hh employer group plan (004) - administration123.com€¦ · employer group plan overview of hooray...

Employer Group Plan Overview of Hooray Health Assurance

This proposal describes both insurance and non-insurance benefits and services. Unless otherwise noted, insurance is underwritten by AXIS Insurance Company. This proposal is not a contract of insurance. This proposal provides only brief descriptions of the coverage available. The policies contain reductions, limitations, exclusions and termination provisions. Full details of the coverage are contained in policies that can be made available to you upon request. If there are any conflicts between this proposal and the policy issued to you, the policy shall govern. The policy is governed by the laws in the state in which it is delivered. Certain terms or provisions may be different if required by the laws of that state. This proposal is valid for 90 days from the date of the proposal. If you accept the terms of this proposal, coverage is subject to the underwriting companies’ determination that trade or economic sanctions or regulations do not prohibit us from binding coverage. Payment of claims under any policy issued shall only be made in full compliance with all United States economic or trade and sanction laws or regulations, including, but not limited to, sanction laws or regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control. Ternian Insurance Group reserves the right to extend or withdraw this proposal at any time by providing written notice to the requestor of this proposal. Not for individual solicitation. This proposal is valid for 90 days unless extended in writing.

Ternian Insurance Group, a subsidiary of AXIS Insurance Company and a leading provider of innovative benefit solutions that meet these types of needs, offers a benefits package precisely designed to help provide affordable first-dollar benefits, flexible coverage options and financial protection for employers and their workers.

The information and products provided in this document should not be construed as providing tax advice. Any questions regarding tax and compliance should be directed to a tax professional or attorney.

www.hoorayhealthcare.com1.866.7.(HOORAY)HOORAY HEALTH 2

PLAN BENEFIT OVERVIEW Hooray Health Assurance Plans are limited-benefit medical plans that pay a fixed dollar amount for covered expenses.

Basic plans with low costs and no annual deductible

Our Basic Plans were designed to cover your employees everyday medical needs. That is

how we can start our plans at just $99/month for a member.

Dedicated and exclusiveprovider network

Employees won’t have to worry about not finding a provider to accept your plan,

because we have over 2,000 urgent care and retail clinics in 41 states for easy access.**

Low copays and nounexpected bills

Everyone has received an unexpected bill that caused a financial burden. Not with Hooray

Health! Your employee’s $25 copay takes care of their in-network physician visits.*

Mobile app for Apple and Android phones

Your employees have access to the Hooray Health mobile app to easily find in-network providers, connect to a concierge or find the

lowest price prescriptions near you.**

Affordable ACA compliant plans

Great health insurance makes employees happy, reducing employee turnover. Create a competitive advantage by offering your

employees a plan they can trust.

Access to concierge coordinators 24/7

Employees have access to our medical concierge coordinators to help them

find in-network providers or provide direct telephonic triage or consult.**

*Hooray Health in-network providers only**The services described are not insurance and are not provided by AXIS Insurance Company.


*The services described above are not insurance and are not provided by AXIS insurance Company. Telephonic triage and consult performed by a credentialed clinician. Services are currently available in AR, AZ, TX, CO, OK, LA and KS ONLY.

PLAN HIGHLIGHTS Fixed indemnity medical plan. Pays a limited fixed dollar amount for the following medical expenses resulting from medically necessary treatment, accidental injury or sickness of a covered member.

Physician Visits Benefit is payable to a licensed physician’s office, urgent care or retail clinic.

Wellness Visit Benefit is payable to routine health visit for covered persons.

Diagnostic, Laboratory and X-Ray Benefit is payable for x-rays, laboratory and other diagnostic tests ordered or performed by a physician in a contracted urgent care or retail clinic.

Hospital Confinement Benefit Benefit is payable for a maximum of 5 days per policy period, for hospital confinement.

ICU Benefit Benefit is payable for a maximum of 5 days per policy period, for hospital confinement in an ICU.

Surgery (in-patient) When surgery is performed benefits are paid for operating and recovery room, surgical charges, medical services and supplies.

Anesthesia Benefits Administration in connection with a covered surgical procedure.

Telephonic Benefits* Benefit is provided for telephonic triage and consults.

