|
Group Insurance Plan Major Medical
Major Medical Highlights
This page provides a quick guide to some of the Major Medical plan features which people most often want to know about. But it's not a complete description of your Major Medical plan. Read the following pages carefully for
a complete explanation of what we pay, limit and exclude.
CGP-3-R3-HL-90 B453.0323 For covered charges from a PPO provider $100.00
For covered charges from a non-PPO provider $250.00
CGP-3-R3-HL-90 B453.0315-R
For each visit to a PPO doctor's office $ 15.00
CGP-3-R3-HL-90 B453.3175
For Covered Hospital Charges:
Note: There are different payment rates for some types of charges. Read all
provisions of this plan carefully.
CGP-3-R3-HL-90 6453.0691 -R
Limit on out-of-pocket expenses, per covered person
Limit on out-of-pocket expenses, per covered family
each benefit year-$3,250.00
CGP-3-R3-HL-90 B453.0329 Lifetime payment limit for most sicknesses or injuries-Unlimited
Note: Some provisions have benefit year or treatment period limits. Read all provisions of this plan carefully.
CGP-3-R3-HL-90 B453.0343
This insurance will pay many of the medical expenses incurred by you and those of your covered dependents who are insured for major medical coverage under this plan. What we pay and the terms for payment are explained below. All terms in italics are defined terms with special meanings. Their definitions are shown in the "Glossary" at the back of this booklet. Other terms are defined where they are used.
CGP-3-R3-1.0 B450.1173
This plan encourages a covered person to use services provided by members of Private Healthcare Systems, Inc. (PHCS), a Preferred Provider Organization (PPO). A PPO is a network of health care providers located in the covered person's geographical area. In addition to an identification card, the covered person will periodically be given up-to-date lists of Private Healthcare Systems, Inc. (PHCS) preferred providers.
Use of the network is strictly voluntary. But, we generally pay a higher level of benefits for most covered services and supplies furnished to a covered person by Private Healthcare Systems, Inc. (PHCS). Conversely, we generally pay a lower level of benefits when covered services and supplies are not furnished by Private Healthcare Systems, Inc. (PHCS) (even if an Private Healthcare Systems, Inc. (PHCS) doctor orders the services and supplies). Of course, a covered person is always free to be treated by any doctor or facility. And, he is free to change doctors or facilities at any time.
A covered person may use any Private Healthcare Systems, Inc. (PHCS) provider. He just presents his Private Healthcare Systems, Inc. (PHCS) i.d. card to the Private Healthcare Systems, Inc. (PHCS) doctor or facility furnishing covered services or supplies. Most Private Healthcare Systems, Inc. (PHCS) doctors and facilities will prepare any necessary claims forms for him, and submit the forms to us. The covered person will receive an explanation of any insurance payments made by this plan. And if there is any balance due, the Private Healthcare Systems, Inc. (PHCS) doctor or facility will bill him directly.
This plan also has utilization review features. Under these features, Private Health Care Systems (PHCS), reviews hospital admissions and surgery performed outside of a doctor's office for us. These features must be complied with whenever a covered person: (a) enters a hospital; or (b) is advised to enter a hospital or have surgery performed outside of a doctor's office. If a covered person does not comply with these utilization review features, he will not be eligible for full plan benefits. See the Utilization Review Features section for details.
What we pay is subject to all the terms of this plan. Read this booklet carefully and keep it available when consulting a doctor.
See the schedule of insurance for specific benefit levels, payment rates, and payment limits.
If you have any questions after reading this plan, please call The Guardian Group Claim Office at the number shown on your i.d. card.
CGP-3-R-MM-86-0.2 B450.0383-R
Important Notice This section must be complied with when a covered person: (a) enters a hospital; or (b) is advised to enter a hospital or have surgery performed outside of a doctor's office. If the doctor who is admitting the covered person to the hospital is a preferred provider, the doctor will assume the responsibility for complying with this section. In all other cases, the covered person must comply with this section himself to avoid incurring penalties under this plan.
Compliance with this plan's utilization review features does not guarantee what we'll pay for covered charges. What we pay is based on: (a) the covered charges actually incurred; (b) the covered person being eligible for coverage under this plan at the tim ' e the covered charges are incurred; and (c) the deductible and co-payment provisions, and all of the other terms of this plan.
Definitions
"Hospital admission" means admission of a covered person to a hospital as an inpatient for medically necessary care and treatment of a sickness or injury.
We call a hospital admission or surgery "emergency" if, after an evaluation of the covered person's condition, the attending doctor determines that failure to make the admission or perform the surgery immediately would pose a serious threat to the covered person's life or health. A hospital admission or surgery made or performed for the convenience of doctors or patients is not an emergency.
By "covered professional charges for surgery" we mean covered charges that are: (a) made by a doctor for performing surgery; (b) made by a doctor or a nurse for assisting in the performance of surgery; or (c) made by a doctor or a nurse for the administration of anesthetics. Any surgical charge which is not a covered charge under the terms of this plan is not payable under this plan.
"Regular working day" means Monday through Friday from 9 a.m. to 9 p.m., Eastern Time, not including legal holidays.
