HomeMy WebLinkAboutExhibit 18The MEGA Life and Health
Insurance Company
Class
Definition
SPECIMAN
SIC Code:
Home Office Use only
PARTICIPATING EMPLOYER
APPLICATION
(1) Participating Employer: City of Miaini
(Correct Legal Name)
(2) Address: 444 S.W. 2"d Avenue, 6th Floor
Street
City County
State Zip Code
(3)
(a) Type of Ownership:
Corporation X Partnership ❑
Proprietorship ❑
(b) Nature of Business: Municipality
(4) The above Participating Employer
requests participation of its Employees
under the applicable Group Insurance
Policies and Riders' issued to:
The Trustees of the [ABC
Employers Trust]
Group Insurance Policy
Number: [12345]
(5) r SUBSIDIARY OR AFFILIATED
EMPLOYERS: The employees of the
following subsidiary or affiliated
employers a1 request participation:
Nance Address
Street City
State Zip Cook
• NA
(6) ELIGIBILITY:
(a) CLASSES ELIGIBLE: All
Employees in the following classes who work at
least hours
per week are eligible for
insurance:
SHR-APP-E-01
1
Miami
I Part -Time / Temporary Employees
(b) EXCLUDED EMPLOYEES:
(c) DATE OF ELIG!BLITY:
PRESENT EMPLOYEES who have
completed Days ' active
employment, except those excluded
above, shall be ei[ ible bi l surance on
the desired effective . date of coverage
requested in Section 12.
ALL OTHER EMPLOYEES who have
completed Days of active
employment, except those excluded
above, shall be eligible for insurance on
the first day of the (insurance month)
(pay period) coinciding with or nerd
following the date they complete the
required period.
(7) ' PRIOR GROUP INSURANCE PLAN:
Will this replace any existing group insurance?
❑ Yes X No
If Yes, give name of prior insurance
company and date of termination:
(8) WORKERS' COMPENSATION:
Are all eligible employees covered tWorkers' Compensation? X Yes
No
(9) THE SCHEDULE OF BENEFITS , this day of
SELECTLD BY THE PARTICIPATING
EMPLOYER:
.(Schedule of Benefits inserted here or
separate page attached)
(10) PREMIUM SCHEDULE: [ Weekly 1
Plan
Employee
Level 1
Level 2
Level 3
$7.25
$13,25
Participating Employer:
Signature of Officer:
Family
$17.75 Typed Name of Offaed126,85
$32.75
Employee & 1 Dependent
520.25
$50.25
(11) PREMIUM PAYMENT AND GRACE
PERIOD: The premium is to be payable
monthly, within 20 days after the end of
each premium accounting period.
This policy has a 31 day grace period.
This provision means that if' a renewal
premium is not paid on or before the
date it is due, it may be paid during the
following grace period. The grace
period will not apply if, at least 30 days
before the premium due date, We have
delivered or mailed to the Participating
Employer's last address shown in Our
records written notice of Our intent not
to renew this policy, During the grace
period, the policy will stay in force. If
the premium is not paid by the end of
the grace period, the policy wi11
terminate on that date.
(12). DESIRED)FFECTIVE DATE: The 1st
day of , 20_,_,,
provided this application has been
accepted in writing by The MEGA Life
and Health Insurance Company.
The Coverage, if issued, shall be subject to all the
terms and conditions of the Policy to which this
Application is attached.
Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a
statement of claim or an application containing any
false, incomplete, or misleading information is
guilty of a felony of the third degree.
Dated at
SHi-APP-E-01 2
Florida Licensed Agent:
Company:
Address:
S49.65
S76.25
Title
of
omc
er:
Signature of Florida
Date:
Florida Agent ID#:
Telephone #:
THE MEGA LIFE AND HEALTH INSURANCE COMPANY
1331 W. Memorial Road, Suite 112
Oklahoma City, OK 73114
Certificate of Insurance
issued under terms of
Group Insurance Policy No. [12345]
issued to
[DEF Company]
a Participating Employer in the [ABC, Employers Trust]
(herein called the Holder)
Policy Date: [January 1, 2002]
The MEGA Life and Health Insurance Company hereby certifies that members of the
class(es) eligible for insurance are insured under the above Policy as deterniried by those
provisions titled Conditions and Effective Date of Insurance.