Rx Discount Card* Unlimited discounts for all policy holders with top 10 contracted retail pharmacies.

Accident Benefits Benefit is payable for covered expenses that occurs during a covered accident period.


Note: MEC only not offered on stand-alone basis; only as a package with limited plans above. MEC pricing on page 5.

(1)The Minimum Essential Coverage option is not underwritten by AXIS Insurance Company. (2)The Fixed Hospital Indemnity, Outpatient Accidental-Only are underwritten by AXIS Insurance Company.

Notice: Applicable to the Fixed Indemnity only, the insurance described in this proposal provides limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to or integrated with comprehensive coverage. This insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

INPATIENT (2) BASIC PLAN PLUS PLAN

Day 1 hospital confinement benefit amount per day Not included $2,000 per day x 1 day

Days 2 + hospital confinement benefit amount per day Not included $1,000 thereafter

Maximum Benefit Not included 5 days per year

ICU benefit amount per day Not included $1,000 per day x 5 days

Surgery benefit amount (incl. maternity) per day Not included $1,500 per day x 1 day

Anesthesia benefit amount per day Not included $375 per day x 1 day

Accident maximum benefit amount per year up to: Not included $10,000

Benefit % payable Not included $100 U&C

OUTPATIENT (2) BASIC PLAN PLUS PLAN

WELLNESS

Annual wellness or athletic physical benefit amount per day $125 per day x 1 day $125 per day x 1 day

LEVEL ONE

Physician office visit plus lab work or prescription when required $125 after $25 copay $125 after $25 copay

LEVEL TWO

Physician office visit plus Level One services plus x-rays, hydration procedure or injectable therapy when required $175 after $25 copay $175 after $25 copay

Maximum visits per year 5 per year 5 per year

Benefit % payable 100% U&C 100% U&C

MONTHLY RATES BASIC PLAN PLUS PLAN

Employee Only $99 $159Employee + Spouse $149 $279Employee + Child(ren) $139 $269Employee + Family $229 $459

SELF-FUNDED MINIMUM ESSENTIAL COVERAGE (MEC)(1) MEC OPTION

ACA Required Preventative Care/ Screening/ Immunization Benefits

Minimum Essential Coverage covers 100% of the government’s listed Preventative and Wellness Benefits when you visit an in-network provider. Self-funded by your employer, this coverage is required to satisfy your individual mandate under healthcare law.

PLAN BENEFIT SUMMARY


Limited Med Pricing MEC Basic MEC PlusEmployee Only $99 $159Employee + Spouse $149 $279Employee + Children $139 $269Employee + Family $229 $459

Admin CostsAdmin Fee $5 $5Cobra Fee $1 $1Admin and Compliance Fee $3 $3Total $9 $9

Hooray Health FeesEmployee Only $13 $13Employee + Spouse $25 $25Employee + Children $25 $25Employee + Family $31 $31

Exected Claims CostsEmployee Only $18 $18Employee + Spouse $36 $36Employee + Children $36 $36Employee + Family $60 $60

Fixed MEC CostEmployee Only $121 $181Employee + Spouse $183 $313Employee + Children $173 $303Employee + Family $269 $499

Expected MEC CostEmployee Only $139 $199Employee + Spouse $219 $349Employee + Children $209 $339Employee + Family $329 $559

(Limited Medical + Fixed Premium + Illustrative Expected Claims)

MEC/LIMITED PACKAGE RATE SUMMARY

Total Minimum Cost - (Fixed Admin + Broker Fee)

(PPO network fees + concierge fees + mobile app + software licensing fee)

Total Expected Cost includes Limited Medical Premium, Expected Claims Factors, Administration, COBRA, Broker Fee and Data Compliance Fee Does not include PCORI Fees PPO Network included in the Limited Medical Premium


PREVENTATIVE HEALTH SERVICES*

*These benefits are subject to change and will be updated as determined by ACA requirements. Preventive Services list was provided by HealthCare.gov, www.healthcare.gov/preventive-care-benefits

18 Covered Preventive Services for Adults

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2. Alcohol Misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease for men and women of certain

ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 8. Diabetes (Type 2) screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. Hepatitis B screening for adults at high risk 11. Hepatitis C screening for adults at increased risk, and one time for everyone

born 1945 – 1965

12. HIV screening for everyone ages 15 to 65, and other ages at increased risk

13. Immunization vaccines for adults — doses, recommended ages, and recom-mended populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococ-cal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella

14. Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years

15. Obesity screening and counseling for all adults 16. Sexually Transmitted Infection (STI) prevention counseling for adults at

higher risk 17. Syphilis screening for all adults at higher risk 18. Tobacco Use screening for all adults and cessation interventions for tobacco

users

23 Covered Preventive Services for Women

1. Anemia screening on a routine basis for pregnant women 2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for

breast cancer 3. Breast Cancer Mammography screenings every 1 to 2 years for women over

40 4. Breast Cancer Chemoprevention counseling for women at higher risk 5. Breastfeeding comprehensive support and counseling from trained

providers, and access to breastfeeding supplies, for pregnant and nursing women

6. Cervical Cancer screening for sexually active women 7. Chlamydia Infection screening for younger women and other women at

higher risk 8. Contraception: Food and Drug Administration-approved contraceptive

methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

9. Domestic and interpersonal violence screening and counseling for all women

10. Expanded tobacco intervention and counseling for pregnant tobacco users

11. Folic Acid supplements for women who may become pregnant 12. Gestational diabetes screening for women 24 to 28 weeks pregnant and

those at high risk of developing gestational diabetes13. Gonorrhea screening for all women at higher risk14. Hepatitis B screening for pregnant women at their first prenatal visit15. HIV screening and counseling for sexually active women16. Human Papillomavirus (HPV) DNA Test every 3 years for women with

normal cytology results who are 30 or older17. Osteoporosis screening for women over age 60 depending on risk factors

18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

19. Sexually Transmitted Infections counseling for sexually active women20. Syphilis screening for all pregnant women or other women at increased risk21. Tobacco Use screening and interventions for all women, and expanded

counseling for pregnant tobacco users22. Urinary tract or other infection screening for pregnant women23. Well-woman visits to get recommended services for women under 65

27 Covered Preventive Services for Children

1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children at the following ages: 0 to 11 months, 1

to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children at the following ages: 0 to 11 months, 1

to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children at higher risk of lipid disorders at the

following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 9. Fluoride Chemoprevention supplements for children without fluoride in

their water source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, Weight and Body Mass Index measurements for children at the

following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

13. Hematocrit or Hemoglobin screening for children 14. Hemoglobinopathies or sickle cell screening for newborns 15. Hepatitis B screening for adolescents at high risk 16. HIV screening for adolescents at higher risk

17. Hypothyroidism screening for newborns18. Immunization vaccines for children from birth to age 18 —doses,

recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot),Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella

19. Iron supplements for children ages 6 to 12 months at risk for anemia20. Lead screening for children at risk of exposure21. Medical History for all children throughout development at the following

ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.22. Obesity screening and counseling23. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4

years, 5 to 10 years.24. Phenylketonuria (PKU) screening for this genetic disorder in newborns25. Sexually Transmitted Infection (STI) prevention counseling and screening for

adolescents at higher risk26. Tuberculin testing for children at higher risk of tuberculosis at the following

ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.27. Vision screening for all children.


CRITICAL ILLNESS PLAN A buy-up option for members enrolled in HealthCare Select that are looking for enhanced cover-age for catastrophic events OR, a standalone option (instead of HealthCare Select) for members who are willing to self-pay their day-to-day medical expenses because they are more concerned about major events.

(1) Critical Illness Benefit Plan is underwritten by AXIS Insurance Company \

Notice The insurance described in this proposal provides limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to or integrated with comprehensive coverage. This insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

Monthly Rates

Critical Illness

Member Only

Member + Spouse

Member + Child(ren)

Member + Family

$11.50

$20.13

$18.98

$31.05

Benefit Amount Payable for 10 conditions: cancer, heart attack, renal failure, stroke, major organ transplant, multiple sclerosis, coronary artery surgery, alzheimer’s, ALS, terminal illness

$15,000.00


DENTAL/VISION PLAN DENTAL PLAN No deductibles; Reimburses 100% of usual amounts listed. Dental $2,000 Dental $3,500