CGP-3-R-UR-86-1.0 B450.0462
Notice of Hospital Admission Required We require notice of all hospital admissions. The times and manner in which
the notice must be given is described below. When a covered person doesn't comply with the requirements of this section we reduce what we pay for covered hospital charges as a penalty.
Pre-Hospital Review All non-emergency hospital admissions must be reviewed by PHCS before they occur.
The covered person or his doctor must notify PHCS and request a pre-hospital review. PHCS must receive the notice and request at least 24 hours before the admission is scheduled to occur.
When PHCS receives the notice and request, they evaluate: (a) the medical necessity of the hospital admission; (b) the anticipated length of stay; and (c) the appropriateness of health care alternatives, like home health care or other out-patient care.
PHCS notifies the covered person's doctor, by phone, of the outcome of their review. And they confirm the outcome of their review in writing.
If PHCS authorizes a hospital admission, the authorization is valid for: (a) the specified hospital; (b) the named attending doctor; and (c) the authorized
length of stay.
The authorization becomes invalid and the covered person's admission must
be reviewed by PHCS again if: (a) he enters a facility other than the
specified facility; (b) he changes attending doctors; or (c) more than 60 days
elapse between the time he obtains authorization and the time he enters the
hospital.
Emergency Admissions PHCS must be notified of all emergency admissions by phone. This must be
done by the covered person or his doctor no later than the end of the next
regular working day after the admission occurs. But, if a covered person or
his doctor is unable to call PHCS in the allofted amount of time, the covered
person or his doctor must call PHCS as soon as reasonably possible after
the emergency admission occurs.
When PHCS is notified by phone, they require the following information: (a)
the covered person's name, social security number, and date of birth; lb) the
covered person's group plan number; (c) the reason for the admission; (d)
the name and location of the hospital; (e) when the admission occurred; and
(f) the name of the covered person's doctor.
Continued Stay Review The covered person, or his doctor, must request a continued stay review for
any emergency admssion. This must be done at the time PHCS is notified of
such admission.
The covered person, or his doctor, must also initiate a continued stay review
whenever it is medically necessary to change the authorized length of a
hospital stay. This must be done before the end of the previously authorized
length of stay.
PHCS also has the right to initiate a continued stay review of any hospital
admission. And PHCS may contact the covered person's doctor or hospital
by phone or in writing.
In the case of an emergency admission, the continued stay review evaluates:
(a) the medical necessity of the hospital admission; (b) the anticipated length
of stay; and (c) the appropriateness of health care alternatives. In all other
cases, the continued stay review evaluates: (a) the medical necessity of
extending the authorized length of stay; and (b) the appropriateness of health
care alternatives.
PHCS notifies the covered person's doctor, by phone, of the outcome of the
review. And PHCS confirms the outcome of the review in writing. The notice
always includes any newly authorized length of stay.
Penalties for Non-Compliance
In the case of a non-emergency hospital admission, as a penalty for non-compliance, we reduce what we pay for covered hospital charges, to 50% if: (a) the covered person does not request a pre-hospital review; or (b) PHCS is not given at least 24 hours to review and evaluate a hospital admission; or (c) PHCS's authorization becomes invalid and the covered person does not obtain a new one; or (d) PHCS does not authorize the hospital admission.
In the case of an emergency admission, as a penalty for non-compliance, we reduce what we pay for covered hospital charges to 50%, if: (a) PHCS is not notified of the admission at the times and in the manner described above; or (b) the covered person does not request a continued stay review. The penalty applies to covered hospital charges incurred after the applicable time limit allowed for giving notice ends.
For any hospital admission, if a covered person stays in the hospital longer than PCHS authorizes, we reduce what we pay for covered hospital charges incurred after the authorized length of stay ends to 50% as a penalty for non-compliance.
Penalties can't be used to meet this plan's: (a) deductibles; or (b) limits on out-ot-pocket expenses.
CGP-3-R-UR-86-2.1 B450.0612
REQUIRED PRE-SURGICAL REVIEW
We require a covered person to get a pre-surgical review for any non-emergency procedure performed outside of a doctor's office. When a covered person does not comply with the requirements of this section, we reduce what we pay for covered professional charges for surgery, as a penalty
The covered person or his doctor must request a pre-surgical review from PHCS. PHCS must receive the request at least 24 hours before the surgery is scheduled to occur. If the surgery is being done in a hospital, on an inpatient basis, the pre-surgical review request should be made at the same time as the request for a pre-hospital review.
When PHCS receives the request, they evaluate the medical necessity of the surgery. And they either: (a) approve the proposed surgery; or (b) require a second surgical opinion regarding the need for surgery. PHCS notifies the covered person's doctor, by phone, of the outcome of the review. And they confirm the outcome of the review in writing.
Required Second Surgical Opinion
If PHCS's review does not confirm the medical necessity of the surgery, the covered person must obtain a second surgical opinion in order to get full plan benefits. If the second opinion does not confirm the medical necessity of the surgery, the covered person may obtain a third opinion, although he is not required to do so.
