HomeMy WebLinkAboutReso 2001-399
RESOLUTION NO. 2001- m
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
SUNNY ISLES BEACH, FLORIDA, INCORPORATING RECITALS;
AWARDING REQUEST FOR PROPOSALS BID NO. 01-10-01 TO
JEFFERSON PILOT LIFE INSURANCE COMPANY FOR THE CITY OF
SUNNY ISLES BEACH EMPLOYEES GROUP DENTAL, LIFE, AND
LONG TERM DISABILITY, AS DETAILED IN THE POLICIES
ATTACHED HERETO AS EXHIBIT "A"; AND TO EYE MED FOR
VISION INSURANCE, OPTION 2, AS DETAILED IN THE POLICY
ATTACHED HERETO AS EXHIBIT "B"; AUTHORIZING THE CITY
MANAGER TO DO ALL THINGS NECESSARY TO EFFECTUATE THE
INTENT OF THIS RESOLUTION; PROVIDING FOR AN EFFECTIVE
DATE.
WHEREAS, the City of Sunny Isles Beach is desirous of having qualified dental, life,
long term disability, and vision insurance for its employees; and
WHEREAS, the City publicly advertised Request for Proposals No. 01-10-01 for Group
Dental, Life Long Term Disability, and Vision Insurance, and sent bid packages to four (4)
potential bidders; and
WHEREAS, on November 16, 2001, the City received two responsive bids, from two
insurance brokers, Brown and Brown, Inc., and Robert J. Shafer & Associates; and
WHEREAS, the City wishes to accept the bids from Brown & Brown, Inc., broker for
Jefferson Pilot Life Insurance Co. for the City of Sunny Isles Beach employees Group Dental,
Life, and Long Term Disability, as detailed in the policies attached hereto as Exhibit "A"; and to
Eye Med for Vision Insurance, Option 2, as detailed in the policy attached hereto as Exhibit "B";
WHEREAS, there is no reduction to the employee's current benefits, and the Long Term
Disability benefits will increase, resulting in an overall savings to the City.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF SUNNY ISLES BEACH, FLORIDA, AS FOLLOWS:
Section 1. Incorporation of Recitals. The recitals set forth in this resolution are incorporated
herein by reference as if fully set forth herein.
Section 2. Award of Bid. The City Commission hereby awards Bid No. 01-10-01 to
Jefferson Pilot Life Insurance Co. for City of Sunny Isles Beach employees Group Dental, Life,
and Long Term Disability, as detailed in the policies attached hereto as Exhibit "A"; and to Eye
Med, for Vision Insurance, Option 2, as detailed in the policy attached hereto as Exhibit "B".
Section 3. Authorization of City Manager. The City Manager is hereby authorized to do all
things necessary to effectuate the intent of this Resolution.
R2001- Award RFP 01-10-01, Group Dental, Life & LTD, Vision Ins.
1
Section 4.
Effective Date. This Resolution will become effective upon adoption.
PASSED AND ADOPTED this 13th day of December, 2001.
ATTESt":. .
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'''''I' ,) ,~' /"." '"
~~~U~
','Richard Brown-Mori1~, City Clerk
"\ I" ~_.....
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Approv.ed As tQ Form and
Legal Sufficiency:
Vote: 5.-'0
Mayor Samson
Vice Mayor Iglesias
Commissioner Edelcup
Commissioner Goodman
Commissioner Kauffman
Moved by:
Seconded by:
~Yes)
~(Yes)
V(Yes)
V (Yes)
~(Yes)
COM""" $S IOiVtR.. r{ A-UFFrYltMl
C DW\rv,,<;S:-, OI\JU2. Eh~ L~U e
_(No)
_(No)
_(No)
_(No)
_(No)
R2001- Award RFP 01-10-01, Group Dental, Life & LTD, Vision Ins,
2
..
I
t.
III
JEFFERSON PILOT
FINANCIAL
Jefferson Pilot Financial Insurance Company
8801 Indian Hills Drive, Omaha NE 68114-4066
(402) 361-7300 A Stock Company
Group Policyholder:
Florida - Life Specimen
In Consideration of the Group Policyholder's application for this Policy and payment of all premiums when due,
Jefferson Pilot Financial Insurance Company agrees to make the payments provided in this Policy to the persons
entitled to them.
The fIrst premium for this Policy is due on its effective date, Subsequent premiums are due on June 1,2001, and on
the same day of each month after that. Policy anniversaries will be each May 1st; unless shown otherwise on the
Premium Rate Schedule inside.
The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited
over the signatures below,
Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in Omaha,
Nebraska. The issue date of this Policy is May 1, 2001.
~~
Chief Executive Officer
~~
Secretary
GROUP INSURANCE POLICY
No. XXXXXXXXXXXX
PROVIDING
LIFE INSURANCE
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
DEPENDENT LIFE INSURANCE
GL1101-TITLE PAGE
Exhibit "A"
95
05/01/01
I
1
TABLE OF CONTENTS
Schedule of Insurance,......,... ,....,.... ,.........,....,.... ,.......,....,... ...... ..... ...... ..........,..,.. .........,........ ...... ............. 3
DefInitions.""....".".",.....,.",.".,.,.....,.".,.""",.,..............,..""..",.,.",.,.......",.,."",.,..,......, ..."...."..."."...... 4
General Provisions,......""."""".,...",.".",.....,.,.........,.."..,.",."..,..,....,.".,.,."..",.........,..,..."."" ,.'"......,..,., 5
Eligibility and Effective Dates for Personal Insurance..,........................................................................... 6
Individual Terminations. .......,..........,.................,......,.,........ ..................... ...... ...,.."..,........,..,..,.... ,........... 7
Premiums and Premium Rates. ..........,.........,. ............................"...... ..... ..........,.." ...............,.., ...... .........., 8
Grace Period"""..,.........."".......,.".".....".,....",.."".".",.,......,.....",...".,........,...",.."........".., ..,...... ........... 9
Policy Termination.......,..,........,.,....,...........,......"'.,.....""""..........,.,...............,.."'..,....,..,.".,..,..... .....,..,., 9
BenefIciary .",.,..."..,..,..."".,.,.........".,.""".,......,.,.,.,..,.,.,.,.",....,....".".".........."".,...",.,."....,.,.,.... .........,. 10
Facility of Payment... .., ",.,. ,.,..,. ."..,., ",..", .,.,.,., ...." ....,."", ".,., ..."..".., ,.,.,." ... ,..., ,.., ,..".,.. ....,..,., ,:,. ".,.....,. 11
Death BenefIt......"".,.......,.".."."..",.........,.""""",.,..,............""",.."..,.......,....,."...,.......,....,., ,........... ....., 11
Settlement Options ..,..,.",.".......".,.".,.,......,.,....,............,..""..,......,.,."..,.,.".....,....."."."........,.".,..,.".. .... 11
Extension of Death BenefIt...,., ,.,..." ,.,.... ...,....,..",...... ,.,.,.., ,. ..........,.,."" ,. ,.., ,.... ,... ,., ,.,..,., ,... .....,..,..,.....,... 12
Living BenefIt.............,..........,...,.,....,.....,.....................,.....",.,...,........,.,...".,..,........,..".."........ ...,....."..... 13
Conversion Privilege .,..., ....,.,.,., ,."" ,., ".... ,.,.,. ,.", "..,.,. .,." ,..,..... ..... ,., ".., .......... ,... ,.. ,.. ..... ..... .,." ..... ........... 15
Dependents Life Insurance.............,.... ..... ,....................... .......... ,.......... ........................... .... .....,..,.... ........ 16
Claims Procedures for Life or Accidental Death and Dismemberment BenefIts ................,..................... 18
Accidental Death and Dismemberment Insurance................,....""...,..".........,.",.......,...........".,."............20
Prior Insurance Credit Provision.......... ............... ......... ...... ....... ................. ........, ...................................... 21
GL1101-1
2
OSlO 1/0 1
I
1
SCHEDULE OF INSURANCE
The amount of an Insured Person's insurance is determined from the following table. The initial amount of coverage is the
amount which applies to an Insured Person's Class on the date his or her coverage takes effect. An Insured Person may
lecome eligible for increases in an amount of insurance in accord with the table. Any such increase will take effect on the
latest of:
(1 )
(2)
(3)
the first day of the Insurance Month which coincides with or follows the date on which the Insured
Person becomes eligible for the increase; provided he or she is Actively at Work on that day;
the day the Insured Person resumes Active Work, if not Actively at Work on the day the increase would
otherwise take effect; or
the day any required evidence of insurability is approved by the Company,
Any decrease will take effect on the day of the change; whether or not the Insured Person is Actively at Work.
The amount of an Insured Person's insurance shall be reduced by the amount of any Life insurance in effect as a result of
exercising the rights under the Conversion Privilege Section of this Policy.
CLASSIFICATION
Class 1
All Full-Time Employees
WAITING PERIOD:
30 days of continuous Active Work (For date insurance begins, ~efer to "Effective Date"
section)
GL1101-2
3
05101/01
I
I
SCHEDULE OF INSURANCE (CONTINUED)
LIFE AND AD&D INSURANCE
Amount of Personal
Life Insurance
AD&D Insurance
Principal Sum
Class 1
$50,000
$50,000
Personal Life and AD&D Insurance will be reduced as follows:
At age 65, benefits will reduce by 35% of the original amount;
At age 70, benefits will reduce an additional 25% of the original amount;
At age 75, benefits will reduce an additional 15% of the original amount.
Benefits will terminate when the Insured Person retires,
If the Insured Person first enrolls for Personal Life and AD&D Insurance at age 65 or older, the above age reductions will
apply to:
Any Guarantee Issue Amount available without evidence of insurability; and
The maximum amount of insurance for which he or she is eligible.
GL1101-2
3-2
05101/01
SCHEDULE OF INSURANCE (CONTINUED)
DEPENDENTS INSURANCE
(For Class 1)
Dependent
Amount of Life Insurance
Spouse
$10,000
Dependent Child
(age 14 days to 6 months)
250
Dependent Child
(age 6 months to 19 years,
23 years if a full-time student)
5,000
Spouse Life Insurance will terminate when the Spouse attains age 70.
Dependent's Life Insurance is subject to a maximum of 50% of the Insured Employee's Life Insurance Benefit.
Insured Persons are not required to make contributions for Personal Life Insurance and AD&D Insurance. Insured
Persons are required to make contributions for Dependent Life Insurance. .