This certificate is evidence of insurance provided under the Policy. All benefits are paid
according to the terms of the Policy. This certificate describes the essential features of the
insurance coverage.
President Secretary
-SHR-CERT-0$ 1 Rev
I, Table o, f Contents
Section
Certificate of Insurance Face Page
Table of Contents 1.
Classes II.
Benefit Specifications III.
Definitions IV.
Conditions and Effective Date V.
Benefit Specifications VI.
Termination of insurance VII.
Conversion Privilege VIII.
Transitional Coverage IX.
Uniform Provisions X.
COBRA _.._ — ' .. XI.........
SHR-CERT-01 2 Rev
II. Classes
Classes Eligible for Insurance:
Part -Time Employees of DEF Company]
Effective Date Information:
[January 1, 2002]
Open Enrollment Period for Medical Expense Benefits: [January 1]
through [January 31] during each Calendar Year.
SHR-CERT-01 3 Rev
III. Benefit Specifications
[Benefits for Insured Persons [and Dependents] --
.Plan [125]
Accidental Death Benefit:
[(Level 1)]
[$10,000.] for an Insured Person
[[$10,000.] for a Dependent spouse
[$10,000.] for each Dependent child]
Basic Medical Expense Benefit [(Sickness)]:
Maximum Benefit per Coverage Year:
Cash Deductible per Coverage Year:
Participation Rate:
Physician Office Visit Benefit:
Physician Office Visit Copayment:
Participation Rates:
[$ 1,000.] per Covered Person
[$ 50.] per Covered Person
[80%] of Covered Expenses in excess of
the Cash Deductible or Copayment
amounts
[$ 15.] per Covered Person per visit
[100%] of the service charge made by the
Physician for the Office Visit.
[80%], in excess of the Cash Deductible,
for any Related Charges in connection with
the Office Visit, whether or not performed
on the same day.
Notes:
keiated Charges include, but are not limited to charges for the following: injections, laboratory,
pathology, radiology, diagnostic testing and venipuncture.
Covered crges subject to the Physician Office Visits Copayment amount are not subject to the
Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum.
[Additional] Accident Benefit:
[(Payable after Basic Medical Expense Benefit exhausted)]
Maximum Benefit per Occurrence: [$1,000.] per Covered Person
Maximum Number of Occurrences
per Coverage Year: [N/A]
Cash Deductible per Occurrence: [$ 50.] per Covered Person
Participation Rate: [80%] of Covered Expenses in excess of
the Cash Deductible amount.]
SHR-CERT-01 4 Rev
Benefit Specifications
[Benefits for Insured Persons [and Dependents]-
Plan 0145]
Accidental Death Benefit:
[(Level 2)]
($15,000.] for an Insured Person
(($15,000.] for a Dependent spouse
[$15,000.] for each Dependent child]
Basic Medical Expense Benefit ((Sickness)]:
Maximum Benefit per Coverage Year:
Cash Deductible per Coverage Year:
Participation Rate:
Prescription Benefit:
Maximum Benefit per Coverage Year:
Participation Rate:
Prescription Copayment:
Physician office Visit Benefit:
Physician Office Visit Copayment:
Participation Rates:
Notes:
($ 1,000.] per Covered Person
($ 100.] per Covered Person
[80%] of Covered Expenses in excess of
the Cath Deductible or Copayment
amounts
[$ 150.] per Covered Person and applied
to Basic Medical Expense Benefit Maximum
(80%] of Covered Expenses in excess of
the [Cash Deductible : Copayment] amount
[$15] for Generic 1[$25] for Name Brand
($ 10.] per Covered Person per visit
[100%] of the service charge made by the
Physician for the Office Visit.
[80%], in excess of the Cash Deductible,
for any Related Charges in connection with
the Office Visit, whether or not performed
on the same day.
Related Charges include, but are not limited to charges for the following: Injecti•
ons, laboratory,
pathology, radiology, diagnostic testing and venipuncture.
Covered charges subject to the Physician Office Visits Copayment amount are not subject to the
Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum.