PHCS will give the covered person a list of doctors in his area who will give a second opinion. The covered person may get the second opinion from a doctor on the list, or from a doctor of his own choosing, if the doctor:.(a) is board certified and qualified, by reason of his specialty, to give an opinion on the proposed surgery; (b) is not a business associate of the covered
person's doctor; and (c) does not perform the surgery if it's needed.
PHCS gives second opinion forms to the covered person. The doctor he
chooses fills them out and then returns them to PHCS.
We cover charges for additional surgical opinion, including charges for
related X-rays and tests. But what we pay is based on all the terms of this
plan.
Pre-Hospital Review If the proposed surgery is to be done on an inpatient basis, the Required
Pre-Hospital Review section must be complied with. See the Required
Pre-Hospital Review section for details.
Penalties for Non-Compliance In the case of a non-emergency hospital admission, as a penallty for non-compliance, we reduce what we pay for covered hospital charges, to 50% if: (a) the covered person does not request a pre-hospital review; or (b) PHCS is not given at least 24 hours to review and evaluate a hospital admission; or (c) PHCS's authorization becomes invalid and the covered person does not obtain a new one; or (d) PHCS does not authorize the hospital admission.
In the case of an emergency admission, as a penalty for non-compliance, we reduce what we pay for covered hospital charges to 50%, if: (a) PHCS is not notified of the admission at the times and in the manner described above; or (b) the covered person does not request a continued stay review. The penalty applies to covered hospital charges incurred after the applicable time limit allowed for giving notice ends.
For any hospital admission, if a covered person stays in the hospital longer than PCHS authorizes, we reduce what we pay for covered hospital charges incurred after the authorized length of stay ends to 50% as a penalty for non-compliance.
Penalties can't be used to meet this plan's: (a) deductibles; or (b) out of pocket expenses.
BENEFIT PROVISION
The Cash Deductable Each benefit year, each covered person must have covered charges that exceed the cash deductible before we pay any benefits to that person. The cash deductible is $100.00 for services from a PPO Provider, and $250.00 for services or supplies from a Non-PPO Provider. The cash deductible can't be met with non-covered expenses. Only covered charges incurred by the covered person while insured by this pian can be used to meet this deductible.
Once the cash deductible is met, we pay benefits for other covered charges above the deductible amount incurred by that covered person, less any applicable co-payments, for the rest of that benefit year. But all charges must be incurred while that covered person is insured by this plan. And what we pay is based on all the terms of this plan.
CGP-3-R3-2.0 B453.0407-R A covered person may have covered charges in the last three months of a
benefit year which are used to meet the cash deductible under this plan for that year. These charges will also be used to meet the deductible for the next benefit year.
CGP-3-R3-3.0 B450.1177 This plan's covered charges are identified below as Group A charges or
Group B charges. There is no cash deductible or co-payment required for Group A charges.
The cash deductible is waived for preventive care, charges due to an
accident and preferred provider charges which are subject to a $15.00 encounter fee.
CGP-3-R3-3.2 B453.0362-R This plan has a family deductible cap of three cash deductibles for each
benefit year. Your covered family's individual cash deductibles are applied to the family deductible cap. Once the cap is met, we pay benefits for other covered charges incurred by any member of your covered family, less any applicable co-payments, for the rest of that benefit year. What we pay is based on all the terms of this plan.
CGP-3-R3-4.0 B450.1178 Sometimes two or more covered family members are injured in the same
accident. If they are, we apply only one cash deductible (each benefit year)
against all covered charges due to that accident. We do the same if two or more covered family members gei the same contagious disease within ten days of each other. What we pay is based on all of the terms of this plan.
Each covered person must still meet the balance of his or her own cash deductible before we pay benefits for charges due to other conditions.
CGP-3-R3-5.0 B450.1182 Co-payments are the percentage of a covered charge that must be paid by a
covered person to a provider. But deductibles and co-payments will never total more in a benefit year, than the out-of-pocket Gap shown in the next provision. This plan's co-payments, shown below, do not include penalties
incurred under this plan's Utilization Review provisions, or any other
non-covered expense.
The co-payments for this plan are as follows:
For Covered Hospital Charges:
CGP-3-R3-6.0 B453.0120-R This plan caps out-of-pocket expenses each benefit year. "Out-of-pocket expenses" are this plan's cash deductibles and co-payment amounts. Non-covered expenses can't be used to meet the out-of-pocket cap, and must be paid by the covered person even if the cap has been met.
There are out-of-pocket caps for: (a) each covered person; and (b) your covered family. The out-of-pocket cap for each covered person is $ 1,250.00 . The out-of-pocket cap for your covered family is $ 3,250.00 .
Each covered person's out-of-pocket expenses are used to meet his or her own out-of-pocket cap, and are combined with out-of-pocket expenses from other covered family members to meet the covered family's out-of-pocket cap. But since the cap is meant to limit what a covered person pays out-of-pocket in a benefit year, it can only be met with covered charges that are actually paid by a covered person out of his own pocket.
Once the covered person meets his own cap, we waive his or her co-payments for the rest of that benefit year.
Once your covered family meets your family out-of-pocket cap, we waive your covered family's deductibles and co-payments for the rest of that benefit year.
