| ||
Sample Policy Certificate for Standard Security Life "Secure STM"
This sample policy certificate is provided as an example
of the type of wording of this type of insurance. This certificate is different than you
insurance policy.
Please see your policy certificate for information about
your own coverage. This certificate is also available in
PDF format.
STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue, New York, NY 10022 CERTIFICATE OF INSURANCE GROUP SHORT TERM MEDICAL EXPENSE INSURANCE Covered Person: [ ] Covered Dependents: [ ] Group Policyholder: Communicating for Agriculture and the Self-Employed, Inc. Effective Date of Coverage: [ ] Term of Coverage [30 days, or exact # of days of coverage (i.e. 33, 67) up to 180 days, 6 months, 9 months, 12 months] Coverage is provided in consideration of payment of the initial premium and continued payment of premiums when due and that the answers in Your application are correct and complete. SCOPE OF CERTIFICATE This Certificate is a part of, and is governed by, Group Policy No. SSL GP-001 that has been issued in the District of Columbia. This Certificate summarizes the Group Policy provisions affecting Covered Persons. References to Covered Dependents’ insurance apply only if You have elected such coverage. The Group Policy is the contract between the Group Policyholder and the Company. The Group Policy is held by the Group Policyholder and may be inspected at any reasonable time on request. This Certificate is evidence that you, as the Certificateholder, have coverage under the Group Policy. The names of the Certificateholder and Group Policyholder are shown above on this face page of the certificate of insurance. 10-DAY RIGHT TO RETURN THE CERTIFICATE If for any reason you are not satisfied with this Certificate, you may return it to us within 10-days after you receive it. We will refund any premium paid and your coverage issued under the Group Policy will be deemed void, just as though coverage had not been issued. THE COVERAGE IS NON-RENEWABLE SHORT TERM INSURANCE. IT WILL NOT BE RENEWED AT THE END OF THE COVERAGE PERIOD. READ THIS CERTIFICATE CAREFULLY. Rachel Lipari, Secretary David Kettig, President TABLE OF CONTENTS The following provisions appear within this Certificate [ ] SCHEDULED HOSPITAL PRECERTIFICATION NOTICE This plan requires a Precertification by a Professional Review Organization prior to in-patient Hospitalization or surgery. A Covered Person must call the Professional Review Organization: 1. For elective or non-emergency Hospitalization or surgery, at least 10-days prior to the date of proposed Hospitalization; 2. Within 48-hours of an emergency admission; or 3. Within 48-hours of delivery for complicated childbirth. Non-compliance with the Pre-Admission Certification procedure will result in a reduction in benefits of 50%, unless the Covered Person is incapacitated and unable to contact us. In such cases, the Covered Person must contact us as soon as possible. You have been provided with information and procedures necessary for Pre- Admission Certification. You may obtain more information regarding Pre-Certification and its procedures from the Company. SECTION I The Deductible, Coinsurance Percentage, Coinsurance Limit and Coverage Period Maximum Benefit Amount for Covered Expenses apply to each Covered Person, unless otherwise stated for a specific benefit, including any maximum benefits for each Covered Person, in SECTION II. THE FOLLOWING SHALL APPLY TO COVERED EXPENSES FOR EACH COVERED PERSON DEDUCTIBLE: [Field for Insured’s Selection]: OR 10,000* OR $20,000* (*available only as approved by Executive Management) Deductible Family Maximum: When 3 Covered Persons each satisfy their individual Deductible, the Deductibles for any remaining Covered Persons are deemed satisfied for the remainder of the Coverage Period. COINSURANCE: Coinsurance Percentage: Field for Insured’s Selection: after payment by the Covered Person of the Deductible, up to the Coinsurance Limit. Coinsurance Limit: $10,000 of Covered Expenses per Covered Person. Coinsurance Percentage Thereafter: 100% COVERAGE PERIOD MAXIMUM BENEFIT AMOUNT: $2,000,000 per Covered Person. SECTION II MAXIMUM BENEFITS FOR COVERED EXPENSES FOR EACH COVERED PERSON: Covered Expenses, not to exceed the Coverage Period Maximum Benefit Amount, are subject to the Usual, Reasonable and Customary charge and the following Maximum Benefit, if applicable. HOSPITAL COVERED EXPENSES: Hospital Room, Board and Up to the most common Average Semi-Private Room General Nursing Care: Rate. Intensive or Specialized Care Unit: Up to 3 times the most common Average Semi-Private Room Rate. OTHER COVERED EXPENSES: Doctor Administering Anesthetics: Up to 20% of the surgeon’s benefit. Assistant Surgeon: Up to 20% of the surgeon’s benefit. Surgeon’s Assistant: Up to 15% of the surgeon’s benefit. Ambulance, Ground or Air Services: Up to $500 per occurrence for Ground ambulance; up to $1,000 per occurrence for Air ambulance. Acquired Immune Deficiency Syndrome (AIDS) Up to $10,000 per Coverage Period. Organ, Tissue, Bone Marrow Transplants Up to $150,000 for all Covered Expenses per Coverage