Under the Policy Termination section on form GL 1101-7, the participation rate requirements in part (3) will not apply during
policy years when the Employer's premium contributions are made through a Section 125 plan.
GL1101-2
3-3
05101/01
DEFINITIONS
ACTIVE WORK or ACTIVELY AT WORK means an employee's full-time performance of all customary duties of his or her
lccupation at:
(1) the GROUP POLICYHOLDER'S place of business; or
(2) any other business location where the employee is required to travel.
Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the
following days:
(1) a Saturday, Sunday or holiday which is not a scheduled workday;
(2) a paid vacation day, or other scheduled or unscheduled non-workday; or
(3) an excused or emergency leave of absence (except a medical leave).
COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home Office address is 8801
Indian Hills Drive, Omaha, Nebraska 68114-4066.
DAY OR DATE means at 12:01 A.M., Standard Time, at the GROUP POLICYHOLDER'S place of business; when used
with regard to eligibility dates and effective dates. It means 12:00 midnight, Standard Time, at the same place; when used
with regard to termination dates,
FULL-TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER:
(1) whose employment with the GROUP POLICYHOLDER is the employee's principal occupation;
(2) who is not a temporary or seasonal employee; and '
(3) who is regularly scheduled to work at such occupation at least 30 hours each week.
GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy.
INSURANCE MONTH means that period of time:
(1) beginning at 12:01 A.M, Standard Time, at the GROUP POLICYHOLDER'S place of business on the
first day of any calendar month; and
(2) ending at 12:00 midnight on the last day of the same calendar month.
INSURED PERSON means a PERSON for whom the coverages provided by this Policy are in effect.
PERSON means a FULL-TIME EMPLOYEE of the GROUP POLICYHOLDER:
(1) who is a member of an employee class which is eligible for coverage under this Policy; and
(2) who has completed an enrollment form.
PERSONAL INSURANCE means the insurance provided by this Policy on Insured Persons,
PHYSICIAN means a licensed practitioner of the healing arts other than the Insured Person or a relative of the Insured
Person.
POLICY means this Group Insurance Policy issued by the Company to the Group Policyholder.
4
(REV)
05101/01
GL1101-391
GENERAL PROVISIONS
ENTIRE CONTRACT. The entire contract between the parties consists of:
(1) this Policy and the Group Policyholder's application (a copy is attached); and
(2) the Insured Persons' enrollment cards, if any,
All statements made by the Group Policyholder and by Insured Persons are representations and not warranties. No
statement made by an Insured Person will be used to contest the coverage provided by this Policy; unless:
(1) it is contained in a written statement signed by that Insured Person; and
(2) a copy of the statement is furnished to the Insured Person or Beneficiary.
Only an Officer of the Company may change this Policy or extend the time for payment of any premium. No change will
be valid unless made in writing and signed by an Officer of the Company. Any change so made will be binding on all
persons referred to in this Policy.
INCONTESTABILITY. Except for the non-payment of premiums, the Company may not contest the validity of this Policy
as to any Insured Person after it has been in force for two years during his or her lifetime. This clause will not affect the
Company's right to contest claims made for disability, accidental death, or accidental dismemberment benefits.
NONPARTICIPATION, This Policy will not be entitled to share in the surplus earnings of the Company.
BASIS OF RESERVE. The reserve for this Policy will not be less than the reserve computed using:
(1) the 1970 Intercompany Group Life Disability Valuation Table; and
(2) interest at not less than three percent per annum.
INFORMATION TO BE FURNISHED, The Group Policyholder may be required to furnish any information needed to
administer this Policy, Clerical error by the Group Policyholder will not:
(1 ) affect the amount of insurance which would otherwise be in effect; or
(2) continue insurance which otherwise would be terminated.
)nce an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the
return of unearned premium, the amount of the return will be limited to the twelve month period which precedes the date
the Company receives proof such an adjustment should be made.
The Company may inspect any of the Group Policyholder's records which relate to this Policy.
MISSTATEMENT OF AGE. If an Insured Person's age has been misstated, premiums will be subject to an equitable
adjustment. If the amount of benefit depends upon age; then the benefit will be that which would have been payable,
based upon the person's correct age,
CERTIFICATES, The Group Policyholder will be furnished with individual Certificates for delivery to each Insured Person.
These certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the
Certificate, the Policy will control.
CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable law, the provision
will be deemed to conform to the minimum requirements of the law.
WORKER'S COMPENSATION, This Policy is not to be construed to provide benefits required by Worker's Compensation
laws,
GL1101-495
5
05/01/01
ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL INSURANCE
ELIGIBILITY, A Person becomes eligible for the coverage provided by this Policy on the later of:
(1) the Policy's date of issue; or
(2) the date the Waiting Period is completed,
WAITING PERIOD. (See Schedule of Insurance),
EFFECTIVE DATE. Personal Insurance becomes effective on the latest of:
(1 ) the first day of the Insurance Month coinciding with or next following the date the Person becomes
eligible for the coverage;
(2) the date the Person resumes Active Work, if not Actively at Work on the day he or she becomes
eligible;
(3) the date the Person makes written application for Personal Insurance; and signs:
(a) a payroll deduction order, if Insured Persons pay any part of the Policy premium; or
(b) an order to pay premiums from the Person's Section 125 Plan account, if Employer
contributions are made through a Section 125 Plan; or
(4) the date the Company approves the Person's coverage, if evidence of insurability is required.
EVIDENCE OF INSURABILITY. Evidence of insurability satisfactory to the Company must be submitted when:
(1) a Person makes written application for Personal Insurance more than 31 days after becoming eligible
for the coverage; or .
(2) a Person makes written application for Personal Insurance after he or she has requested:
(a) to cancel Personal Insurance;
(b) to stop payroll deductions for the coverage; or
(c) to stop premium payments from the Section 125 Plan account.
EXCEPTION, If an Insured Person's coverage terminates due to an approved leave of absence or military leave, the
Sompany will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided:
(1) the Person returns within six months after the leave begins;
(2) the Person applies or is enrolled within 31 days after resuming Active Work; and
(3) the reinstated amount of insurance does not exceed the amount which terminated.
6
(FMLA)
05101/01
GL1101-593
INDIVIDUAL TERMINATIONS
An Insured Person's coverage will terminate on the earliest of:
(1) the date this Policy terminates;
(2) the last day of the Insurance Month in which the Insured Person requests termination;
(3) the last day of the last Insurance Month for which premium payment is made on the Insured Person's
behalf;
(4) the date the Insured Person ceases to be in a class of employees which is eligible for coverage under
this Policy;
(5) with respect to any particular insurance benefit, the date the portion of the Policy providing that benefit
terminates;
(6) the date on which the Insured Person's employment with the Group Policyholder or Participating
Employer terminates; or
(7) the date the Insured Person enters the armed services of any state or country on active duty; except for
duty of 30 days or less for training in the Reserves or National Guard. (If the Insured Person sends
proof of military service, the Company will refund any unearned premium.)
Ceasing Active Work results in termination of insurance; but coverage may be continued as follows:
(1) If the Insured Person is disabled due to illness or injury, then coverage may be continued:
(a) until the Person is no longer disabled;
(b) provided premium payments are made on his or her behalf,
(2) If the Insured Person ceases work due to a temporary layoff, an approved leave of absence, or a
military leave; then coverage may be continued:
(a) for three Insurance Months after the layoff or leave begins;
(b) provided premium payments are made on his or her behalf,
7
(FMLA)
05/01/01
GL1101-5 93
PREMIUMS AND PREMIUM RATES
PAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium for such coverage
is paid, For coverage to remain in effect, each subsequent premium must be paid on or before its due date, The Group
lolicyholder is responsible for paying all premiums as they become due. Premiums are payable on or before their due
dates at the Company's Home Office. The premium must be paid in U.S, dollars,
PREMIUM RATE CHANGE. The Company may change any premium rate on any of the following dates:
(1) the date this Policy's terms are changed;
(2) the date the Company's liability is changed due to a change in federal, state or local law;
(3) the date the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, or
is added to or removed from this Policy;
(4) the date the number of Insured Persons changes by 25% or more from the enrollment on the date this
Policy took effect, or the most recent Rate Guarantee Date expired, if later; or
(5) on any premium due date on or after this Policy's first anniversary, or any later Rate Guarantee Date
agreed upon by the Company.
Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days' advance written
notice of any increase in premium rates.
PREMIUM AMOUNT. The amount of premium due on each due date will be the sum of the products obtained by
multiplying each rate shown in the Premium Rate Schedule by the amount of insurance to which the rate applies,
Premium adjustments will not be pro-rated daily. Instead, premium will be adjusted as follows.
(1) When an Insured Person's insurance or increase takes effect, premium will be charged from the
monthly due date coinciding with or next following that change. '
(2) When all or part of an Insured Person's insurance terminates, the applicable premium will cease on the
monthly due date coinciding with or next following that termination.
(3) When premiums are paid other than monthly, increases or decreases will result in adjustment from the
premium due date coinciding with or next following that change.
The above manner of charging premium is for accounting purposes only. It will not extend coverage beyond a date it
fould have otherwise terminated, Each premium payment will include any adjustments in past premiums, which are
needed due to changes that have not yet been taken into account. If a premium adjustment involves a return of unearned
premium, the refund will be limited to the prior 12-month period,
PREMIUM RATE SCHEDULE
Monthly Group Life Rate
$.xx per $1,000 of insurance
Monthly AD&D Rate
.xx per $1,000 of insurance
Monthly Dependent Life Rate
x,xx per Family Unit
The above rates are guaranteed until May 1, 2002, unless an exception listed in the Premium Rate Change section
applies.
After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group
Policyholder a renewal letter prior to each Policy Anniversary.
GL1101-6 99 FL
8
05101/01
GRACE PERIOD
A grace period of 31 days from the due date will be allowed for the payment of each premium after the first. The Policy
viii remain in effect during the grace period; unless the Group Policyholder gives the Company advance written notice of
termination. The Group Policyholder will remain liable for payment of a pro rata premium for the time this Policy remained
in force during the grace period.