CGP-3-R3-7.0 B450.1184 For each sickness or injury we pay up to the payment limit shown below:
Charges for in-patient confinement in an extended care or rehabilitation center, per benefit year-100 Days
Charges for home health care, per benefit year-100 Visits
Charges for treatment of infertility, in your lifetime-$25000
Charges for treatment of diasease or deformity of the feet, per benefit year-$2500
Charges fir manipulation, or adjustment of the spine, per benefit year-30 Visits
All other Charges
Lifetime payment limit for each sickness or injury not listd above-Unlimited
CGP-3-R3-8.0 B450.1187
For private room and board accommodations, we cover charges up to the hospital's average daily semi-private room and board charge, or if the hospital does not have semi-private accommodations, 90% of its lowest daily room and board charge.
For special care units, we cover charges up to the hospital's actual daily room and board charge.
CGP-3-R3-9.0 B453.0158
A covered person may be covered by two or more plans that provide similar benefits. For instance, your spouse may be covered by this plan and a similar plan through his or her own employer. When another plan furnishes benefits which are similar to ours, we coordinate our benefits with the benefits from that other plan. We do this so that no one gets more in benefits than he or she incurs in charges. Read "Coordination of Benefits" to see how this works.
The benefits under this plan may also be affected by Medicare. See the provision "How This Plan Interacts With Medicare" for an explanation of how this works.
GP-3-R3-10.1 B450.1 1 90
If a covered person's insurance ends and he or she is totally disabled, under a doctor's care, and not covered by another plan of group benefits, we extend major medical benefits for that person under this plan as explained below. This is done at no cost to you.
We only extend benefits for covered charges due to the disabling condition. The charges must be incurred before the extension ends. And what we pay is based on all the terms of this plan.
We don't pay for charges due to other conditions. And we don't pay for charges incurred by other covered family members.
The extension ends on the earliest of: (a) the date the total disability ends; or
We don't grant an extension if the person's insurance ended because he or she failed to make required payments. And if a person receives benefits under this extension of benefits provision, he will not be eligible for coverage under any continuation of coverage provisions of this plan when the extension ends.
You are totally disabled if, due to sickness or i . nl . ury, you can't perform the main duties of your occupation. A covered dependent is totally disabled if, due to sickness or injury, the covered dependent can't perform the normal activities of someone of the same age. You must submit evidence to us that you or your dependent is totally disabled, if we request it.
CGP-3-R3-1 1.0 B450.1193
COVERED CHARGES
This section lists the types of charges we cover. But what we pay is subject to all the terms of this plan. Read the entire plan to find out what we limit or exclude.
CGP-3-R3-12.0 B450.1194
We cover charges for hospital room and board and routine nursing care, up
to the daily room and board limit, when it is provided to you or a covered dependent by a hospital on an inpatient basis. And we cover other medically necessary hospital services and supplies provided to you or your covered dependent during the inpatient confinement.
If you or a covered dependent incur charges as an inpatient in a special care unit, we cover the charges, up to the daily room and board limit for special care units.
We also cover outpatient hospital services. These include emergency room treatment and services provided by a hospital outpatient clinic.
Any charges in excess of the hospital daily room and board limit are a non-covered expense. This plan's utilization review features have penalties for non-compliance that may reduce what we pay for hospital charges.
We limit what we pay for the treatment of mental and nervous conditions, drug abuse and alcohol abuse. See the "Charges Covered with Special Limitations" section of this plan.
CGP-3-R3-13.0 B450.1195
We cover pre-admission tests needed for a planned hospital admission or surgery. We cover these tests if: (a) the tests are done within seven days of the planned admission or surgery; and (b) the tests are accepted by the hospital in place of the same post-admission tests.
We don't cover tests that are repeated after admission or before surgery, unless the admission or surgery is deferred solely due to a change in the covered person's health.
Extended Care and Rehabilitation Charges We cover charges, up to the daily room and board limit, for room and board
and routine nursing care provided to you or a covered dependent on an
inpatient basis in an extended care center or rehabilitation center. Charges above the daily room and board limit are a non-covered expense.
And we cover all other medically necessary services and supplies provided to you or your covered dependent during the confinement. But the confinement must start within 14 days of a hospital stay. And we only cover the first 100 days of confinement in each benefit year. Charges for any additional days are a non-covered expense.
We also cover outpatient services furnished by an extended care or rehabilitation center.
But we limit what we pay for the treatment of mental and nervous conditions, drug abuse and alcohol abuse. See the "Charges Covered With Special Limitations" section of this plan.
CGP-3-R3-14.0 B450.1196
When home health care can take the place of inpatient care, we cover such
care furnished to a covered person, in his home, under a written home health care plan. We cover all medically necessary services and supplies we would have covered if the covered person had been an inpatient in a recognized facility. Such services and supplies may include: (a) nursing care, including nursing care by a vocational nurse; (b) the services of a home health aide; (c) prescribed drugs; (d) occupational therapy; (e) physical therapy; (f) respiratory therapy; and (g) speech therapy.
But coverage for home health care is subject to all of the terms, of this plan and to the following conditions:
Each visit by any other representative of a home health agency will be considered as one home health care visit.