Maximum Plan Year Limit $2,000 $3,500Periodontics lifetime maximum $1,000 $1,750Orthodontics lifetime maximum $1,000 $2,000TYPE 1: Preventative & Diagnostic Oral exams, including prophalaxis $43 $75Bitewings, per film $6 $11X-ray, panoramic or cephalometric $43 $75Sealants/ topical fluoride $13 $23Space maintainers $129 $226TYPE 2: Major RestorativeCrowns, bridges and dentures $216 $250Pre-fabricated crowns $72 $126Crown build-up procedures $57 $100TYPE 3: Minor RestorativeFillings $50 $88Crowns, bridges and denture repair $28 $49Relining or rebasing dentures $72 $126TYPE 4: Endodontics Root canals, apicoectomies $230 $250Rootamputations $115 $201Therapeutic pulpotomy, retrograde, fillings, apexification, hemisection $57 $100TYPE 5: Periodontics Lifetime Maximum $1,000 $1,750Tissue grafts or bone surgery $115 $201Gingivectomy (per quadrant) $72 $126Gingivectomy (per tooth) $43 $75Periodontal scaling, periodontal splinting, root planning, gingival curettage (per quadrant) $28 $49TYPE 6: Oral SurgerySurgeries Level 1 (example: removal of exostosis) $144 $250Surgeries Level 2 (example: removal of impacted tooth) $79 $138Surgeries Level 3 (example: simple extraction) $43 $75TYPE 7: General Anesthesia and IVIV, first half hour general, each additional 1/4 hour general $86 $151TYPE 8: OrthodontiaPer course of treatment (Lifetime Maximum) $1,000 $2,000Type 1 through 7: subject to annual maximum $2,000 $3,500Type 2, 5, 6, 8: subject to 12 month waiting periodVision Indemnity BenefitsExamination benefit/ Plan Year $35 $35Materials benefit every two plan years $75 $75

MONTHLY RATES

Member Only $33.33 $58.83Member + Spouse $53.33 $102.43Member + Child(ren) $54.99 $96.57Member + Family $89.99 $158.03


TERMS & QUALIFICATIONS - FIXED INDEMNITY PLANS

*Coverage may not be available in all U.S. states and jurisdictions. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitations may vary depending on state laws. If applicable, state specific Exclusions and Limitations pages will be provided at the end of the proposal.

Pre-existing ConditionLimitation

Fixed Indemnity Limited Medical Plans:6 Month Treatment Period/12 Month Limitation Period on Hospital Confinement and Surgery Benefits only

Critical Illness:- Benefit Waiting Period - 90 Days - Survival Period - 30 Days - State variation apply

Continuation of Coverage When Employment Ends - Continuation of coverage provision in policy

Issue Ages- Employee/Spouse: 18-64 (All benefits terminate at age 65)- Dependent Child: to 26- For Critical Illness benefit, covered person must be under age 65

Coordination of Benefits None

Rate Guarantee 1 Year

Rate ContingencyRates are based upon demographic and company information provided in proposal request. Any deviation may require recalculation; Participation minimum - 25 enrolled employees.

Situs State Policy will be issued in the situs state of client


LIMITATIONS & EXCLUSIONS Pre-Existing Condition Limitations

For Hospital Confinement or Surgery Benefits on all plans: 6 Month Treatment Period/12 Month Limitation Period

Pre-Existing Condition Limitation The Insurance Company will not pay Hospital Confinement Benefits for any Pre-existing Condition. A “Pre-existing Condition” means a disease or physical condition for which the Employee received medical treatment, during the treatment period shown above before his or her most recent effective date of insurance. The Pre-existing Condition Limitation will apply to any added benefits or increase in benefits. It will not apply after the Limitation Period shown above.

For Critical Illness benefit on all plans: 24 Month Treatment Period/24 Month Limitation Period

Pre-Existing Condition Limitation The Insurance Company will not pay Critical Illness Benefits for any Pre-existing Condition. A “Pre-existing Condition” means a disease or physical condition for which the Employee received medical treatment, during the treatment period shown above. Any increase in benefits will be delayed for 12 months. The Pre-existing Condition Limitation will not apply after the Limitation Period shown above.