SHR-CERT-01 • 5 Rev
Plan [145] (Con't)
[Additional] In -Hospital Medical :Expense Benefit [[Sickness)]:
[(Payable after Basic Medical Expense Benefit exhausted)]
Daily In -Hospital Benefit: [$ 300.] Per day for up to [5] days per
Covered Person per Coverage Year
Participation Rate: [80%] of Covered Expenses
Surgery Benefit:
Maternity Benefit:
Cash Deductible per Coverage Year:
Participation Rate:
Maximum number of Occurrences
Per Coverage Year:
[Additional] Accident Benefit:
[(Payable after Basic Medical Expense Benefit exhausted)]
Maximum Benefit per Occurrence:
Maximum Number of Occurrences
per Coverage Year:
Cash Deductible per Occurrence:
Participation Rate:
($1,000] Per Covered Person per
Occurrence
[$1,000] Per Covered Person per
Occurrence
[$ 100] Per Covered Person
[80%) of Covered Expenses in, excess of
the Cash Deductible amount.
[N/A]
[$2,000.]1per Covered Person
[NIA]
[$ 100.] per Covered Person
[80%] of Covered Expenses in excess of
the Cash Deductible amount.]
SHR-CERT-01 6 Rev
Benefit Specifications
[Benefits for Insured Persons [and Dependents] —
Plan [165]
Accidental Death Benefit:
[(Level 3)]
[$25,000.j for an insured Person
[[$25,000.] for a Dependent spouse
[$25,000.] for each Dependent child]
Basic Medical Expense Benefit [(Sickness)];
Maximum Benefit per Coverage Year:
Cash Deductible per Coverage Year:
Participation Rate:
Prescription Benefit:
Maximum Benefit per Coverage Year: ,
Participation Rate:
Prescription Copayment:
Physician Office Visit Benefit:
Physician Office Visit Copayment:
Participation Rates:
[$1,000.] per Covered Person
[$ 150.] per Covered Person
[80%] of Covered Expenses in,excess of
the Cash Deductible or Copayment
amounts
[$ 250.] per Covered Person and applied
to Basic Medical Expense Benefit Maximum
180%1 of Covered Expenses in excess of
the [Cash Deductible: Copayment] amount
[$15] for Generic / [$25] for Name Brand
[$ 10.] per Covered Person per visit
[100%0] of the service charge made by the
Physician for the Office Visit.
[80%1 in excess of the Cash Deductible,
for any Related Charges in connection with
the Office Visit, whether or not performed
on the same day,
Notes:
Related Charges include, but are not limited to charges for the following: Injections, laboratory,
pathology, radiology, diagnostic testing and venipuncture.
Covered charges subject to the Physician Office Visits Copayment amount are not subject to the
Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum.
SHR-CERT-01 7 Rev
Plan [165] (Con't)
[Additional] In -Hospital Medical Expense Benefit [(Sickness]:
[(Payable after Basic Medical Expense Benefit exhausted)]
Daily In -Hospital Benefit: [$ 300.] Per day for up to [5] days per
Covered Person per Coverage Year
Participation Rate: [80%] of Covered Expenses
Surgery Benefit:
Maternity Benefit:
Cash Deductible per Coverage Year:
Participation Rate:
Maximum number of Occurrences
Per Coverage Year:
[Additional] Accident Benefit: '
[(Payable after Basic Medical Expense Benefit exhausted)]
Maximum Benefit per Occurrence:
Maximum Number of Occurrences
per Coverage Year:
Cash Deductible per Occurrence:
Participation Rate:
SHR-CERT-01
8
1$1,0001 Per Covered Person per
Occurrence
[$1,000] Per Covered Person per
Occurrence
[$ 100] Per Covered Person
[80%] of Covered Expenses in excess of
the Cash, Deductible amount.
[N/A]
[$3,0001 per Covered Person
[NIA]
[$ 150.] per Covered Person
[80%] of Covered Expenses in excess of
the Cash Deductible amount.]