POLICY TERMINATION
TERMINATION BY THE COMPANY. To terminate this Policy, the Company must give the Group Policyholder at least 45
days' advance written notice of its intent to do so. Until the premium rate has been in effect for at least 12 months, the
Company can terminate coverage only if:
(1) the total number of Insured Persons is less than ten;
(2) all of the premium is paid by the Group Policyholder and less than 100% of those eligible for coverage
are insured;
(3) part of the premium is paid by Insured Persons and less than 75% of those eligible for coverage are
insured;
(4) the Group Policyholder, without good cause:
(a) fails to promptly furnish any information the Company reasonably requires; or
(b) fails to perform its duties pertaining to this Policy in good faith;
(5) the Company's liability is changed as a result of any change in federal, state or local law which affects this Policy;
(6) the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, di~solves or merges,
or is added to or removed from this Policy;
(7) any coverage for one, or more classes ceases to be provided under this Policy; or
(8) the number of Insured Persons changes by 25% or more from the enrollment on the date this Policy
took effect, or the most recent Rate Guarantee Date expired, if earlier.
After the premium rate has been in effect for at least 12 months, the Company can terminate coverage on any premium
1ue date, by giving 45 days' advance written notice, Such termination may be with respect to this Policy as a whole, to
Jny coverage(s) provided under it, or to any class of Insured Persons under it.
TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any time, by giving
the Company advance written notice. Coverage will then terminate:
(1) on the date the Company receives the notice; or
(2) any later date the Group Policyholder and the Company have agreed upon.
The Group Policyholder remains responsible for the payment of premiums to the date of termination.
POLICY TERMINATION DUE TO NONPAYMENT OF PREMIUM. If any premium remains unpaid at the end of the Grace
Period; then this Policy will terminate:
(1) at midnight on the last day of the Grace Period, if the Company sends the Group Policyholder a written
cancellation notice by the 45th day after the Grace Period expires; or
(2) on the day the Company sends the Group Policyholder a written cancellation notice, if the notice is sent
more than 45 days after the Grace Period expires.
EFFECT ON INCURRED CLAIMS. Termination of this Policy will not affect benefits otherwise payable for a claim
incurred while this Policy is in force,
9
No Bene.-ten lives
05101/01
GL1101-7 99 FL
BENEFICIARY
PAYMENTS TO BENEFICIARY. At an Insured Person's death, the amount of his or her Personal Life Insurance will be
'Jaid to the surviving Beneficiary. If the Insured Person has not named a Beneficiary, or if no named Beneficiary survives
the Insured Person; then payment will be made to that Insured Person's:
(1) surviving spouse; or, if none
(2) surviving child or children in equal shares; or, if none
(3) surviving parent or parents in equal shares; or, if none
(4) surviving brothers and sisters in equal shares; or, if none
(5) estate, or in accord with the Facility of Payment section of this Policy,
The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility of Payment
section.
In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class of relatives to
receive payment. The Company will make payment based upon the affidavit it has; unless it receives notice of a valid
claim by some other person, at its Home Office, before paying the proceeds. Such payment will release the Company
from any further obligation for the Insured Person's life insurance benefit.
If an Insured Person's named Beneficiary dies:
(1) within 15 days of the Insured Person's death; and
(2) before the Company receives satisfactory proof of the Insured Person's death;
then payment will be made as if the Insured Person had survived that Beneficiary; unless other provisions have been
made.
NAMING THE BENEFICIARY. An Insured Person's Beneficiary will be as shown on his or her enrollment card, unless
changed. This Policy may replace a group policy providing similar coverages. In that event, the Beneficiary which the
Insured Person named under the prior policy will be the Beneficiary under this Policy, until changed.
':;HANGING THE BENEFICIARY. Only the Insured Person, or his or her assignee, may change the Beneficiary. A new
Beneficiary may be named by filing a written notice of the change with the Company at its Home Office. The change will
be effective as of the date it was signed; subject to any action the Company takes before receiving notice of the change.
When applying for a conversion policy under the Conversion Privilege Section, an Insured Person must name a
Beneficiary. The Beneficiary named for the conversion policy may be someone other than the person named under this
Policy, In that event, the application for the conversion policy will be treated as a written notice of change of Beneficiary.
10
Pref. Bene,
05101/01
GLlIOl-7.1A 96
FACILITY OF PAYMENT
Policy benefIts may become payable to an Insured Person's estate, to a minor, or to a person who the Company does not consider
;ompetent to give a valid release. In that event, the Company has the option to pay one or more of the following:
(1) a person who has assumed the care and support of the Insured Person or BenefIciary;
(2) a person who has incurred expense as a result of the Insured Person's last illness or death;
(3) the personal representative of the Insured Person's estate; or
(4) any person related by blood or marriage to the Insured Person.
No payment made under this section may exceed $2,000. Any payment made in good faith under this section will fully discharge the
Company to the extent of the payment. Any remaining amount of benefIt will be paid as shown in the BenefIciary section.
DEATH BENEFIT
AMOUNT PAYABLE ON DEATH, Upon receipt of satisfactory proof of an Insured Person's death, the Company will pay a death
benefIt equal to the amount of Personal Life Insurance in effect on the date of death, This amount is shown in the Schedule of
Insurance, The benefIt will be paid as shown in the BenefIciary, Facility of Payment, and Settlement Options sections.
SETTLEMENT OPTIONS
INSTALLMENTS, All or part of the death benefIt may be received in installments, by making written election to the Company.
ELECTION. While living, an Insured Person may direct the Company to pay the death benefIt in installments. Ifno such direction is
in effect at the time of the Insured Person's death, the BenefIciary may make such an election,
CONDITIONS. Any election, whether by an Insured Person or a BenefIciary, must comply with the Company's practices at the time
it is made, The amount applied under a settlement option must be at least $2,000, It must be suffIcient to provide a payment of at
least $20 per month.
GLll01-896
11
05101/01
EXTENSION OF DEATH BENEFIT
BENEFIT. Life insurance will be continued, without payment of premiums, for an Insured Person who:
(1) becomes Totally Disabled while insured under this policy and before reaching age 70;
(2) remains Totally Disabled for at least 6 months in a row; and
(3) submits satisfactory proof within the 7th through the 12th months of disability; or:
(a) as soon as reasonably possible after that; but
(b) not later than the 24th month of disability, unless he or she was legally incapacitated,
PREMIUM PAYMENT, Premium payments must continue until:
(1) the day the Insured Person is approved for this Extension of Death BenefIt; or
(2) the day this Policy terminates (whichever occurs fIrst).
Upon receipt of satisfactory proof, the Company will refund up to 12 months' premium paid for the Insured Person's life insurance,
from the 1st day of Total Disability.
DEFINITION. For this benefIt, Total Disability or Totally Disabled means an Insured Person:
(1) is unable, due to sickness or injury, to engage in any employment or occupation for which such Insured Person is or
becomes qualifIed by reason of education, training, or experience; and
(2) is not engaging in any gainful employment or occupation.
AMOUNT CONTINUED. The life insurance continued by this section:
(1) will be the amount of Personal Life Insurance and any Dependent Life Insurance in effect on the day the Insured
Person's Total Disability begins; and
(2) will be subject to the reductions and terminations in effect under this Policy on that day,
If the Insured Person receives an Accelerated Death BenefIt, the amount will be reduced in accord with that provision, Any
Accidental Death and Dismemberment BenefIt will not be continued.
ADDITIONAL PROOF, At any time during this continuation, the Company may require the Insured Person:
(1) to submit further proof of his or her continued Total Disability; and
(2) to be examined by a Physician of the Company's choice, as often as reasonably necessary.
After the fIrst two years of Total Disability, the Company will not request proof or an exam more than once a year. Proof will be at
'he Insured Person's expense; unless the Company requests an exam by a Physician of its choice.
When an Insured Person dies after submitting proof, further proof must be submitted to the Company showing that he or she remained
continuously and Totally Disabled until death, When an Insured Person dies within 12 months after Total Disability begins, but
before submitting proof; then his or her death benefIt will still be paid under the terms of this Policy, But the Company must fIrst
receive satisfactory proof of his or her continuous Total Disability, from the last day of Active Work until the date of death,
TERMINATION, Any life insurance extended under this section will terminate automatically on:
(1) the day the Insured Person ceases to be Totally Disabled;
(2) the day the Insured Person fails to take a required medical examination;
(3) the 60th day after the Company mails a request for additional proof, if it is not given;
(4) the effective date of the Insured Person's individual conversion policy, with respect to any amount of life
insurance converted in accord with the Conversion Privilege section; or
(5) the day the Insured Person reaches age 70 (whichever occurs fIrst),
RIGHTS AFTER TERMINATION. If Total Disability ends, and the Insured Person does not return to a class eligible for Policy
coverage; then he or she may exercise the Conversion Privilege. If Total Disability ends, and the Insured Person does return to an
eligible class; then his or her Policy coverage will resume when premium payments are resumed, and any conversion policy is
surrendered as provided below.
CONVERSION POLICIES, If the Insured Person has exercised the Conversion Privilege, and the benefIts payable under this Policy
and the conversion policy combined would exceed:
(1) the Insured Person's original amount of Policy coverage prior to the conversion; or
(2) any greater amount for which he or she later becomes insured under this Policy; .
then benefIts will be payable under the terms of this Policy. But the conversion policy must fIrst be surrendered to the Company; and
no claim may be made under the conversion policy, except for refund of premium less any dividends and policy loans,
12
Stand. Ext.
05/01/01
GL1101-9 96 FL
LIVING BENEFIT
BENEFIT. The Living Benefit is an advance payment of part of the Insured Person's Personal Life Insurance. It may be
'Jaid to a Terminally III Insured Person, in a lump sum, once during his or her lifetime, To qualify, the Insured Person
must:
(1 )
(2)
(3)
(4)
have satisfied the Active Work requirement under this Policy;
have been insured under this Policy for at least 12 months;
have qualified for the Extension of Death Benefit under this Policy; and
have at least $2,000 of Personal Life Insurance under this Policy on the day before the Living Benefit is
paid.
Receiving the Living Benefit will reduce the Remaining Life Insurance and the Death Benefit payable at the Insured
Person's death, as shown on the next page,
"Terminally III" means the Insured Person has a medical condition which is expected to result in death within 12 months,
despite appropriate medical treatment.
APPLYING FOR THE LIVING BENEFIT. To withdraw the Living Benefit, the Insured Person (or his or her legal
representative) must send the Company:
(1) written election of the Living Benefit, on forms supplied by the Company; and
(2) satisfactory proof that the Insured Person is Terminally III, including a Physician's written statement.
The Company reserves the right to decide whether such proof is satisfactory. The Company may have the Insured
Person examined, at its own expense, by one or more Physicians of its choice.
Before paying a Living Benefit, the Company must also receive the written consent of any irrevocable beneficiary,
assignee or bankruptcy court with an interest in the benefit. (See Limitations 5, 6 and 7.)