CGP-3-R3-15.0-TX B450.1491 We cover doctor's charges for the. medically necessary non-surgical care
and treatment of a sickness or injury, in excess of the encounter fee, if any.
But we limit what we pay for the treatment of mental and emotional
conditions.
You and your covered dependents must pay an encounter fee for each visit
to a PPO doctor's office. The encounter fee is a non-covered expense.
Doctor's Charges for Surgery We cover doctor's charges in excess of the encounter fee if any, for
medically necessary surgery. We don't pay for cosmetic surgery. But we
cover reconstructive surgery needed due to a sickness or injury. This
surgery can be performed either at the same time as, or after, other needed
surgery. We also cover reconstructive surgery needed due to a birth defect
in a covered dependent child. "Covered dependent. child" includes a
newborn child.
You and your covered dependents must pay an encounter fee for each visit
to a PPO doctor's office. The encounter fee is a non-covered expense.
This plan's utilization review features have penalties for non-compliance that
may reduce what we pay.
Second Opinion Charges We cover doctor's charges for a second opinion and charges for related
X-rays and tests when a covered person is advised to have surgery or enter
a hospital. If the second opinion differs from the first, we cover charges for a
third opinion. We cover such charges if the doctors who give the opinions:
(a) are board certified and qualified, by reason of their speciality, to give an
opinion on the proposed surgery or hospital admission; (b) are not business
associates of the doctor who recommended the surgery; and (c) in the case
of a second surgical opinion, they do not perform the surgery if it's needed.
Ambulatory Surgical Center Charges We cover charges made by an ambulatory surgical center in connection with
covered surgery.
CGP-3-R3-16.0-TX B453.0437 We cover charges made by a hospice for palliative and supportive care
furnished to a terminally ill covered person under a hospice care program.
"Palliative and supportive care" means care and support aimed mainly at
lessening or controlling pain or symptoms; it makes no attempt to cure the
covered person's terminal illness.
Hospice care must be furnished, according to a written "hospice care
program." A "hospice care program" is a coordinated program for meeting
the special needs of the terminally ill covered person. It must be set up and
reviewed periodically by the covered person's doctor.
Under a hospice care program, subject to all the terms of this plan, we cover
any services and supplies including prescription drugs, to the extent they are
otherwise covered by this plan. Services and supplies may be furnished on
an inpatient and outpatient basis.
The services and supplies must be: (1) needed for palliative and supportive
care; (2) ordered by the covered person's doctor, (3) included in the hospice
care program; and (4) furnished by, or coordinated by a hospice.
We don't pay for: (a) services and supplies provided by volunteers or others
who do not regularly charge for their services; (b) funeral services and
arrangements; (c) legal or financial counseling or services; (d) treatment not
included in the hospice care plan; (e) services supplied to family members,
other than the terminally ill covered person; or (f) counseling of any type
which is for the sole purpose of adjusting to the terminally ill covered
person's death.
CGP-3-R3-17.0 B450.1199 We cover charges for preventive care for your covered dependent children,
as explained below.
Covered preventive services for children are limited to the following for each child: (a) a health history and developmental assessment; (b) a physical exam; and (c) needed immunizations and laboratory tests.
We cover two visits for preventive care for each child, each benefit year. But we only cover preventive care services if they are in keeping with prevailing medical standards, and furnished or supervised by a doctor. And all the services must be provided to a covered dependent child or ordered in one visit, with the charge for the visit payable to one doctor. We don't cover eye or hearing exams.
Preventive care visits for any covered person who is more than 16 years old are covered under the "Preventive Care for Adults" provision below.
CGP-3-R3-18.0 B450.1200 We cover charges for routine preventive care for a covered person over the
age of 16, as explained in this provision.
Preventive care under this provision includes a physical exam every year, related X-rays and laboratory tests, mammograms, pap smears, and routine immunizations. We don't cover eye or hearing exams.
The preventive care services must be provided in keeping with prevailing medical standards and be furnished or supervised by a doctor. All services must be provided or ordered in one visit, with the charge for the visit payable to one doctor. What we pay is based on all the terms of this plan.
CGP-3-R3-19.0 B450.1201 We cover anesthetics and their administration; inhalation therapy;
hemodialysis; radiation and chemotherapy; physical therapy by a licensed
physical therapist; casts; splints; and surgical dressings.
We cover the initial fifting and purchase of braces, trusses, orthopedic
footwear and crutches. But we don't pay for replacements or repairs.
We cover blood, blood products, and blood transfusions. But we don't pay
for blood which has been donated or replaced on behalf of you or a covered
dependent.
We cover medically necessary charges for transporting you or a covered
dependent to: (a) a local hospital if needed care and treatment can be
provided by a local hospital; or (b) the nearest hospital where medically
necessary care and treatment can be given, if a local hospital can't provide
this treatment. But it must be connected with an inpatient confinement. It can
be by professional ambulance service, train or plane. But we don't pay for
chartered air flights. And we won't pay for other travel or communication
expenses of patients, doctors, nurses or family members.