Period. STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue, New York, NY 10022 AMENDATORY ENDORSEMENT (Applicable to the Pennsylvania Residents Only) This Amendatory Endorsement is attached to and made a part of the Group Policy and Certificate shown above. The provisions of this Amendatory Endorsement are effective on the Effective Date shown above and will expire concurrently with the Group Policy and Certificate unless otherwise terminated. In consideration of issuance, the Group Policy and Certificate is hereby amended and modified, as follows: If any benefits appearing in these mandated benefits are also provided in the Certificate, we will not duplicate the payment of benefits. Benefits will be payable either under the Certificate or these mandated benefits, whichever provides the better benefit. A. The following are added to the Covered Expenses provision under the section entitled Description of Benefits: Childhood Immunizations, including booster doses which are considered Medically Necessary, subject to the same coinsurance amount as for any other sickness or injury. Benefits for childhood immunizations are not subject to the Policy Deductible or limited by any dollar amount. The schedule of immunizations will be determined by the Pennsylvania Department of Health. Medical Foods Coverage are payable for the cost of nutritional supplements (formulas) as Medically Necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a Physician. Such benefit will not be subject to the Policy Deductible. Except as stated herein, this Amendatory Endorsement does not change coverage in any other way and is subject to all provisions, terms, and conditions of the Group Policy and Certificate. If there is a conflict between the Group Policy, the Certificate, and this Amendatory Endorsement, the terms of this Amendatory Endorsement will govern. Rachel Lipari, Secretary David Kettig, President Group Policy Number: SSL-GP-001 Group Policyholder: Communicating for Agriculture and the Self-Employed, Inc. Effective Date: [January 1, 2005] STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue, New York, NY 10022 AMENDATORY ENDORSEMENT This Amendatory Endorsement is attached to and made a part of the Group Policy and Certificate shown above. The provisions of this Amendatory Endorsement are effective on the Effective Date shown above and will expire concurrently with the Group Policy and Certificate unless otherwise terminated. In consideration of issuance, the Group Policy and Certificate is hereby amended and modified, as follows: [The deductible amount has been changed from $250 to $500.] Except as stated herein, this Amendatory Endorsement does not change coverage in any other way and is subject to all provisions, terms, and conditions of the Group Policy and Certificate. If there is a conflict between the Group Policy, the Certificate, and this Amendatory Endorsement, the terms of this Amendatory Endorsement will govern. Rachel Lipari, Secretary David Kettig, President [Group Policy Number: Group Policyholder: Effective Date: ] SUMMARY OF THE LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT AND NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS INTRODUCTION Residents of Pennsylvania who purchase life insurance, annuities, or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Pennsylvania Life and Health Insurance Guaranty Association (PLHIGA). The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in Pennsylvania and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Association is limited, however. As noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well-managed and financially stable. IMPORTANT DISCLAIMER The Pennsylvania Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require residency in Pennsylvania. You should not rely on coverage by the Pennsylvania Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk. Insurance companies or their agents are required by law or give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the association to induce you to purchase any kind of insurance policy. This Information is Provided By: Pennsylvania Life and Health Pennsylvania Insurance Department Insurance Guaranty Association Bureau of Consumer Services 290 King of Prussia Road 1300 Strawberry Square Radnor Station Bldg. Suite 218 Harrisburg, PA 17120 Radnor, PA 19087 (610) 975-0572 (717) 787-2317 SUMMARY The state law that provides for this safety-net coverage is called the Pennsylvania Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Association. Coverage. Generally, individuals will be protected by the Pennsylvania Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they hold certificates under a group life or health insurance contract, or annuity, issued by a member insurer. The beneficiaries, payees, or assignees of insured persons are protected as well, even if they live in another state. Exclusions From Coverage. Persons holding such policies or contracts are not protected by this Association if: * they are not residents of the State of Pennsylvania, except under certain very specific circumstances; * the insurer was not authorized or licensed to do business in Pennsylvania at the time