Under the Group Hospital Indemnity Policy, AXIS Insurance Company will not pay benefits for any loss, injury or sickness that is caused by, or results from:

• Intentionally self-inflicted injury, suicide or any attempt while sane or insane;

• Commission or attempt to commit a felony or an assault; • Commission of or active participation in a riot or

insurrection; • Declared or undeclared war or act of war; • Release, whether or not accidental, or by any person

unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;

• An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;

• Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency; Flight in, boarding or alighting from an Aircraft except as: - a fare-paying passenger on a regularly scheduled commercial or charter airline; - a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;

• Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder, if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;

• Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;

• Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

• The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;

• An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;

• Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Physician unless specifically provided herein;

• Repair or replacement of existing dentures, partial

dentures, braces, fixed or removable bridges, or other artificial dental restoration;

• Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses;

• Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed;

• Mental and nervous disorders; • Elective surgery or cosmetic surgery, except for

reconstructive surgery needed as the result of a Covered Injury or Covered Sickness;

• Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II, or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption;

• Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications;

• Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery;

• Services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness;

• Treatment or services provided by a private duty nurse; • Organ or tissue transplants and related services; • Personal comfort or convenience items; • Rest or custodial cures; • Hearing aids. • An Injury or Sickness for which the Insured Person is

paid benefits under any Workers’ Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.


In addition, benefits will not be paid for services or treatment rendered by any person who is:

• employed or retained by the Policyholder; Subscriber; • living in the Insured Person’s household; • an Immediate Family Member of either the Insured

Person or the Insured Person’s Spouse; • the Insured Person.

Under the Accident Medical Expense Policy, AXIS Insurance Company will not pay benefits for any loss or Injury that is caused by, results from, or is contributed to by:

• Intentionally self-inflicted injury, suicide or any attempt while sane or insane;

• Commission or attempt to commit a felony or an assault;

• Commission of or active participation in a riot or insurrection; Declared or undeclared war or act of war;

• An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;

• Flight in, boarding or alighting from an Aircraft except as a fare-paying passenger on a regularly scheduled commercial or charter airline;

• Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

• Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice;

• The Insured Person’s intoxication; The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officers report, or similar items will be considered proof of the Insured Person’s intoxication;

• Aggravation or re-injury of a prior injury the Insured Person suffered prior to His Coverage Effective Date, unless the Company receives a written medical release from the Insured Person’s Physician;

• Sickness, disease or any bacterial infection, except one that results from an Accidental cut or wound, or pyogenic infections that result from accidental ingestion of contaminated substances;

• Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;

• Travel in any Aircraft owned, leased or controlled by the policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the policyholder if the Aircraft may be used as the policyholder wishes for more than 10 straight days, or more than 15 days in any year.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

• employed or retained by the Policyholder; • living in the Insured Person’s household; • an Immediate Family Member of either the Insured

Person or the Insured Person’s spouse; • the Insured Person.

In addition to the above Exclusions, under the Accident Medical Expense Policy, AXIS Insurance Company will not pay for any loss, treatment or services resulting from or contributed to by:

• Treatment by persons employed or retained by the Policyholder, or by any Immediate Family or member of the Insured Person’s household.

• Treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances;

• Treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appendicitis; osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness; detached retina unless caused by a Covered Accident;

• Mental disorder or psychological or psychiatric care or treatment whether or not caused by a Covered Accident;

• Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions;

• Mental and nervous disorders; • Damage to or loss of dentures or bridges, or damage to

existing orthodontic equipment; • Expenses incurred for treatment of temporomandibular

or craniomandibular joint dysfunction and associated myofacial disorders;

• Injury covered by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder.

• Cosmetic and elective surgery; • Any elective treatment, health treatment, or examination,

including any service, treatment or supplies that: (a) are deemed by us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States;

• Eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices;


• Expenses payable by any automobile insurance policy without regard to fault;

• Conditions that are not caused by a Covered Accident; • Any treatment, service or supply not specifically covered

by the Policy; or • Injuries paid under medical payment coverage or no-fault

coverage contained in an automobile insurance policy or liability insurance policy.