AMOUNT OF THE LIVING BENEFIT. The Insured Person may elect to withdraw a Living Benefit in any $1,000 increment;
subject to:
(1) a minimum of $1,000 or 10% of the Insured Person's amount of Personal Life Insurance (whichever is
greater); and
(2) a maximum of $100,000 or 50% of the Insured Person's amount of Personal Life Insurance (whichever
is less).
To determine the Living Benefit, the Company will use the lesser of A or B below:
A. the Insured Person's amount of Personal Life Insurance which is in force on the day before the Living
Benefit is paid; or
the Insured Person's amount of Personal Life Insurance which would be in force 12 months after that
date; if the coverage is scheduled to reduce, due to age, within 12 months after the Living Benefit is
paid.
Before making payment to the Insured Person, the Company will reduce the Living Benefit by an early withdrawal fee.
This early withdrawal fee will be 12 months' interest at the lesser of:
(1) the annual interest rate the Company then charges on policy loans under its nonvariable individual life
insurance policies;
(2) the annual discount rate any applicable state law then permits for accelerated death benefits under life
insurance contracts; or
(3) the annual discount rate federal income tax regulations then permit for qualified accelerated death
benefits under life insurance contracts.
B.
13
LB
05101/01
GL1101-9,7
EFFECT ON AMOUNT OF LIFE INSURANCE, "Remaining life Insurance" means the amount of Personal life Insurance
which remains in force on the Insured Person's life after a living Benefit is paid. The Remaining life Insurance will equal:
(1) the Insured Person's amount of Personal Life Insurance which was used to determine the living Benefit
(A or B on the prior page); minus
(2) any percentage by which the Insured Person's coverage is scheduled to reduce, due to age; if the
reduction occurs more than 12 months after the Living Benefit is paid, and while he or she is still living;
minus
(3) the amount of the Living Benefit withdrawn (including the early withdrawal fee retained by the
Company),
CONDITIONS, If the Insured Person exercises the Conversion Privilege after a living Benefit is paid, the amount of the
conversion policy will not exceed the amount of his or her Remaining life Insurance. If the Insured Person has Accidental
Death and Dismemberment benefits under this Policy, the Principal Sum will not be affected by the payment of a living
Benefit.
EFFECT ON DEATH BENEFIT, When the Insured Person dies after receiving a Living Benefit, the amount of Remaining
Life Insurance in force on the date of death will be paid as a Death Benefit. Payment will be made in accord with the
Beneficiary section of this Policy.
If the Insured Person dies after applying for a Living Benefit, but before the Company has made payment; then the request
will be void and no Living Benefit will be paid, The amount of Personal Life Insurance in force on the date of death will be
paid in accord with the Beneficiary section of this Policy.
EFFECT ON TAXES AND GOVERNMENT BENEFITS. Any Living Benefit amount withdrawn m~y be taxable income to
the Insured Person, Receipt of the Living Benefit may also affect the Insured Person's eligibility for Medicaid,
Supplemental Security Income and other government benefits, The Insured Person should consult his or her own tax and
legal advisor before applying for a Living Benefit. The Company is not responsible for any tax owed or government benefit
denied, as a result of the living Benefit payment.
LIMITATIONS. No Living Benefit will be paid:
(1) if this Policy does not include an Extension of Death Benefit provision;
(2) if any required premium is due and unpaid;
(3) on any Dependent Life Insurance under this Policy;
(4) on any conversion policy purchased in accord with the Conversion Privilege;
(5) without the written approval of the bankruptcy court, if the Insured Person has filed for bankruptcy;
(6) without the written consent of the beneficiary, if the Insured Person has named an irrevocable
beneficiary;
(7) without the written consent of the assignee, if the Insured Person has assigned his or her rights under
this Policy;
(8) if any part of the Personal Life Insurance must be paid to the Insured Person's child, spouse or former
spouse; pursuant to a legal separation agreement, divorce decree, child support order or other court
order;
(9) if the Insured Person is Terminally III due to a suicide attempt, while sane or insane; or due to an
intentionally self-inflicted injury;
(10) if a government agency requires the Insured Person to use the Living Benefit to apply for, receive or
continue a government benefit or entitlement; or
(11) if the Insured Person has previously received a Living Benefit under this Policy.
14
LB
05101/01
GL1101-9.7
"
CONVERSION PRIVILEGE. CONVERSION BENEFITS
GENERAL BENEFIT. An individual life policy, known as a conversion policy, may be purchased from the Company
vithout evidence of insurability, if all or part of anyone's life insurance, provided by this Policy, terminates for any reason
except:
(1 )
(2)
termination or amendment of the Policy; or
the Insured Person's request for:
(a) termination of insurance; or
(b) cancellation of payroll deduction.
To purchase a conversion policy, application and payment of the first premium must be made within 31 days after the life
insurance is terminated.
Any policy issued under the General Conversion Benefit will:
(1) be for an amount not to exceed the amount of the life insurance which was terminated;
(2) be on any form (except term) then issued by the Company at the age and amount for which application
is made;
(3) be issued at the Insured Person's age at nearest birthday;
(4) be issued without disability or other supplemental benefits; and
(5) require premiums based on the class of risk to which the person then belongs,
CONVERSION BENEFIT-POLICY TERMINATION OR AMENDMENT. A conversion policy also may be purchased from
the Company if:
(1) all or a part of anyone's insurance terminates due to amendment or termination of this Policy; and
(2) that person has been covered continuously under this Policy for at least five years.
Any conversion policy issued due to Policy termination or amendment will be subject to the same conditions as a policy
issued under the General Conversion Benefit except its amount may not exceed the lesser of:
(1) $10,000; or
(2) the Amount of Life Insurance which terminates less the amount of any group life insurance for which the
Insured Person becomes eligible within 31 days after the termination.
PROVISIONS APPLICABLE TO ALL CONVERSION POLICIES
..:FFECTIVE DATES. The coverage provided by a conversion policy issued under this Section will be effective on the
later of:
(1) its date of issue; or
(2) 31 days after the date on which the person's life insurance terminated.
DEATH DURING CONVERSION PERIOD. The Company will pay a death benefit under this Policy equal to the amount
of the life insurance which could have been converted, if the person:
(1) was entitled to purchase a conversion policy; and
(2) dies within the 31 day conversion period,
This death benefit will be paid even if no one applied for the conversion policy. If the first premium was paid for the
conversion policy, the amount of the premium will be refunded and the conversion policy will be void,
NOTICE OF CONVERSION PRIVilEGES-INSURED PERSONS. When an Insured Person's Personal Insurance
terminates, written notice of the right to convert will be:
(1) given personally to the Insured Person;
(2) mailed by the Group Policyholder to the Insured Person at his last known address; or
(3) mailed by the Company to the Insured Person at his last known address as furnished by the Group
Policyholder.
An additional period in which to convert will be granted if this written notice is not given to the Insured Person at least 15
days before the end of the 31 day conversion period. Any such extension of the conversion period will expire on the
earliest of:
(1) 15 days after the Insured Person is given the written notice; or
(2) 60 days after the end of the 31 day conversion period even if the Insured Person is never given such
notice,
No death benefit will be payable under this Policy after the 31 day conversion period has expired even though the right to
convert may be extended,
GL1101-10 DEP,
15
05101/01
..,'
DEPENDENTS LIFE INSURANCE
BENEFIT. Upon receipt of satisfactory proof of a Dependent's death while insured under this Policy, the Company will pay the
amount of the Dependents Life Insurance in effect on the date of such death. This amount is shown in the Schedule of Insurance.
The death benefIt will be paid:
( 1) to the Insured Person; or
(2) if the Insured Person fails to survive the Dependent, to the Insured Person's BenefIciary or according to the
Facility of Payment Section.
DEPENDENT. A Dependent means a person who meets the defmition of a dependent of the Insured Person under the provision of
the U.S. Internal Revenue Code; and is an Insured Person's:
(1) spouse who is not legally separated from the Insured Person;
(2) unmarried child at least 14 days but less than 19 years of age;
(3) unmarried child less than 23 years of age, if attending an accredited educational institution for the minimum
credit hours required to maintain full-time student status there; or
(4) unmarried child who is totally and permanently disabled and who became so disabled prior to reaching 19 years
of age.
A legally adopted child is considered the Insured Person's child from the date of placement in the Insured Person's home for an
agency adoption; or from the date the adoption petition is fIled, if later, for a private adoption.
In addition to naturally born and legally adopted children, the word "child" includes an Insured Person's stepchild or foster child;
provided the child resides in the Insured Person's household and is dependent on the Insured Person for principal support.
The term Dependent does not include anyone serving in the armed forces of any state or country; except for duty of 30 days or less for
training in the Reserves or National Guard.
ELIGIBILITY. An Insured Person becomes eligible for Dependents Life Insurance on the latest of:
(1) the date the Insured Person becomes eligible for Personal Insurance;
(2) the effective date of this Section; or
(3) the date the Insured Person fIrst acquires a Dependent.
SFFECTIVE DATES, An Insured Person's Dependents Life Insurance will become effective on the latest of the following dates:
(1) the date the Insured Person becomes eligible for Dependents Life Insurance;
(2) the date the Insured Person makes written application for Dependents Life Insurance and signs a payroll
deduction order; and
(3) the date the Company approves any required evidence of insurability on all the Insured Person's Dependents.
If an Insured Person acquires a new Dependent while insured for Dependents Life Insurance, insurance for that Dependent will take
effect on the date the Dependent is acquired.
If a Dependent is confmed in a hospital on the date his or her Dependents Life Insurance would otherwise take effect, then
Dependents Life Insurance for that Dependent will not take effect until ten days after fmal discharge from the hospital.
16
B - wlo Suicide Exclusion
05101/01
GLllOl-1lB 97
. ".
EVIDENCE OF INSURABILITY, Each Insured Person's Dependent must submit evidence of insurability satisfactory to
the Company if the Insured Person:
(1) makes application for Dependents Insurance more than 31 days after the date such Insured Person
becomes eligible for Dependents Insurance; or
(2) elects to be insured for Dependents Insurance after such Insured Person had requested:
(a) termination of the Dependents Insurance; or
(b) cancellation of the payroll deduction order; or
(3) makes application for Dependents Insurance after it has automatically terminated, due to failure to pay
premium by the end of the grace period.