We cover charges for the rental of durable medical equipment needed for
therapeutic use. At our option, and with our advance written approval, we
may cover the purchase of such items when it is less costly and more
practical than rental. But we don't pay for: (1) any purchases without our
advance written approval; (2) replacements or repairs; or (3) the rental or
purchase of items (such as air conditioners, exercise equipment, saunas and
air humidifiers) which do not fully meet the definition of durable medical
equipment.
CGP-3-R3-20.0 B450.1202
CGP-3-R3-22.0 B453.0102
Recognized Providers Covered charges must be provided by recognized providers. The providers
we recognize are listed in the glossary. We recognize both public and private facilities. But all providers must be properly licensed or certified under all applicable state and local laws to provide the services they render, and be operating within the scope of their license.
Providers We Don't Recognize We don't recognize: (a) rest homes; (b) old age homes; (c) places that
mainly provide custodial care, education or training; or (d) nurses' aides, home attendants, or massage therapists unless this plan provides specific benefits for their services.
CGP-3-R3-24.0--FX @53.0409 We cover: (a) the diagnosis and treatment of oral tumors and cysts; and (b)
the surgical removal of impacted teeth.
We also cover treatment of an injury to natural teeth or the jaw, but only if: (a) the injury occurs while the covered person is insured; lb) the injury was not caused, directly or indirectly by biting or chewing; and (c) all treatment is finished within six months of the date of the injury. Treatment includes replacing natural teeth lost due to such injury. But in no event do we cover orthodontic treatment.
Prosthetic Devices We limit what we pay for prosthetic devices. We cover only the initial fifting and purchase of artificial limbs and eyes, and other prosthetic devices. And they must take the place of a natural part of a covered person's body, or be needed due to a functional birth defect in a covered dependent child. We don't pay for replacements or repairs, or for wigs, or dental prosthetics or devices.
CGP-3-R3-25.0 B450.1207 A pre-existing condition is a sickness or injury for which, in the three months before his or her insurance starts, a covered person: (a) receives advice or treatment from a doctor, lb) takes prescribed drugs; or- (c) receives other medical care or treatment.
We exclude charges for pre-existing conditions until three consecutive months have passed during which the covered person: (a) is insured; and lb) receives no medical care or treatment. If treatment is continual, we exclude these conditions until the covered person has been insured for 12 consecutive months.
This limitation doesn't affect benefits for other unrelated conditions. And it doesn't apply to birth defects in a covered dependent child. The next section shows other exceptions.
GP-3-R3-26.0-TX B453.041 0 The employer who purchased this plan may have purchased it to replace a
plan he or she had with some other insurer.
When this happens, we cover a covered person's pre-existing condition, if the covered person was insured by this employer's old plan. But this plan must start right after the employer's old plan ends.
We limit our payments to the lesser of: (a) what this employer's old plan would have paid; or (b) what we'd normally pay. And we deduct any benefits actually paid by the employer's old plan under any extension provision.
The covered person may have incu ' rred charges for covered expenses under the employer's old plan before it ended. If so, these charges will be used to meet this plan's deductible if: (a) the charges were incurred during the calendar year in which this plan starts; (b) this plan would have paid benefits for the charges, if this plan had been in effect; (c) the covered person was covered by the old plan when it ended and enrolled in this plan on its effective date; and (d) this plan starts right after the old plan ends.
CGP-3-R3-27.0-TX B453.0472 We only cover Charges by a nurse for medically necessary private duty
nursing care, if: (a) a covered person is confined to a recognized facility which can't provide skilled nursing care at the level or intensity required by the covered person's condition; or (b) such care is authorized as part of a home health care plan, coordinated by a home health agency, and covered under our "Home Health Care Charges" provision. We exclude any other charges for private duty nursing care.
CGP-3-R3-28.0 B450.1210 We cover charges for the treatment of infertility, subject to all of the following
conditions.
The couple experiencing the infertility must have a medically documented history of unexplained infertility lasting at least two yea rs, or the infertility treatment must be certified by a doctor as medically necessary.
All treatment must be performed on an outpatient basis. We do not cover inpatient treatment for infertility.
The treatment must be performed in a facility which is licensed or certified for what it does by the state in which it operates.
We cover hormonal therapy, artifical insemination, monograms or other treatment which meets the protocol set by the American College of Obstetricians and Gynecologists. But we only cover in-vitro fertilization, in-vivo fertilization, gamete inter-fallopian transfer (GIFT), or similar procedures if the couple has not been able to obtain a successful pregnancy through other means.
We limit what we pay for treatment of infertility, per covered family, to $25,000.00 during your lifetime. Charges for treatment in excess of this limit, are a non-covered expense under this plan. This lifetime limit does not apply to in-vitro fertilization.
Unless this plan provides specific benefits, we don't pay for the resulting
pregnancy.
COP-3-R3-29.0--FX 6453.0411 This plan pays for pregnancies the same way we would cover a sickness.
Birthing Center Charges We cover birthing center charges made for pre-natal care, delivery, and post
partum care in connection with you or a covered dependent's pregnancy.
We cover charges up to the daily room and board limit for the room and
board and routine nursing care when inpatient care is provided to you or a
covered dependent by a birthing center. But charges above the daily room
and board limit are a non-covered expense.