In addition, Critical Illness Benefits will not be paid for: • The Insured Person’s suicide or intentional self-inflicted

injury or Sickness, while sane or insane; • The Insured Person’s being under the influence of an

excitant, depressant, hallucinogen, narcotic, and other drug, or intoxicant including those taken as prescribed by a Physician;

• The Insured Person’s commission of or attempt to commit an assault or felony;

• The Insured Person’s engaging in an illegal activity or occupation;

• The Insured Person’s voluntary participation in a riot, • Any illness, loss or condition specifically exclude from the

definition of any Critical Illness; • A Critical Illness that was initially Diagnosed before the

Coverage Effective Date; • War, whether declared or not; • Balloon angioplasty, laser relief of an obstruction, and/or

other intraarterial procedure unless covered under this Certificate; or

• Any injury or Sickness covered under any state or federal Worker’s Compensation, Employer’s Liability law or similar law.

Under the Dental Policy, benefits will not be paid for the following:

• For services and supplies not listed in the Schedule of Ben-efits or not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.

• For cosmetic procedures, including but not limited to ve-neers and bleaching of teeth and procedures performed primarily for cosmetic reasons.

• For services related to, performed in conjunction with, or resulting from a non-covered procedure.

• For charges in excess of the Usual and Customary rate. • For any treatment program which began prior to the date

the Insured Person is covered under the Policy. • For crowns, inlays and onlays on teeth that can be restored

by direct placement materials. • For the replacement of crowns, bridges, dentures, inlays or

onlays that can be restored to normal function. • For the replacement of crowns, bridges, inlays, onlays or

prosthetic appliance within 5 years from the date of last placement.

• For service or supplies payable under any medical expense potion of an auto or no-fault plan.

• For any condition paid under any Worker’s Compensation Act or similar law.

• For services applied without cost by any municipality,

county or other political subdivision or for which there would be no charge in the absence or insurance.

• During any Waiting Period the Company requires. When the Insured Person voluntarily ends this insurance with-out a qualifying event and re-enrolls at a later date, the Waiting Period is 2 years and begins on the date coverage first ended.

• For services that are applied toward the satisfaction of a Deductible, if any.

• For services subject to a Waiting Period that were in-curred during the Waiting Period.

• For charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed ex-ceed the amount incurred if one provider had performed all services.

• For Hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, Hospital confinement.

• For drugs or the dispensing of drugs. • For oral hygiene instruction; plaque control; acid etch;

prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Oc-cupational Safety & Health Agency); or diagnostic photo-graphs (except for orthodontic purposes).

• For implants; myofunctional therapy; athletic mouth guards; precision or semi-precision attachments; treat-ment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.

• For orthodontia, unless included within the Schedule of Benefits.

• For services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continu-ous coverage on the Plan. Abutment teeth will be re-viewed for eligibility of prosthetic benefits.

• For composite, resin, or white fillings on posterior primary teeth. Benefits will be reduced to that of an amalgam or silver filling.

• For the replacement of a filling within 24 months of place-ment, unless for specific health reasons.

• For the replacement of retainers. • For sealants not applied to permanent bicuspid or molar;

applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.

• For lab fees for higher metals or porcelain crowns,bridges, inlays, or onlays.

Vision Benefits will not be paid for: • Broken or lost or stolen lenses contact or frames. • Medical or surgical treatment of the eye. • Services or materials which are payable under any Work-

ers’ Compensation Act or similar law or public program other than Medicaid.

• Services or materials rendered by a provider other than an Ophthalmologist, Optometrist, or Optician acting within the scope of their license.


• Services rendered after the date an Insured Person ceases to be covered under the Policy, except when vision material ordered before coverage ended are delivered and the services rendered to Insured Person(s) within 31 days of such order.

• Services rendered or material ordered before the date coverage began for a Insured Person under the Policy.

• Regardless of Optical Necessity, benefits are not available more frequently than that which is specified in the Schedule of Benefits

The insurance coverage provided herein may be considered a welfare benefit plan pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”). If ERISA applies the plan sponsor has certain responsibilities. Please consult with your legal or tax counsel for guidance as to whether ERISA would apply to this coverage and the responsibilities of a plan sponsor.


This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit AXIS Insurance Company from providing insurance, including, but not limited to, the payment of claims.

Payment of claims under any insurance policy issued shall only be made in full compliance with all United States economic or trade and sanction laws or regulation, including, but not limited to, sanctions, laws and regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”).

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