Rev
Benefit Specifications
[Benefits for Insured Persons [and Dependents]
In -Hospital Indemnity Benefit
Part A:
In -Hospital Indemnity
Daily Benefit:
[$1,000.] per day
Maximum Benefit Period
Per Period of Hospital Confinement: [1] day
Per Coverage Year: [1] period of Hospital confinement
Part B:
In -Hospital Indemnity
Daily Benefit:
[$100.] per day
•
Maximum Benefit Period
Per Period of Hospital Confinement: [100] days
Per Coverage Year:
[3] periods of Hospital confinement]
ti
SHR-CERT-01 9 Rev
Benefit Specifications
[Benefits for Insured Persons
Short Term Disability Benefit
[Option I:
Weekly Benefit: [$125]
Elimination Period
Accident: [0] Days
Sickness: [7] Days
Day of Total. Disability on Which Benefit Begins
Accident [1 "] Day
Sickness: [81 Day
Maximum Benefit Period: [26] Weeks]
{
[Option II:
Basic Coverage:
Weekly Benefit: [$250]
Elimination Period.
Accident [0] Days
Sickness: [7] Days
Day of Total Disability on Which Benefit Begins
Accident: [1"] Day
Sickness: [81 Day
Maximum nefit Period: [13] Weeks
Extended Coverage:
Payable after [13] Week Basic Coverage
Monthly Benefit: [$1,000]
Maximum Benefit Period: [18] Months]
An Insured Person is covered for Total Disability due to pregnancy only if the Total Disability
starts after she has been insured without break for 9 months. Benefits are limited to a
maximum of 6 weeks for any one pregnancy, and there is no Elimination Period.]
SH13-CERT-01
10 Rev
Benefit Specifications
Benefits for Insured Persons [and Dependents]
[Life
Amount of Life Insurance
Employee [$10,000]
Spouse [$5,000]
Each Child [$2,000]
IN
The amount of Life Insurance in force for a Covered Person age 70 or over or attaining age
70 after becoming insured shall be reduced by 50%.]
[Dental
See List of Covered Dental Procedures.]
SHR-CERT-01 11 Rev
IV Definitions
Any word in the male gender equally applies to the female gender unless a distinction is
specified.
("Child" includes Your natural children. it also includes adopted children, stepchildren and
other children provided:
1. They depend upon You for support; and
2. They have a parent -child relationship with You.
If both parents of a Child are Insured Persons, the Child will be considered as a Dependent
of either parent The Child may not be considered a Dependent of both parents.]
"Covered Person" means an Employee [or Dependent] who is insured under the policy.
"Dependent" means:
1. Your spouse;
2. Unmarried children who are under 19 years of age; and
3. Unmarried children who are 19 years of age through 25. years of age if the child:
a. Is attending an accredited school full-time; and
b. Is financially dependent upon You for support]
"Employee" means a person who is:
1. Employed by an Employer contributing to the Holder; and
2. Eligible for insurance according to the Holder's. Rules of Eligibility which have been
agreed to by Us.
"Individual" means an Employee .
insured Person" or "You" means an Employee who is insured under the policy.
"We," "Our" or "Us" means The MEGA Life and Health Insurance Company.
SHR-CERT-01 12 Rev
Terms have different meanings when applied to Life Insurance than they have with •
respect to Health Insurance,
[The following definitions apply onlyy fo the Life Insurance coverage:
"Injury" means bodily injury caused by an accident. The accident must occur while
coverage is in force.
"Sickness" means sickness or disease. The Sickness must commence while insured
under the policy.]
[The following definitions apply only,to the Accidental Death, Dental, Short Term
Disability, In -Hospital Indemnity and Health insurance coverage:
"Accident" means a sudden, unexpected and unforeseen, identifiable event producing at
the time objective symptoms of an Injury. The Accident must occur while the Insured is
covered under this Policy.
"Authorities" means:
1. Textbooks:
a. Cecil Textbook of Medicine, (newest edition, W. 8. Saunders Company,
Publisher);
b. Scientific American Medicine, (newest update, Scientific American, Inc.,
Publisher);
c. Conn's Current Therapy, (newest edition, W. B. Saunders Company, Publisher);
-d. Schwartz Principles of Surgery, (Newest edition, McGraw-Hill, Publisher);
e. Nelson's Textbook of Pediatrics, (Newest edition, W. B. Saunders Company,
Publisher);
f. Sabiston's Textbook of Surgery, (Newest edition, W. B. Saunders Company,
Publisher).