INDIVIDUAL TERMINATION OF DEPENDENT INSURANCE. An Insured Person's Dependents Insurance will cease for
all of the Insured Person's Dependents on the earliest of:
(1) the date the Insured Person's Personal Insurance terminates;
(2) the date Dependent Insurance is discontinued under this Policy;
(3) the date the Insured Person ceases to be in a class of employees eligible for Dependent Insurance;
(4) the date the Insured Person requests that the Dependent Insurance be terminated; or
(5) the last day of the premium paying period for which the Insured Person has made any required
contribution toward the cost of the Dependent Insurance,
Dependents Insurance on a particular Dependent will cease on the earliest of:
(1) the date he or she ceases to be a Dependent as defmed in this Policy;
(2) the date he or she becomes covered under this Policy as an Insured Person; or ,
(3) the date he or she enters the armed forces of any state or country; except for duty of 30 days or less in the
Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any
unearned premium.)
MISSTATEMENT OF AGE. If the age of a Dependent has been misstated, premiums will be subject to an equitable adjustment. If
the amount of benefIt is dependent upon age, the benefIt will be that which would have been payable based upon the Dependent's
~orrect age,
ASSIGNMENT. Dependents Insurance may not be assigned.
INCONTESTABILITY. Except for non-payment of premiums, the Company may not contest the validity of this Policy as to any
Dependent, after it has been in force for two years during the lifetime of that Dependent. This clause will not affect the Company's
right to contest claims made for accidental death, or dismemberment benefIts.
GL1101-12 97
17
05101/01
t-,. .
CLAIMS PROCEDURES
FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
~OTE: If this Policy Includes an Extension of Death Benefit or a Living Benefit (also called an Accelerated Death
Benefit), please refer to that section for special claim procedures.
NOTICE OF CLAIM. Written notice of claim must be given within 20 days after the loss occurs. The notice must be sent
to the Company's Home Office, It should include:
(1) the Insured Person's name and address; and
(2) the number of this Policy.
If this is not possible, written notice must be given as soon as it is reasonably possible.
CLAIM FORMS. When notice of claim is received, the Company will send claim forms for filing the required proof. If the
Company does not send the forms within 15 days; then the Insured Person or Beneficiary may send the Company written
proof of claim in a letter stating the nature, date and cause of the loss.
PROOF OF CLAIM, The Company must be given written proof of claim within 90 days after the date of the loss. If it was
not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this
reason; provided the proof is filed as soon as reasonably possible. In any event, proof of claim must be given no later
than one year from such time. These time limits will not apply while the Insured Person or Beneficiary lacks legal
capacity, however.
Proof of claim must be provided at the Insured Person's or Beneficiary's own expense. It must show the nature, date and
cause of the loss. Documentation must include:
(1) a certified copy of the death certificate, for proof of death;
(2) a copy of any police report, for proof of accidental death or dismemberment;
(3) a signed authorization for the Company to obtain more information; and
(4) any other items the Company may reasonably require in support of the claim,
EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may:
(1) have the Insured Person examined by a Physician of the Company's choice, as often as reasonably
required; and
(2) deny or suspend benefits if the Insured Person fails to attend an exam, without good cause; or fails to
cooperate with the examiner.
In case of death, the Company may also have an autopsy done, where it is not forbidden by law. Any such exam or
autopsy will be at the Company's expense,
TIME OF PAYMENT OF CLAIMS. Death or dismemberment benefits payable under this Policy will be paid as soon as
the Company receives acceptable proof of claim.
In any event, the Company shall payor deny any claim within 120 days after receiving it. If payment is not sent by the
120th day, any overdue payment of accidental death or dismemberment benefits will accrue simple interest at the rate of
10% per year.
TO WHOM PAYABLE. Any benefits payable for the Insured Person's death will be paid in accord with the Beneficiary,
Facility of Payment and Settlement Options sections of this Policy. If this Policy includes Dependent Life Insurance, any
benefits payable for an insured Dependent's death will be paid to:
(1) the Insured Person, if he or she survives that Dependent; or
(2) the Insured Person's Beneficiary, or in accord with the Facility of Payment section; if the Insured Person
does not survive that Dependent.
If this Policy includes Accidental Death and Dismemberment Benefits; then any benefit, other than the Insured Person's
death benefit, will be paid to the Insured Person,
NOTICE OF CLAIM DECISION. Within a reasonable time after receiving proof of claim, the Company will send the
Insured Person or Beneficiary a written notice of their claim decision. If the Company denies any part of the claim, the
written notice will:
(1) explain the reason for the denial under the terms of this Policy; and
(2) inform the Insured Person or Beneficiary of the right to a review of the Company's decision,
If the Insured Person or Beneficiary does not receive a written decision within 90 days after the Company receives the
;Iaim; then there is a right to an immediate review, as if the claim was denied,
18
LlADD
05101/01
GL1101-13A FL
. ." .
CLAIMS PROCEDURES. CONTINUED
REVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Person or Beneficiary may request a
;Iaim review by sending the Company a written request, along with any written comments or other items to support the
claim. The Insured Person or Beneficiary may review certain non-privileged information relating to the request for review.
The Company will review the claim and send the Insured Person or Beneficiary a written notice of their decision within 60
days after receiving the request for review; or within 120 days, if special circumstances require an extension. The notice
will state the reasons for the Company's decision under the terms of this Policy.
RIGHT OF RECOVERY. If benefits have been overpaid on any claim, full reimbursement to the Company is required
within 60 days, If reimbursement is not made, the Company has the right to:
(1) reduce future benefits until full reimbursement is made; and
(2) recover such overpayments from the Insured Person or his or her Beneficiary or estate,
Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or
any other reason,
LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of
claim has been given, No legal action may be brought after the expiration of the applicable statute of limitations, running
from the time written proof of claim must be given.
COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically reserves to the
Group Policyholder or Employer, the Company has the authority to manage this Policy, to administer claims, to interpret
Policy provisions, and to resolve questions arising under this Policy, The Company's authority includes (but is not limited
to) the right to:
(1) establish and enforce procedures for administering this Policy and claims under it;
(2) determine Employees' eligibility for insurance and entitlement to benefits;
(3) determine what information the Company reasonably requires to make such decisions; and
(4). resolve all matters when a claim review is requested.
my decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured
Person's or Beneficiary's right to request a state insurance department review or to bring legal action,
19
UADD
05101/01
GLllOl-13A FL
,.
. -. ~
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
BENEFIT. If an Insured Person sustains an accidental bodily injury, and the injury directly causes one of the following
osses within 90 days of the date of that injury; then the Company will pay the benefit listed:
LOSS
BENEFIT
Loss of one hand by severance at
or above the wrist
One-half the Principal Sum
Loss of one foot by severance at
or above the ankle
One-half the Principal Sum
Irrecoverable loss of the sight
in one eye
One-half the Principal Sum
Any combination of two or more
of the losses listed above
Principal Sum
Loss of life
Principal Sum
The total benefit for all losses resulting from the same accident may not exceed the Principal Sum, The Principal Sum for
the Insured Person's classification is shown in the Schedule of Insurance, '
TO WHOM PAYABLE. Benefits for loss of life will be paid in accord with the Beneficiary Section. All other benefits will be
paid to the Insured Person.
LIMITATIONS. Benefits are not payable for any loss to which a contributing cause is:
(1) intentional self-inflicted injury or self-destruction;
(2) disease, bodily or mental infirmity, or medical or surgical treatment of these;
(3) the Insured Person's participation in a riot;
(4) duty as a member of any military, naval or air force;
(5) war or any act of war, declared or undeclared;
(6) the Insured Person's participation in the commission of a felony;
(7) use of drugs; except when prescribed by a Physician;
(8) voluntary inhalation of gas, including carbon monoxide;
(9) travel or flight in any aircraft, including balloons and gliders; except as a fare paying passenger on a
regularly scheduled flight; or
(10) the Insured Person's driving a vehicle while having an alcohol concentration of .10 grams of alcohol or
more per 100 milliliters of blood.
20
OCC.
05101/01
GLllOI-1490
"*. .: I. ...'"
AMENDMENT TO BE A TIACHED TO AND MADE PART OF GROUP POLICY NO.: 000011100388
ISSUED TO: Florida - Life Specimen
The Policy is amended by the addition of the following provisions.
PRIOR INSURANCE CREDIT UPON TRANSFER OF
LIFE INSURANCE CARRIERS
This provision prevents loss of life insurance coverage for an Insured Person, which could otherwise occur solely because of a transfer
of insurance carriers. This Policy will provide the following Prior Insurance Credit, when it replaces a prior plan,
"Prior Plan" means a prior carrier's group life insurance policy, which this Policy replaced within 1 day of the prior plan's termination
date,
FAILURE TO SATISFY ACTIVE WORK RULE, Subject to payment of premiums, this Policy will provide life coverage for a
Person who:
(1) was insured under the prior plan on its termination date;
(2) was otherwise eligible under this Policy; but was not Actively-At-Work due to Injury or Sickness on its Effective
Date;
(3) is not entitled to any extension of life insurance under the prior plan; and
(4) is not Totally Disabled (as dermed in the Extension of Death BenefIt section of this Policy) on the date this Policy
takes effect. .
AMOUNT OF LIFE INSURANCE, Until the Person satisfIes this Policy's Active Work rule, the amount of his or her group life
insurance under this Policy will not exceed the amount for which the Person was insured under the prior plan on its termination date.
This Amendment takes effect on the effective date of coverage under this Policy. In all other respects, this Policy rertlains the same.
Jefferson Pilot Financial Insurance Company
~~
Officer of the Company
21
Prior Ins. Cred. - Life
05101/01
GL1101-AMEND. PCl
.,. t.
IJ1
JEFFERSON PILOT
FINANCIAL
Jefferson Pilot Financial Insurance Company
8801 Indian Hills Drive, Omaha NE 68114-4066
(402) 361-7300 A Stock Company
In Consideration of the application for this Policy made by
Florida - L TO Specimen
(herein called the Policyholder)
and the payment of all premiums when due, Jefferson Pilot Financial Insurance Company agrees to make
the payments provided in this Policy to the person or persons entitled to them.
Policy No.
xxxxxxxxxxxx
Policy Effective Date: January 1, 2001
Monthly Premium: ,XX of Total Covered Payroll per Month
The above rate is guaranteed until January 1, 2002, unless any of the Policy's terms are changed.
Policy Anniversaries will be annually beginning on: January 1,2002
The first premium is due on the Policy's Effective Date, and subsequent premiums are due on February 1,
2001, and on the same day of each month thereafter.