the policy or contract was issued; * their policy was issued by a nonprofit hospital or health service corporation (e.g., the "Blue"), an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for: * any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk; * any policy of reinsurance (unless an assumption certificate was issued); * plans of employers, associations or similar entities to the extent they are self-funded or uninsured (that is, not insured by an insurance company, even if an insurance company administers them); * interest rate yields that exceed an average rate; * dividends; * experience rating credits; * credits given in connection with the administration of a policy or contract; * annuity contracts or group annuity certificates used by nonprofit insurance companies to provide retirement benefits for nonprofit educational institutions and their employees; * policies, contracts, certificates or subscriber agreements issued by a prepaid dental care plan; * sickness and accident insurance when written by a property and casualty insurer as part of an automobile insurance contract; * unallocated annuity contracts issued to an employee benefit plan protected under the federal Pension Benefit Guaranty Corporation; * financial guarantees, funding agreements or guaranteed investment contracts not containing mortality guarantees and not issued to or in connection with a specific employee benefit plan or governmental lottery; * any kind of insurance or annuity, the benefits of which are exclusively payable or determined by a separate account required by the terms of such insurance policy or annuity maintained by the insurer or by a separate entity. Limits On Amount Of Coverage. The act also limits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a policy or contract. Also, for any one insured life, the Association will pay a maximum of $300,000 - no matter how many policies and contracts there were with the same company, even if they provided different types of coverages. Subject to the over-all $300,000 limit, the Association will pay up to $300,000 in life insurance death benefits but not more than $100,000 in net cash surrender or withdrawal values. For annuities, the Association will pay up to $300,000 in annuity benefits, including $100,000 in net cash surrender or withdrawal benefits. For health insurance, the Association will pay up to $100,000, including any net cash surrender or withdrawal benefits. STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue • New York, NY 10022 (Herein called the Company, We, Us, or Our) HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice describes how we protect personal health information we have about you which relates to our medical, dental, vision, and prescription drug coverage. Protected Health Information (“PHI”) is individually identifiable information about you. All of the following are examples of PHI: demographic information like your name, address and social security number; medical information that relates to your past, present or future physical or mental health that is collected, created or received from you, a health care provider, a health plan, employer or a health care clearinghouse; the providing of health care; or the past present or future payment for providing health care to you. Our Legal Duty We are required by applicable federal and state laws to maintain the privacy of your PHI. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003 or the date coverage became effective for you, whichever is later, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and send the new notice to our Insureds at the time of change. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. Uses and Disclosures of Your PHI In conducting our business we will create records regarding you and the insurance services we provide you. The main reasons for which we may use and may disclose your PHI are to evaluate and process any requests for medical coverage and claims for benefits you may make. The following describe these and other uses and disclosures, together with some examples: Treatment: We may use or disclose your PHI to facilitate medical treatment by providers. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you. We may request the services of a business associate to assist us in these activities. Payment: We may use and disclose your PHI to facilitate payment of benefits under your insurance coverage. For example, we might disclose your PHI to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain payments and to issue explanations of benefits. We also may use your PHI to obtain payment from third parties that may be responsible for your premium payments, such as family members. Health Care Operations: We may use and disclose your PHI as necessary, and as permitted by law, to operate our business. Health care operations include: (i) rating our risk and determining our premiums for your insurance; (ii) conducting quality assessment and improvement activities; (iii) conducting or arranging for medical review, legal services, audit services, fraud and abuse detection and compliance programs; and (iv) business planning and development. On Your