We cover all other medically necessary services and supplies during the
confinement. But, unless this plan provides specific benefits, we don't cover
routine nursery charges for the newborn child.
CGP-3-R3-30.1 B450.1213 Subject to all of the terms of this plan, we cover the care and treatment of
your covered newborn child if he or she is sick, injured, premature, or born
with a congenital birth defect.
And we cover charges for your child's routine nursery care while he or she is in the hospital. This includes: (a) nursery charges; (b) charges for routine doctor's examinations and tests; and (c) charges for routine procedures, like circumcision. But, unless this plan provides specific benefits, we don't pay for the routine care of the child once he or she leaves the hospital.
CGP-3-R3-32.0 B450.1215 We cover speech therapy.
CGP-3-R3-33.0-TX B453.0412 We limit what we cover for spinal manipulation to 30 visits per benefit year.
And we cover no more than two modalities per visit. Charges for such treatment above these limits are a non-covered expense.
CGP-3-R3-34.0 B450.1218 We pay benefits for covered charges for treatment of sickness or deformity
below the ankle, but what we pay for such treatment is subject to a benefit
year payment limit of $2,500.00 per covered person (not per foot). This limitation does not apply to dislocations or fractures of the feet.
CGP-3-R3-35.0 B450.1219 We limit what we pay for the treatment of obesity. If a covered person is
morbidly obese, we cover visits to a doctor's office, and related laboratory tests for the treatment of the morbid obesity. But we only cover one course of treatment. "Morbidly obese" means the covered person weighs at least twice as much as a normal person of the same height, age and sex. Treatment must be provided by a doctor on an outpatient'basis according to a written treatment plan.
We don't pay for anything not included in the written treatment plan. And we don't pay for appetite or weight control drugs, dietary supplements, special foods or food supplements, health or weight control centers or resorts, health club memberships or exercise equipment.
A course of treatment begins and ends as specified in the treatment plan, or sooner if the covered person discontinues treatment.
We exclude more than one course of treatment or repeated attempts to lose weight. And we exclude all treatment of obesity for any covered person who is not morbidly obese.
CGP-3-R3-36.0 B450.1220 We pay benefits for covered charges for the medically necessary care and treatment of temporomandibular joint disorders (TMJ) in a covered person. We treat such charges the same way we treat any other covered charges for sickness. But what we pay is based on all of the terms of this plan.
Unless this plan provides specific benefits, we don't cover any charges for the dental treatment of TMJ.
CGP-3-R3-37.2-TX B450.1496 We cover charges for formulas medically necessary for the treatment of
heritable diseases the same way as we cover charges for drugs prescribed by a doctor. But what we pay is based on all the terms of this plan.
"Heritable disease" means an inherited disease that may result in mental or physical retardation or death.
But unless this plan provides for specific benefits. we don't pay for prescription drugs.
CGP-3-R3-37.4-TX B450.1498 We limit what we pay for the treatment of mental and nervous conditions. We include a sickness under this provision if it manifests symptoms which are primarily mental or nervous, regardless of any underlying physical cause.
A covered person may receive such treatment as an inpatient in a hospital, residential treatment facility, or in a mental health center. If so, we pay benefits for the covered charges he incurs for such treatment, the same way we would for any other sickness. But, we only pay such benefits for the first 30 days of confinement each treatment period. After the first 30 days of a treatment period, we'll cover 50% of the charges incurred for such treatment. The 50% of the charge we cover is not subject to this plan's co-payment. The portion of the charges we don't cover is a non-covered expense.
We also pay benefits for treatment received in a residential treatment center for children and adolescents or in a crisis stabilization unit. But such treatment must be based on an individual treatment plan. If treatment is received in a residential treatment center for children and adolescents or in a crisis stabilization unit we pay benefits the same way we pay inpatient coverage, except that we consider two days of treatment as the equivalent of one day of inpatient coverage as defined above.
A treatment period starts on the date that a covered person is confined for such treatment. It ends on the date the covered person has resumed and carried out the normal activities of a healthy person of the same age for 12 consecutive months.
A covered person may also receive such treatment as an outpatient. If so, we cover 50% of the charges incurred for such treatment. The 50% of the charge we cover is not subject to this plan's co-payment. The portion of the charges we don't cover is a non-covered expense. We limit what we pay for outpatient treatment under this provision to $1,500.00 each benefit year.
Outpatient treatment can be furnished by a hospital, or by a mental health center. It can also be furnished by any properly licensed or certified doctor, psychologist, or social worker.
The benefits that we pay for the treatment of these conditions are subject to a payment limit of $10,000.00 during the covered person's lifetime.
We don't pay for custodial care, education, or training.
CGP-3-R3-37.0-TX-MN B450.1489-R We pay benefits for covered charges for the treatment of alcohol abuse or drug abuse in a covered person. We treat such charges the same way we treat a covered charge for sickness. But what we pay is based on all of the terms of this plan.
Treatment may be furnished by any properly licensed or certified doctor, psychologist or social worker. Or it may be furnished by a hospital, alcohol abuse center or drug abuse center.