2. Periodicals:
a. Medical Letter;
b: Joumal ofAmerican Medical Association;
c. New England Joumal of Medicine;
d. Disease -a -Month, (Mosby -Yearbook, Inc., Chicago, IL).
SHR-CERT-01 13 Rev
"Complications of Pregnancy" means:
1. Conditions, requiring Hospital confinement (when the pregnancy is not terminated),
whose diagnoses are distinct from pregnancy but are adversely affected by
pregnancy or are caused by pregnancy. Examples are acute nephritis, nephrosis,
cardiac decompensation, missed abortion and similar medical and surgical
conditions of comparable severity. False labor, occasional spotting, Physician
prescribed rest during the period of pregnancy, morning sickness, hyperemesis
gravidarum, pre-eclampsia and similar conditions associated with the management
of a difficult pregnancy not constituting a nosologically distinct complication of
pregnancy are not considered "Complications";
2. Non -elective caesarean section;
3. Ectopic pregnancy which is terminated;
4. Spontaneous termination of pregnancy which occurs during a period of gestation in
which a viable birth is not possible.
"Complications of Pregnancy" as defined above are covered under the policy to the same
extent as any other Sickness.
"Coverage Year" means a consecutive 12-month period or any part of such period,
beginning on an Insured Person's effective date of coverage and ending on the certificate
anniversary date. Each Covered Person will be required to satisfy a new Cash Deductible
for each Coverage Year.
"Creditable Coverage" means prior health benefits coverage that may include any of, or a
combination of, the following:
1. A group health plan;
2. A health insurance plan or health maintenance organization (HMO) plan;
3. An individual health insurance policy;
4. COBRA continuation of coverage;
5. A health plan under Chapter 55, Title 10, United States Code pertaining members
of the uniformed services of the United States;
6. Medicare or Medicaid;
7. A medical care program of the Indian Health Service or of a tribal organization;
8. ASfate health benefits risk pool;
9. A health plan offered under FEHBP (chapter 89 of Title 5, United States Code);
10. A health plan under section 5(e) of the Peace Corps Act; or
11. A public health plan.
"Custodial Care" means care which is designed to help a person in the activities of daily
living. Continuous attention by trained medical or paramedical personnel is not necessary.
Such care may involve:
1. Preparation of special diets;
2. Supervision over medication that can be self-administered; and
3. Assisting the person in getting in or out of bed; to walk; to bathe; to dress; to eat
and to use the toilet
SHR-CERT-01 14 Rev
"Dental Treatment Plan" is a Dentist's report, on a form satisfactory to Us which:
1. Itemizes the dental services recommended;
2, Shows the charge to be made :for each dental service; and
3. Is accompanied by supporting pre -operative X-rays or other diagnostic materials as
We may require.
"Dentist" means a duly licensed dentist acting within the scope of his license. It includes a
Physician furnishing covered dental services which he is licensed to perform. He may not
be a Covered Person or a member of a Covered Person's Immediate Family. A Dentist Is
considered a health care provider.
"Emergency Care" means medical care and treatment provided after the sudden onset of
a medical condition manifesting itself by acute symptoms, including severe pain, which are
severe enough that the lack of immediate medical attention could reasonably be expected
to result in any of the following:
1., The patient's health would be placed in serious jeopardy;
2. Bodily function would be seriously impaired;
3. There would be serious dysfunction of a bodily organ or part.
"Experimental/Investigational TreatTent" includes:
1. Medical devices;
2. Drugs and/or pharmaceutical agents; and
3. Procedures or treatments;
as defined below:
1. Medical device if any of the following applies:
a. It does not have FDA approval to be marketed; or
b.- It has a 51-0K--number,-and its use is other -than for thepurposeor in the manner
for which the original FDA approval was received. Final determination of the
similarity of use per the original approval will be made by Us; or
c. It has FDA approval to be marketed or has a 510K number, and its use is not in
"cordance with the FDA approval guidelines/instructions; or
d. The device, alone or in combination with any drug, pharmaceutical agent, other
medical device, procedure or treatment performed by a Physician or under a
Physician's supervision, is not currently reported by one of the Authorities listed
to be safe and effective for the treatment of the disease or condition for which
the device is being used;
SHR-CERT-01 15 Rev