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Group Insurance Plan General Provisions
As used in this booklet:
"Accident and health" means any dental, dismemberment, hospital, long term disability, major medical, prescription drug, surgical, or weekly loss-of-time insurance provided by this plan.
"Covered person" means an employee or a dependent insured by this plan.
"Employer" means the employer who purchased this plan.
"Our," "The Guardian," "us" and "we" mean The Guardian Life Insurance Company of America.
"Plan" means the Guardian plan of group insurance purchased by your employer.
"You" and "your" mean an employee insured by this plan.
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No person, except by a writing signed by the President, a Vice President or a Secretary of The Guardian, has the authority to act for us to: (a) determine whether any contract, plan or certificate of insurance is to be issued; (b) waive or alter any provisions of any insurance contract or plan, or any requirements of The Guardian; (c) bind us by any statement or promise relating to any insurance contract issued or to be issued; or (d) accept any information or representation which is not in a signed application.
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This plan is incontestable after two years from its date of issue, except for non-payment of premiums.
No statement in any application, except a fraudulent statement, made by a person insured under this plan shall be used in contesting the validity of his insurance or in denying a claim for a loss incurred, or for a disability which starts, after such insurance has been in force for two years during his lifetime.
If this plan replaces a plan your employer had with another insurer, we may rescind the employer's plan based on misrepresentations made by the employer or an employee in a signed application for up to two years from the effective date of this plan.
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We have the right to have a doctor of our choice examine the person for whom a claim is being made under this plan as often as we feel necessary. And we have the right to have an autopsy performed in the case of death,
where allowed by law. We'll pay for all such examinations and autopsies.
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Your right to make a claim for any accident and health benefits provided by
this plan, is governed as follows:
Notice You must send us written notice of an injury or sickness for which a claim is
being made within 20 days of the date the injury occurs or the sickness
starts. This notice should include your name and plan number. If the claim is
being made for one of your covered dependents, his or her name should
also be noted.
Proof of Loss We'll furnish you with forms for filing proof of loss within 15 days of receipt
of notice. But if we don't furnish the forms on time, we'll accept a written
description and adequate documentation of the injury or sickness that is the
basis of the claim as proof of loss. You must detail the nature and extent of
the loss for which the claim is being made. You must send us written proof
within 90 days of the loss.
If this plan provides weekly loss-of-time insurance, you must send us written
proof of loss within 90 days of the end of each period for which we're liable.
If this plan provides long term disability income insurance, you must send us
written proof of loss within 90 days of the date we request it. For any other
loss, you must send us written proof within 90 days of the loss.
Late Notice of Proof We won't void or reduce your claim if you can't send us notice and proof of
loss within the required time. But you must send us notice and proof as soon
as reasonably possible.
Payment of Benefits We'll pay benefits for loss of income once every 30 days for as long as
we're liable, provided you submit periodic written proof of loss as stated
above. We'll pay all other accident and health benefits to which you're
entitled within 60 days after we receive written proof of loss.
We pay all accident and health benefits to you, if you're living. If you're not
living, we have the right to pay all accident and health benefits, except
dismemberment benefits, to one of the following: (a) your estate; (b) your
spouse; (c) your parents; (d) your children; (e) your brothers and sisters; and
(f) any unpaid provider of health care services. See "Your Accidental Death
and Dismemberment Benefits" for how dismemberment benefits are paid.
When you file proof of loss, you may direct us, in writing, to pay health care
benefits to the recognized provider of health care who provided the covered
service for which benefits became payable. We may honor such direction at
our option. But we can't tell you that a particular provider must provide such
care. And you may not assign your right to take legal action under this plan
to such provider.
Limitations of Actions You can't bring a legal action against this plan until 60 days from the date
you file proof of loss. And you can't bring legal action against this plan after three years from the date you file proof of loss.
Workers' Compensation The accident and health benefits provided by this plan are not in place of.
and do not affect requirements for coverage by Workers' Compensation.
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