Authorization: You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your PHI for any reason except those described in this notice. To Your Family and Friends: We may disclose your PHI to a family member, friend, or other person to the extent necessary to help with your health care or for payment of your health care. We may use or disclose your name, location and general condition or death to notify, or assist in the notification, of (including identifying or locating) a person involved in your care. Before we disclose your PHI to a person involved with your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your PHI based on our professional judgment of whether the disclosure would be in your best interest. Your Employer or Organization Sponsoring Your Health Plan: We may disclose Your PHI and the PHI of others enrolled in your group insurance plan to the employer or other organization that sponsors your group insurance plan to permit the plan administrator to perform plan administration functions. We may also disclose summary information about the enrollees in your group insurance plan to the plan administrator to use to obtain premium bids for the health insurance coverage offered through your group insurance plan or to decide whether to modify, amend or terminate your group insurance plan. The summary information we may disclose will summarize claims history, claims expenses, or types of claims experienced by the enrollees in your group insurance plan. The summary information will be stripped of demographic information about the enrollees in the group insurance plan, but the plan administrator may still be able to identify you or other participants in your group health plan from the summary information. We may also disclose enrollment and disenrollment information to either the plan administrator or plan sponsor of your group insurance plan. Underwriting: We may receive your PHI for underwriting, premium rating or other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits. We will not use or further disclose this PHI for any other purpose, except as required by law, unless the contract of health insurance or health benefits is placed with us, or where we disclose such information to MIB Group, Inc., a non-profit membership organization of life and health insurance companies, which operates an information exchange on behalf of its members. In those cases, our use and disclosure of your PHI will only be as described in this notice. Public Benefit: We may use or disclose your PHI as authorized by law for the following purposes deemed in the public interest or benefit: -as required by law; -for public health activities, including disease and vital statistic reporting, child abuse reporting; FDA oversight, and to employers regarding work-related illness or injury; -to report adult abuse, neglect, or domestic violence; -to health oversight agencies; -in response to court and administrative orders and other lawful processes; -to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; -to coroners, medical examiners, and funeral directors; -to organ procurement organizations; -to avert a serious threat to health and safety; -to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities; -to correctional institutions regarding inmates; and -as authorized by state worker’s compensation laws. Business Associates: Certain aspects and components of our business are preformed through contracts with outside persons or organizations. Examples of these outside persons and organizations include our duly appointed insurance agents, third party administrators, financial auditors, actuarial and underwriting services, reinsurers, legal services, enrollment and billing services, claim payment and medical management services and collection agencies. At times it may be necessary for us to provide your PHI to one or more of these outside persons or organizations who assist us with our payment or health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information. Individual Rights Access: In most cases, you have the right to inspect and obtain a copy of the PHI that we maintain about you. To inspect and copy PHI, you must submit your request in writing using the “Contact Information” provided at the end of this Notice. To receive a copy of your PHI, you may be charged a fee for the costs of copying, mailing or other supplies associated with your request. However, certain types of PHI will not be made available for inspection and copying. This includes psychotherapy notes and PHI collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances we may deny your request to inspect and obtain a copy of your PHI. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes other than for treatment, payment, health care operations or as otherwise authorized by you since April 14, 2003 or the date coverage became effective for you, whichever is later. For example, we would account for your PHI or demographic information we disclose during an audit by an insurance department or pursuant to a court order. You must make your request in writing using the “Contact Information” provided at the end of this Notice. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Restriction: You have the right to request a restriction or limitation on PHI we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing using the “Contact Information” provided at the end of this Notice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on PHI uses or disclosures that are legally required, or which are necessary to administer our business. Confidential Communications: You have the right to request that we communicate with you about PHI in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing using the “Contact Information” provided at the end of this Notice and specify how or where you wish to be contacted. We will accommodate all reasonable requests. Amendment: If you believe that your PHI is incorrect or that an important part of it is missing, you have the right to ask us to amend your PHI while it is kept by or for us. You must provide your request and your reason for the request in writing using the “Contact Information” provided at the end of this Notice. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend PHI that: (i) is accurate and complete; (ii) was not created by us, unless the person or entity that created the PHI is no longer available to make the amendment; (iii) is not part of the PHI kept by or for us; or (iv) is not part of the PHI which you would be permitted to inspect and copy. Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, submit your complaint using the “Contact Information” provided at the end of this Notice. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint. Contact Information: If you have questions regarding this Notice or need further assistance regarding this Notice, please contact us at: STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue, New York, NY 10022 AMENDATORY ENDORSEMENT This Amendatory Endorsement made a part of the Group Policy and Certificate to which it is attached. The provisions of this Amendatory Endorsement are effective on the Effective Date stated herein and will expire concurrently with the Group Policy and Certificate unless otherwise terminated. In consideration of issuance, the Group Policy and Certificate is hereby amended and modified, as follows: Under the Section entitled “Definitions” the following changes are hereby made: 1. The definition of “Deductible” is deleted and replaced with the following: Deductible. The Deductible means the amount of Covered Expenses that each Covered Person must pay before benefits will be payable. The Deductible amount must be satisfied each Coverage Period. The daily Deductible amount must be satisfied each day, and applies per calendar day regardless of the number of providers rendering services on that day. The applicable Deductible or daily Deductible, as elected by You, is shown in the Schedule. 2. The following definition is added: Copay/Copayment. The Copay/Copayment means the amount the Covered Person must pay to each provider for each service or each supply as specified in the Schedule. If the Covered Person has a Copay, the Copay amount is specified in the Schedule. Copayments do not apply toward the Deductible, Coinsurance or Coinsurance Limit. This Rider is endorsed and made part of the Group Policy and Certificate as of Your Effective Date of coverage. This Rider is subject to all provisions of the Policy and Certificate which are not in conflict with the provisions of this Amendatory Endorsement. Nothing in this Endorsement will be held to vary, alter, waive, or extend any of the terms, conditions, provisions, agreements, or limitations of the Policy other than stated above. IN WITNESS WHEREOF, the Insurance Company has caused this Rider to be signed by its President. STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK Rachel Lipari, Secretary David Kettig, President STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK 485 Madison Avenue, New York, NY 10022 AMENDATORY ENDORSEMENT This Amendatory Endorsement made a part of the Group Policy and Certificate to which it is attached. The provisions of this Amendatory Endorsement are effective on the Effective Date stated herein and will expire concurrently with the Group Policy and Certificate unless otherwise terminated. In consideration of issuance, the Group Policy and Certificate is hereby amended and modified, as follows: Under the Section entitled “Limitations and Exclusions” the exclusion pertaining to expenses incurred during the first 6-months after the Effective Date of coverage for a Covered Person is deleted in its entirety. This Rider is endorsed and made part of the Group Policy and Certificate as of Your Effective Date of coverage. This Rider is subject to all provisions of the Policy and Certificate which are not in conflict with the provisions of this Amendatory Endorsement. Nothing in this Endorsement will be held to vary, alter, waive, or extend any of the terms, conditions, provisions, agreements, or limitations of the Policy other than stated above. IN WITNESS WHEREOF, the Insurance Company has caused this Rider to be signed by its President. STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK Rachel Lipari, Secretary David Kettig, President |
||
|