The Policy is delivered in the state of Florida and subject to the laws of that jurisdiction.
Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in Omaha,
Nebraska this 18th day of May, 2001,
~~ ~~
Chief Executive Officer
Secretary
GROUP LONG TERM DISABILITY INSURANCE POLICY
GL3001-L TD-1
Policy Face Page
01/01/01
TABLE OF CONTENTS
Schedule of BenefIts....., ,....... ,...,....,....,.... ......,..,...... .............,'.... ........,..,....,.., .............,.., .......,..,.. ............ 3
Defmitions ..... .......... .... ........ ..... ..., ... ......, ........"""",. ,.,.,. ,. ."..., ..... ..... ... ,.. ,.,..""" ,., ,., ,." ..". ,.. ..,. ,..", ,.." ,.,." 4
General Provisions,.........,.,..,.."...."..,.,......,...,.,.""..,.,.,..,.,.,...".,....,.",.."...""...,.."..,..".",.."..,.,.. .,...,."",. 9
Claims Procedures.".,........,........,..".....".....,..,.."........,........,.......,..""..,.,.",.,...............,.....,..",.",. ...,.,.,... 11
Eligibility..,.......................,....,.......,.......""",.,.......,....,.......,....,....".,.",.,...".."""",....,. ...."..,...".,."..,.,.,... 13
Effective Dates .."",.".,.",.""".".."."",."",.,..",.".,..,...........,.......,...."..........,......,.........,....,....,..... ....,....... 13
Individual Termination...., ...., :...,....,.... ....,.........., ......, ............. ..............., ..............,... ..............,....,...,.., ..... 15
Policy Termination ,.., ,.".." ,...,.." ",...,.,., ,.,.,...,.,., ,.", ". .."" '" ",... "., ...."., ...,.......,.. ..."."" ,.." ,., ,..,., "...." ,..." 16
Conversion Privilege ............. ,.,..,........,.. ...,.... ............ ,.....,.., ..", ".., ..,..,.. ". ... ..... ....... .....,.. ,.,......,.,........ ..... 17
Premiums and Premium Rates..............,...........,............................................,....,..,..,....",.......,................. 18
Total Disability Monthly BenefIt....,......... ..................., .......,..,.. ....... .............. ...... ......... ......., ......... ....., ..... 19
Partial Disability Monthly BenefIt." ..,.. ,... ......,...,., ,.,., "... "... ,.,., ,." ,., ,.,., ,..,.,..".,., ,., .., ,...... ,... ,., .... ,. ,.., ..,..... 20
Other Income BenefIts .... .., .., ......., ,.......,.,..,..." "..,.,.... "........"." ",.,.. ..,........ ......,....", ,.,..,. ,.....,.....,... ,........ 22
Recurrent Disability.."..,.,...,.,."'.."'....".,............................,.,..,...,..,.,...,......,.......,....................""'. """..... 23
Exclusions..........""."."..".,.,..,.,..,.,..,.....,........,......................,........,........................,.".,. .".".".....,.."........ 24
SpecifIed Injuries or Sicknesses Limitation..,..............,.........,.........................................,......"......."........ 25
Voluntary Vocational Rehabilitation BenefIt Provision............................................................................ 26
Reasonable Accommodation BenefIt ......... "......., ,...,.. ...... ".........,., ,.... ...... .......... ...... ,..", .,., ,.,..,..", ....,. .,., 27
Prior Insurance Credit Upon Transfer ofInsurance Carriers..................................................................... 28
Family Income BenefIt .... .......... .., ,.... ,...,.,., ,......... ....... ................... ........... ......." "."" "...", ,. ,........,.,....... ... 29
GL3001-LTD-2
2
01/01/01
Florida - Life Specimen
000011100264
SCHEDULE OF BENEFITS
ELIGIBLE CLASS means: Class 1
All Full-Time Employees
MINIMUM HOURS PER WEEK: 30
BENEFIT PERCENTAGE: 60%
MAXIMUM MONTHLY BENEFIT: $5,000
MINIMUM MONTHLY BENEFIT: $50
Benefits for PRE-EXISTING CONDITIONS will be subject to the Pre-Existing Condition Exclusion on the Exclusion page.
ELIMINATION PERIOD: 90 days of Disability due to the same or a related Sickness or Injury, which must be accumulated
within a 180 day period,
MAXIMUM BENEFIT PERIOD (For Sickness or Injury): The Insured Employee's Social Security Normal Retirement Age,
or the Maximum Benefit Period shown below (whichever is later).
Age at Disability
Less than Age 60
60
61
62
63
64
65
66
67
68
69 and Over
Maximum Benefit Period
To Age 65
60 months
48 months
42 months
36 months
30 months
24 months
21 months
18 months
15 months
12 months
OWN OCCUPATION PERIOD means a period beginning at the end of the Elimination Period and ending 24 months later
for Insured Employees,
WAITING PERIOD:
30 days of continuous Active Work (For date insurance begins, refer to "Effective Dates"
section)
CONTRIBUTIONS:
Insured employees are not required to contribute to the cost of the coverage.
GL3001-L TD-SB
3
01/01/01
"
DEFINITIONS
As used throughout this Policy, the following terms shall have the meanings indicated below, Other parts of this Policy
ontain definitions specific to those provisions,
ACTIVE WORK or ACTIVELY -AT -WORK means an Employee's full-time performance of all main duties of such
Employee's occupation at:
1. the Employer's usual place of business; or
2. any other business location to which the Employer requires the Employee to travel.
Unless Disabled on the prior workday or on the day of absence, an Employee will be considered Actively at Work on the
following days:
1, a Saturday, Sunday or holiday which is not a scheduled workday;
2. a paid vacation day or other scheduled or unscheduled non-workday; or
3. an excused or emergency leave of absence (except a medical leave) of 30 days or less,
ANNUAL SALARY means the Insured Employee's Basic Monthly Earnings or Predisability Income multiplied by 12.
BASIC MONTHLY EARNINGS or PREDISABILITY INCOME means the Insured Employee's average monthly base salary or
hourly pay from the Employer before taxes on the determination date. The determination date is the last day worked just prior to
the date the Disability begins,
It also includes:
1. commissions averaged over the 12 months just prior to the determination date or over the actual period of
employment with the Employer just prior to that date, if shorter.
It does not include bonuses, overtime pay, or any other extra compensation. It does not include income from a source other than
the Employer. It will not exceed the amount shown in the Employer's fmancial records, the amount for which premium has been
paid, or the maximum covered earnings permitted by this Policy; whichever is less.
;OMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home Office address is
8801 Indian Hills Drive, Omaha, Nebraska 68114.
GL3001-LID-398
4
01/01/01
DEFINITIONS
(continued)
AYor DATE means the period of time which begins at 12:01 a.m, and ends at 12:00 midnight, standard time, at the
r'olicyholder's place of business, When used with regard to effective dates, it means 12:01 a,m. When used with regard
to termination dates, it means 12:00 midnight.
DISABLED or DISABILITY means Totally Disabled andlor Partially Disabled,
DISABILITY BENEFIT when used with the term Retirement Plan, means a benefit which:
1, is payable under a Retirement Plan due to disability as defined in that plan; and
2. does not reduce the benefits which would have been paid as Retirement Benefits at the normal
retirement age under the plan if the disability had not occurred,
If the payment of the benefit does cause such a reduction, the benefit will be deemed a Retirement Benefit as defined in
this Policy.
ELIGIBILITY WAITING PERIOD means the period of time that:
1. begins with an Employee's most recent date of employment with the Employer; and
2. ends on the day prior to the day such Employee is eligible for coverage under this Policy.
ELIMINATION PERIOD means the number of days of Disability during which no benefit is payable. The Elimination
Period is shown in the Schedule of Benefits, It applies as follows.
1. The Elimination Period:
(a) begins on the first day of Disability; and
(b) is satisfied when the required number of days is accumulated within a period which does
not exceed two times the Elimination Period.
During a period of Disability, the Insured Employee may return to full-time work, at his or her
own or any other occupation, for an accumulated number of days not to exceed the Elimination
Period,
2. Only days of Disability due to the same or a related Sickness or Injury will count towards the Elimination
Period. Days on which the Insured Employee returns to full-time work will not count towards the
Elimination Period.
EMPLOYEE means a person:
1. whose employment with the Employer is:
(a) on a regular full-time basis;
(b) the person's principal occupation; and
(c) for regular wage or salary;
2. who is regularly scheduled to work at such occupation at least the minimum number of hours shown in the
Schedule of BenefIts; and
3. who is a member of an Eligible Class which is eligible for coverage under this Policy;
4. who is not a temporary or seasonal employee; and
5, who is a citizen of the United States or legally works in the United States.
EMPLOYER means the Policyholder and includes any division, subsidiary or affIliated company named in the Application.
EVIDENCE OF INSURABILITY means a statement of proof of an Employee's medical history. The Company uses this to
determine his or her acceptance for insurance, or for an increased amount of insurance, Such proof will be provided at the
Employee's own expense.
5
Residual Partial
01/01/01
GL3001-LTD-3A 98
DEFINITIONS
(continued)
:AMIL Y OR MEDICAL LEAVE means a leave of absence which is approved in writing by the Employer; and which is
subject to:
1. the federal Family and Medical Leave Act of 1993, and any amendments to it; or
2, any similar state law requiring the Employer to grant family or medical leaves,
INSURED EMPLOYEE means an Employee for whom Policy coverage is in effect.
INJURY means bodily injury which is caused by and results directly from an accident, independently of all other causes.
For purposes of determining benefits under this Policy, a Disability will be considered due to an Injury only if:
1, the Disability begins within 90 days after the Injury; or
2. the Injury occurred while the Employee was insured under this Policy.
The term "Injury" shall not include any:
1. condition to which a physical or mental sickness, the natural progression of a sickness, or the treatment
of a sickness is a substantial contributing factor (based upon the preponderance of medical evidence);
2. condition caused solely by emotional stress or mental trauma;
3. repetitive trauma condition which results from repetitious, physically traumatic activities that occur over
time;
4, pregnancy; except for complications which result from a covered Injury;
5.' condition caused by infection; except pyogenic bacterial infection of a covered Injury; or
6, condition caused by medical or surgical treatment; except when the treatment is needed solely because
of a covered Injury.