If a covered person receives treatment as an inpatient in an alcohol abuse or a drug abuse center, we limit what we pay for room and board and routine nursing care during his confinement to this plan's hospital room and board limit.
We don't pay for custodial care, education, or training.
CGP-3-R3-37.0-TX-AD B450.1521
We don't pay for any charge identified as a non-covered expense.
We don't pay for services and supplies for which no charge is made, or for which, in the absence of this insurance, the covered person is not required to pay. This usually means services and supplies furnished by: (a) a covered person's employer, labor union or similar group, in its medical department or clinic; (b) a hospital or clinic owned or run by any government body; or (c) any public program, except Medicaid, paid for or sponsored by any government body. ("A hospital or clinic owned or run by any government body" does not include a tax supported institution of the State of Texas except as permitted by article 3.70-2, subsection D of the Texas Insurance Code.) But, if a charge is made and we are legally required to pay it, we will.
We don't pay for services and supplies which are not: (a) furnished or ordered by a recognized provider; lb) medically necessary to diagnose or treat a sickness or injury, (c) accepted by a professional medical society in the United States as beneficial for the control or cure of the sickness or injury being treated; and (d) furnished within the framework of generally accepted methods of medical management currently used in the United States.
We don't pay for experimental treatment.
We don't pay for care and treatment of sickness or injury caused, directly or indirectly, by declared or undeclared war or act of war. And we don't pay for
care and treatment of sickness or injury which occurs while a covered
person is on active duty in any armed force.
We don't pay for services or supplies furnished by close relatives. By "close
relatives" we mean: (a) your spouse, children, parents, brothers and sisters; and (b) any person who is part of your household. And we don't pay for services or supplies furnished by business or professional associates of you or your family.
CGP-3-R3-38.0-TX B453.0435
CGP-3-R3-40.0 B450.1225
CGP-3-R3-41.0 B450.1226
We don't pay for custodial care, education or training. And we don't pay for room and board in a rest home, old age home, or any place which is mainly a school.
We don't pay for eyeglasses or contact lenses. And we don't pay for the prescribing and fifting of such, or for vision visits.
We don't pay for wigs, toupees, hair transplants, hair weaving or any drug used to restore hair growth.
CGP-3-R3-42.0-TX B450.1499
CGP-3-R3-43.0 B450.1228
We don't pay for cosmetic surgery, except for reconstructive surgery needed due to a sickness or injury or a birth defect in a covered dependent child as explained in the provision Doctor's Charges for Surgery."
CGP-3-R3-46.0--rX B453.0436
We don't pay for services and supplies which are specifically limited or excluded in other parts of this plan.
CGP-3-R3-53.0 B450.1239
This section does not apply to coverages which provide benefits for loss of life, loss of income due to disability, prescription drug expense, or dental expense, if provided under this plan.
If An Employee's Group Health Benefits End: If an employee's group health benefits end for any reason, other than non-medical involuntary termination for cause, he may obtain a converted policy. But, he must have been insured under the group plan for at least three consecutive months immediately prior to the date his group health benefits end. The converted policy will cover the employee and those of his dependents whose group health benefits end.
If An Employee Dies While Insured: If an employee dies while insured, after any applicable continuation period has ended, his then insured spouse may convert. The converted policy will cover the spouse and those of the employee's dependent children whose group health benefits end. If the spouse is not living, each dependent child whose group health benefits end may convert for himself.
If An Employee's Marriage Ends: If an employee's marriage ends by legal divorce or annulment, his former spouse may convert. The converted policy will cover the former spouse and those of the employee's dependent children whose group health benefits end.
When A Dependent Loses Eligibility: When an insured dependent stops being an eligible dependent, as defined in this plan, he may convert. The converted policy will only cover the dependent whose group health benefits end.
How And When To Convert: To convert, the applicant must apply to us in writing and pay the required premium. He has 31 days after his group health benefits end to do this. We don't ask for proof of insurability. The converted policy takes effect on the date the applicant's group health benefit end.. If the applicant is a minor or incompetent, the person who cares for and supports the applicant may apply for him.
The Converted Policy: The applicant may convert to one of the individual health insurance policies we normally issue for conversions at the time he applies. The policy will be renewable until the applicant becomes eligible for Medicare by reason of age. The converted policy will comply with- the laws of the place the applicant lives when he applies. But it won't provide the same benefits the applicant had under the group plan. Ask the employer for more details, or write to us.
The premium for the converted policy will be based on: (a) the plan the applicant selects; lb) the risk and rate class, under the group plan, of the people to be covered; and (c) the ages of the people to be covered, as of the date the converted policy takes effect.
Restrictions: A covered person can't convert, if:
(a) his group health benefits end because he failed to make required payments;
(b) his discontinued group health benefits are replaced by similar coverage within 31 days of such discontinuance;
(c) he is covered for similar benefits under another plan or is eligible for similar benefits on an insured or uninsured basis;
(d) similar benefits are provided for, or available to him, under any state or federal law;
(e) he is insured for similar benefits elsewhere which, together with the converted policy would result in overinsurance by our standards; or
(f) he is eligible for Medicare by reason of age.
|