.0058
Coordination Between Continuation Sections CGP-3-R-COC-87 B240.0044 An Important Notice About Continuation Rights CGP-3-R-NCC-87 B240.0064
YOUR CONTINUATION RIGHTS Federal Continuation Rights
Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-1 B235.0164 CGP-3-R-COBRA-96-2 B235.0075
Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-3 B235.0178
Federal Continuation Rights (Cont.)
Federal Continuation Rights (Cont.) CGP-3-R-COBRA-96-4 B235.0198 Uniformed Services Continuation Rights. CGP-3-R-COBRA-96-4 B235.0195
ELIGIBILITY FOR DENTAL COVERAGE B489.0002 Employee Coverage employee.. employee employees full-time employee,, ;. CGP-3-EC-90-1.0 B489.0122 Employee full-time full-time full-time CGP-3-EC-90-2.0 B489.0070 full-time employees. employees, employees
Employee Coverage (Cont.) CGP-3-EC-90-3.0 B489.0075 eligible dependents Dependent Coverage B200.0271 CGP-3-DEP-90-2.0 B200.0515 CGP-3-DEP-90-3.1 B489.0231,
Dependent Coverage (Cont.) CGP-3-DEP-90-4.0 B449.0042 CGP-3-DEP-90-5.0 B200.0749, initial dependents eligibility date eligibility date, enrollment period,
Dependent Coverage (Cont.) dependents enrollment period initial initial dependents, newly acquired dependent acquired dependent, newly CGP-3-DEP-90-6.0 B489.0055 hospital CGP-3-DEP-90-7.0 B200.0692 CGP-3-DEP-90-8.0 B489.0232 eligible dependents;
Dependent Coverage (Cont.) s, employees employees employee s eligible dependent. CGP-3-DEP-90-9.0 B489.0048
DENTAL HIGHLIGHTS.
DENTAL EXPENSE INSURANCE CGP-3-DNTL-90-1 B490.0036 DentalGuard Preferred - This Plan s Dental Preferred Provider Organization dentists covered person covered person s covered person person s, covered person covered covered person,. CGP-3-DENT-PPO-A B490.0153
Covered Charges dentist s dentists covered person device prosthetic appliance orthodontic treatment CGP-3-DNTL-90-3 B490.0038 Pre-Treatment Review covered person s dentist orthodontic treatment, covered person s dentist. covered person s covered person person dentist,.. covered CGP-3-DNTL-90-4 B490.0039
Benefits From Other Sources, employer s employer, employer s employer. CGP-3-DNTL-90-5 B497.0968 The Benefit Provision - Qualifying For Benefits charges benefit year benefit year year, covered person covered charges covered benefit Covered charges covered person s covered person s covered charges covered person covered charges benefit year. covered charges benefit year. covered person CGP-3-DNTL-92-7 B497.0101 covered charges covered charges
The Benefit Provision - Qualifying For Benefits (Cont.) appliance covered person covered person s. benefit year CGP-3-DNTL-92-8 B497.0051 year. year.. benefit year benefit year covered charges benefit benefit CGP-3-DNTL-90-9 B490.0137 CGP-3-DRATE-90 B497.0038
After This Insurance Ends prosthetic device, orthodontic treatment CGP-3-DNTL-90-10 B490.0045 Special Limitations treatment ; ; orthodontic. injury s CGP-3-DNTL-90-11.0 B490.0046 covered person. prosthetic device. employer covered person covered person benefit year, s benefit year, s CGP-3-DNTL-90-11.1 B490.0053
Exclusions appliance prosthetic device orthodontic treatment. prosthetic devices. prosthetic devices appliance prosthetic device covered person s injury appliance appliance prosthetic device. covered person s employer, CGP-3-DNTL-90-12 B497.0039
List of Covered Dental Services dentist. CGP-3-DNTL-90-13 B490.0048 Group I - Preventive Dental Services (Non-Orthodontic) persons covered covered persons covered persons
Group I - Preventive Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL-90-14 B497.0057 Group II - Basic Dental Services (Non-Orthodontic)
Group II - Basic Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL-90-15.0 B497.0058
Group II - Basic Dental Services (Cont.) (Non-Orthodontic) CGP-3-DNTL-90-15.1 B497.0059 Group III - Major Dental Services (Non-Orthodontic) injury,
Group III - Major Dental Services (Cont.) (Non-Orthodontic) dentist CGP-3-DNTL-90-16 B497.0060 Group IV - Orthodontic Services orthodontic treatment. orthodontic treatment appliances appliance, CGP-3-DNTL-90-17 B490.0052
DISCOUNT - THIS IS NOT INSURANCE Discounts on Dental Services Not Covered By This Plan B499.0077 Discounts on Services Not Covered Due To Contractual Provisions B499.0079
COORDINATION OF BENEFITS Definitions
Definitions (Cont.)
Definitions (Cont.) CGP-3-R-COB-05 B555.0294 Order Of Benefit Determination
Order Of Benefit Determination (Cont.) CGP-3-R-COB-05 B555.0295 Effect On The Benefits Of This Plan Right To Receive And Release Needed Information
Facility Of Payment Right Of Recovery CGP-3-R-COB-05 B555.0296
CERTIFICATE AMENDMENT The Guardian CGP-1-A-CAL-PR B590.9027
GLOSSARY CGP-3-GLOSS-90 B900.0118 appliance orthodontic treatment CGP-3-GLOSS-90 B750.0192 prosthetic device. CGP-3-GLOSS-90 B750.0193 s CGP-3-GLOSS-90 B750.0293 relatives. covered person s covered person s close CGP-3-GLOSS-90 B750.0195 s covered dependents. employee CGP-3-GLOSS-90 B750.0196. CGP-3-GLOSS-90 B750.0198 CGP-3-GLOSS-90 B900.0003 CGP-3-GLOSS-90 B750.0015 employer employer s CGP-3-GLOSS-90 B750.0006 CGP-3-GLOSS-90 B900.0051 CGP-3-GLOSS-90 B900.0004
Glossary (Cont.) employee employer s employer CGP-3-GLOSS.1 B750.0230 eligible dependents employee dependents, initial dependents. eligible eligible dependents CGP-3-GLOSS-90 B900.0006 s covered person s injury appliances prosthetic devices CGP-3-GLOSS-90 B750.0199 eligible dependent initial dependents. CGP-3-GLOSS-90 B900.0008 active appliance; active appliances. CGP-3-GLOSS-90 B750.0201 Guardian employer, CGP-3-GLOSS-90 B900.0039 CGP-3-GLOSS-90 B750.0203
STATEMENT OF ERISA RIGHTS
Statement of Erisa Rights (Cont.) B800.0094
The Guardian s Responsibilities B800.0048 B800.0053 B800.0049
Group Health Benefits Claims Procedure
Group Health Benefits Claims Procedure (Cont.)
Group Health Benefits Claims Procedure (Cont.)
Group Health Benefits Claims Procedure (Cont.) B800.0076
Termination of This Group Plan employer employer B800.0086
YOUR BENEFITS INFORMATION - ANYTIME, ANYWHERE
0000/9999/A /0001/Q11127/B/*EOD*