GL3001-LID-498
6
01/01101
DEFINITIONS
(continued)
\1AIN DUTIES or MATERIAL AND SUBSTANTIAL DUTIES means those job duties which:
1, are normally required to perform the Insured Person's regular occupation; and
2. cannot reasonably be modifIed or omitted,
It includes those main duties as performed in the national workforce; not as performed for a certain frrm or at a certain work site,
MEDICALLY APPROPRIATE TREATMENT means diagnostic services, consultation, care or services which are consistent with
the symptoms or diagnosis causing the Insured Employee's Disability, Such treatment must be rendered:
1. by a Physician whose license and any specialty are consistent with the disabling condition; and
2, according to generally accepted, professionally recognized standards of medical practice,
MONTHLY BENEFIT means the amount payable monthly by the Company to the Insured Employee who is Totally or Partially
Disabled.
OWN OCCUPATION PERIOD means a period as shown in the Schedule of BenefIts.
P ARTIALL Y DISABLED or PARTIAL DISABILITY shall be as defmed in the Partial Disability Monthly BenefIt sections,
PARTIAL DISABILITY EMPLOYMENT means the Insured Employee is working at his or her own or any other occupation; but
because of a Partial Disability:
1,' the Insured Employee's hours or production is reduced;
2, one or more main duties of the job are reassigned; or
3. the Insured Employee is working in a lower-paid occupation.
His or her current earnings must be at least 20% of Predisability Income, and may not exceed the percentage specifIed in the Partial
Disability BenefIt section.
PHYSICIAN means:
1. a legally qualifIed medical doctor who is licensed to practice medicine, to prescribe and administer drugs, or to
perform surgery; or
2, any other duly licensed medical practitioner who is deemed by state law to be the same as a legally qualifIed
medical doctor.
The medical doctor or other medical practitioner must be acting within the scope of his or her license; and must be qualifIed to
provide medically appropriate treatment for the Insured Employee's disabling condition.
Physician does not include the Insured Employee or a relative of the Insured Employee receiving treatment. (Relatives include the
Insured Employee's spouse, siblings, parents, children and grandparents; and his or her spouse's relatives of like degree.)
POLICY means this Group Long Term Disability Insurance Policy issued by the Company to the Policyholder.
POLICYHOLDER means the person, individual, frrm, trust or other organization as shown on the Face Page of this Policy,
PREDISABILITY INCOME - See Basic Monthly Earnings.
GL3001-LlD-598
7
01/01/01
DEFINITIONS
(continued)
REGULAR CARE OF A PHYSICIAN or REGULAR ATTENDANCE OF A PHYSICIAN means the Insured Employee:
1. personally visits a Physician, as often as medically required according to standard medical practice to effectively
manage and treat his or her disabling condition; and
2. receives medically appropriate treatment, by a Physician whose license and any specialty are consistent with the
disabling condition.
REGULAR OCCUPATION or OWN OCCUPATION means the occupation, trade or profession:
1. in which the Insured Employee was employed with the Employer prior to Disability; and
2, which was his or her primary source of earned income prior to Disability.
It includes any work in the same occupation for payor profIt; whether such work is with the Employer, with some other fIrm or on a
self-employed basis, It includes the main duties of that occupation as performed in the national workforce; not as performed for a
certain fIrm or at a certain work site.
RETIREMENT BENEFIT when used with the term Retirement Plan, means a benefIt which:
1. is payable under a Retirement Plan either in a lump sum or in the form of periodic payments;
2. does not represent contributions made by an Employee (payments which represent Employee contributions are
deemed to be received over the Employee's expected remaining life regardless of when such payments are
actually received); and
3. is payable upon:
(a) early or normal retirement; or
(b) disability, if the payment does reduce the benefIt which would have been paid at the normal
retirement age under the plan, if disability had not occurred.
RETIREMENT PLAN means a defmed benefIt or defmed contribution plan which provides Retirement BenefIts to Employees and
which is not funded wholly by Employee contributions. The term shall not include any 401 (k), profIt-sharing or thrift plan; informal
salary continuance plan; individual retirement account (IRA); tax sheltered annuity (TSA); stock ownership plan; or a non-qualifIed
plan of deferred compensation. An Employer's Retirement Plan is deemed to include any Retirement Plan:
1. which is part of any federal, state, county, municipal or association retirement system; and
2. for which the Employee is eligible as a result of employment with the Employer.
SICK LEAVE or ANY SALARY CONTINUANCE PLAN means a plan which:
1. is established and maintained by the Employer for the benefIt of Insured Employees; and
2. continues payment of all or part of an Insured Employee's Predisability Income for a specifIed period after he or
she becomes Disabled.
It does not include compensation the Employer pays an Insured Employee for work actually performed during a Disability,
SICKNESS means illness, pregnancy or disease.
For a licensed health care practitioner, Sickness includes testing positive on an HIV (human immunodefIciency virus) test; but only
when a state licensing board restricts the Insured Employee's ability to perform his or her profession, as a result of such test. In that
case:
1.
2.
a Disability will be deemed to commence on the date of the state licensing board's action; and
the HIV positive status will be deemed Total Disability, if the state licensing board's action results in a loss of at
least 80% of the Insured Employee's predisability income,
TOTAL COVERED PAYROLL means the total amount of Basic Monthly Earnings for all Employees insured under this Policy.
TOTAL DISABILITY or TOTALLY DISABLED shall be defmed in the Total Disability Monthly BenefIt section.
GL3001-L TD-6 98 FL
8
01/01/01
GENERAL PROVISIONS
ENTIRE CONTRACT, The entire contract between the parties shall consist of:
1. this Policy and the Application (a copy of which is attached);
2. the Employer's Participation Agreement, if any; and
3, the Insured Employee's enrollment forms, if any,
In the absence of fraud, all statements made by the Policyholder and by Insured Employees are representations and not warranties.
No statement made by an Insured Employee will be used to contest the coverage provided by this Policy; unless a copy of the
statement has been furnished to such Insured Employee.
AUTHORITY TO MAKE OR AMEND CONTRACT. Only a Company Officer located in the Company's Home Office has the
authority to:
1, determine the insurability of a group or any individual within a group;
2. make a contract in the Company's name;
3. amend or waive any provision of this Policy; or
4, extend the time for payment of any premium,
No change in this Policy will be valid; unless it is made in writing and signed by such a Company Officer.
INCONTESTABILITY, Except for the non-payment of premiums or fraud, the Company may not contest the validity of this Policy
as to any Insured Employee, after it has been in force for two years during his or her lifetime.
RESCISSION, The Company has the right to rescind any insurance for which evidence of insurability was .required, if:
1. an Insured Employee incurs a claim during the fIrst two years of coverage; and
2. the Company discovers that the Insured Employee made a material misrepresentation on his or her enrollment
form.
A material misrepresentation is an incomplete or untrue statement that caused the Company to issue coverage which it would have
disapproved, had it known the truth, To rescind means to cancel insurance back to its effective date. In that event, the Company will
refund all premium paid for the rescinded insurance, less any benefIts paid for the Insured Employee's Disability. The Company
reserves the right to recover any claims paid in excess of such premiums,
NON-PARTICIPATION. This is a non-participating Policy, It will not share in the divisible surplus of the Company.
INFORMATION TO BE FURNISHED. The Employer is required to furnish the Company any information needed to administer this
Policy, including:
1. information about Employees who become eligible for insurance; whose amounts of coverage change; and whose
eligibility or coverage ends;
2, occupational information and other facts that may be needed to manage a claim; and
3, any other information that the Company may reasonably require.
The Company may inspect any of the Employer's records which relate to this Policy, at any reasonable time,
Clerical error by the Employer:
1, will not affect insurance which otherwise would be in effect; and
2, will not continue insurance which otherwise would be terminated.
Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of
unearned premium, the amount of the return will be limited to the 12-month period which precedes the date the Company receives
proof that such an adjustment should be made.
GL3001-LTD-798
9
01/01/01
GENERAL PROVISIONS
(continued)
IISST A TEMENTS OF F AcrS. If relevant facts about any person were misstated:
1. a fair adjustment of the premium will be made; and
2. the true facts will decide if and in what amount insurance is valid under this Policy,
If an Insured Employee's age has been misstated; then any benefIts shall be in the amount the paid premium would have purchased at
the correct age,
Acrs OF THE POLICYHOLDER. In administering this Policy, the Policyholder must:
1. treat Employees the same in like situations; and
2. allow the Company, without inquiry, to rely on its acts.
POLICYHOLDER'S AGENCY. For all purposes of this Policy, the Policyholder acts on its own behalf or as Agent of the Employee.
Under no circumstances will the Policyholder be deemed the Agent of the Company,
COMPANY'S DISCRETIONARY AUTHORITY, Except for those functions which this Policy specifIcally reserves to the
Policyholder or Employer, the Company has sole authority to manage this Policy, to administer claims, to interpret Policy provisions,
and to resolve questions arising under this Policy. The Company's authority includes (but is not limited to) the right to:
1, establish and enforce procedures for administering this Policy and claims under it;
2. determine Employees' eligibility for insurance and entitlement to benefits;
3, determine what information the Company reasonably requires to make such decisions; and
4. resolve all matters when a claim review is requested.
Any decision the Company makes in the exercise of its authority shall be conclusive and binding.
CERTIFICATES. The Employer will be furnished with individual CertifIcates for delivery to each Insured Employee. These
CertifIcates summarize the benefIts provided by this Policy. If there is a conflict between this Policy and the CertifIcate, this Policy
will control.
CONFORMITY WITH STATE STATUTES, If, on its effective date, any provision of this Policy conflicts with any applicable law;
then the provision will be deemed to conform to the minimum requirements of the law.
CURRENCY. In administering this Policy, all Predisability Income will be expressed in U.S, dollars; and all premium and benefIt
amounts must be paid in u.s. dollars,
WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE. This Policy does not replace or provide benefIts required
by Workers' Compensation laws or any state disability insurance plan laws,
ASSIGNMENT. The rights and benefIts under this Policy may not be assigned.
GL3001-LTD-798
10
01/01/01
CLAIMS PROCEDURES
NOTICE OF CLAIM, Written notice of claim:
1. may be given at any time during the Elimination Period; and
2. must be given by the 20th day after a covered period of Disability ends.
The notice must be sent to the Company's Home OffIce, It should include:
1. the Insured Employee's name and address; and
2. the number of this Policy,
If this is not possible, written notice must be given as soon as it is reasonably possible,
CLAIM FORMS. When notice of claim is received, the Company will send claim forms to the Insured Employee. If the
Company does not send the forms within 15 days; then the Insured Employee may send the Company written proof of
Disability in a letter stating the date the Disability started, its cause and degree. The Company will periodically send the
Insured Employee additional Claim Forms.
PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the end of each period for which the
Company is liable, If it was not reasonably possible to give written proof in the time required, the claim will not be reduced or denied
solely for this reason; provided the proof is fIled as soon as reasonably possible, In any event, proof of claim must be given no later
than one year from such time, These time limits will not apply while an Insured Employee lacks legal capacity, however,
Proof of claim must be provided at the Insured Employee's own expense, It must show the date the Disability started, its cause and
degree, It must show any restrictions on performing the duties of the Insured Employee's regular occupation. Documentation must
include:
1, completed statements by the Insured Employee, the Employer and the attending Physician;
2. a signed authorization for the Company to obtain more information; and
3. any other items the Company may reasonably require in support of the claim,
Proof of continued Disability and regular attendance of a Physician must be given to the Company, within 60 days after the Company
requests it; if it is not, benefIts may be denied or suspended.
EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may:
1. have the Insured Employee examined by a Physician, specialist or vocational rehabilitation expert of the
Company's choice, as often as reasonably required; and
deny or suspend benefIts for an Insured Employee who fails to attend an exam, without good cause; or who fails
to cooperate with the examiner.
The Company may also have an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's
expense.
TIME OF PAYMENT OF CLAIMS. When the Company receives proof of claim, benefIts payable under this Policy will be paid as
follows.
1.
2.
Any Long Term Disability benefIts will be paid monthly, during any period for which the Company is liable. If
benefIts are due for less than a month, they will be paid on a prorata basis. The daily rate will equal 1/30 of the
monthly benefIt.
Any balance which remains unpaid at the end of the period of liability will be paid immediately upon receipt of
due written proof.
TO WHOM PAYABLE. All benefIts are payable to the Insured Employee; except after his or her death benefIts will be payable as
follows.
1. Any Survivor BenefIt will be payable in accord with that Policy provision.
2, Any other benefIts will be payable to the Insured Employee's estate.
When a benefIt becomes payable to the Insured Employee's estate, a minor or any other person who is not legally competent to give a
valid receipt; then up to $3,000 may be paid to any relative of the Insured Employee that the Company fmds entitled to payment. If
payment is made in good faith to such a relative, the Company will not have to pay that benefIt again.
NOTICE OF CLAIM DECISION, Within a reasonable time after receiving proof of loss, the Company will send the Insured
Employee a written notice of their claim decision, If the Company denies any part of the claim, the written notice will:
1, explain the reason for tIie denial under the terms of this Policy; and
2. inform the Insured Employee of the right to a review of the Company's decision,
If the Insured Employee does not receive a written decision within 90 days after the Company receives his or her claim; then the
Insured Employee has a right to an immediate review, as if the claim was denied,
2.
GL3001-LTD-8 98 FL
11
01/01101
CLAIMS PROCEDURES
(continued)
1EVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Employee may request a claim review by
sending the Company a written request, along with any written comments or other items to support the claim, The Insured Employee
may review certain non-privileged information relating to the request for review,
The Company will review the claim and send the Insured Employee a written notice of their decision within 60 days after receiving
the request for review; or within 120 days, if special circumstances require an extension, The notice will state the reasons for the
Company's decision under the terms of this Policy,
RIGHT OF RECOVERY. If benefIts have been overpaid on any claim, full reimbursement to the Company is required within 60
days. If reimbursement is not made, the Company has the right to:
1. reduce future benefIts until full reimbursement is made; and ,
2. recover such overpayments from the Insured Employee or his or her estate,
Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, the Insured
Employee's receipt of Other Income BenefIts, or any other reason.
LEGAL ACTIONS. No legal action to recover any benefIts may be brought until sixty days after the required written proof of claim
has been given, No legal action may be brought after the expiration of the applicable statute of limitations, from the time written
proof of claim must be given.
GL3001-LTD-8 98 FL
12
01/01/01
ELIGIBILITY
ELIGIBLE CLASSES, The classes of Employees eligible for insurance are shown in the Schedule of Benefits, The
Company has the right to review and terminate any or all classes eligible under this Policy, if any class ceases to be
covered by this Policy,
ELIGIBILITY DATE. An Employee becomes eligible for coverage provided by this Policy on the later of:
1. the Policy's effective date; or
2. the date the Employee satisfies the Waiting Period,
Prior service in an Eligible Class will apply toward the Waiting Period, when:
1. a former Employee is rehired within one year after his or her employment ends; or
2. an Employee returns from a Family or Medical Leave within the leave period required by federal or state
law (whichever is greater),
EFFECTIVE DATES
EFFECTIVE DATE. Except as stated in the Delayed Effective Date provision, coverage for an Employee becomes
effective at 12:01 a.m. on the latest of:
1. the first day of the Insurance Month coinciding with or next following the date the Employee becomes
eligible for coverage;
2, the date the Employee makes written application for coverage; and signs:
(a) a payroll deduction order, if the Employees pay any part of the Policy premiums; or
(b) an order to pay premiums from the Employee's Flexible Benefits Plan account, if
premiums are paid through such an account; or
3, the date the Company approves the Employee's evidence of insurability, if required.
Evidence of insurability satisfactory to the Company must be submitted (at the Employee's expense) if:
1. written application for coverage (or an increased amount of coverage) is made more than 31 days after
the Employee becomes eligible for such coverage;
2. coverage is elected after the Employee has requested:
(a) to terminate the insurance;
(b) to stop payroll deductions for the insurance; or
(c) to stop premium payments through a Flexible Benefits Plan account;
3. coverage is elected after the Employee has caused insurance to lapse by failing to pay the required
premium when due; or
4. optional, supplemental, voluntary or Buy-Up Benefit coverage is elected in excess of any guaranteed
issue amounts shown in the Schedule of Benefits.
DELAYED EFFECTIVE DATE. An Employee's Effective Date of any initial, increased or additional coverage will be
delayed; if such Employee is not Actively-at-Work on the date that coverage would otherwise be effective. Coverage will
take effect on the Employee's second consecutive day of Active Work,
GL3001-LTD-994
13
01/01/01
EFFECTIVE DATE FOR CHANGE IN ELIGIBLE CLASS. An Insured Employee may become a member of a different
Eligible Class. Except as stated in the Delayed Effective Date provision, coverage under the different Eligible Class will
be effective:
1. immediately, if the different Eligible Class involves any reduction in coverage; or
2, the first day of the month after the Insured Employee has been Actively-at-Work for at least 15 days, as
a member of a diff~rent Eligible Class; if the different Eligible Class involves enhancement of any
coverage.
REINSTATEMENT AFTER FAMILY OR MEDICAL LEAVE. A new Waiting Period and evidence of insurability will be
waived for an Employee, upon return from an approved Family or Medical Leave, provided:
1. the Employee returns within the leave period required by federal or state law (whichever is greater);
2. the Employee applies for insurance or is enrolled under this Policy within 31 days after resuming Active
Work; and
3. the reinstated amount of insurance does not exceed the amount which terminated,
If the above conditions are met, the months of leave will count towards any unmet Pre-Existing Condition Exclusion
period; and a new Pre-Existing Condition Exclusion will not apply to the reinstated amount of insurance. A new Pre-
Existing Condition Exclusion will apply to any increased amount of insurance, however,
GL3001-LlD-994
14
01/01/01
INDIVIDUAL TERMINATION
INDIVIDUAL TERMINATION OF COVERAGE, An Insured Employee's coverage will terminate at 12:00 midnight on the
Jarliest of:
1. the date this Policy or the Employer's participation terminates; but without prejudice to any claim
incurred prior to termination;
2. the date the Insured Employee's Class is no longer eligible for insurance;
3. the date such Insured Employee ceases to be a member of an Eligible Class;
4. the end of the period for which the last required premium has been paid; or
5. the date on which the Insured Employee's employment with the Employer terminates; unless coverage
is continued as provided below.
CONTINUATION. Ceasing Active Work is deemed termination of employment; but insurance may be continued as
follows.
1. Disability. If an Insured Employee is absent due to Total Disability, or is engaged in Partial Disability
Employment; then Long Term Disability insurance may be continued during:
(a) the Elimination Period; provided the Company receives the required premium from the
Employer; and
(b) the period for which Long Term Disability benefits are payable, without payment of
premium.
2. Family or Medical Leave. If an Insured Employee goes on an approved Family or Medical Leave, and
is not entitled to continue insurance due to Disability, as provided above; then Long Term Disability
insurance may be continued, until the earliest of:
(a) the end of the leave period approved by the Employer;
(b) the end of the leave period required by federal or state law (whichever is greater);
(c) the date the Insured Employee notifies the Employer that he or she will not return; or
(d) the date the Insured Employee begins employment with another employer;
provided the Company receives the required premium from the Employer.
3. Lay-off or Other Leave, When an Insured Employee goes on a temporary lay-off, or an approved
leave of absence which is not subject to the federal Family and Medical Leave Act (or any similar state
law); then Long Term Disability insurance may be continued:
(a) until the end of the calendar month following the month in which the lay-off or leave
began;
(b) provided the Company receives the required premium from the Employer.
The Employer must not act so as to discriminate unfairly among Employees in similar situations. Insurance may not be
continued when an Insured Employee ceases Active Work due to a labor dispute, strike, work slowdown or lockout.
INDIVIDUAL TERMINATION DURING DISABILITY. Termination of an Insured Employee's coverage during a Disability will
have no effect on benefIts payable for that period of Disability.
EXTENSION OF BENEFITS. In the event of Total Disability of an Insured Employee on the date of Policy termination, benefIts will
be continued for such disability until the earliest of:
1. the date the Insured Employee ceases to be Totally Disabled;
2. the date the Insured Employee fails to take a required medical exam;
3, the date the Insured Employee fails to submit any required proof to the Company;
4, the date the Insured Employee dies; or
5, the date the Maximum BenefIt Period ends,
GL3001-LTD-I0 98 FL
15
01/01/01
POLICY TERMINATION
POLICY TERMINATION BY THE COMPANY. Until the premium rate has been in effect for at least 12 months, or any
'3ter Rate Guarantee Date agreed upon by the Company; the Company may terminate this Policy on the due date of any
premium if:
1. the number of Insured Employees totals less than 10;
2, part of the premium is paid by the Insured Employee and less than 75% of those eligible for coverage
are insured;
3. all of the premium is paid by the Policyholder and less than 100% of those eligible for coverage are
insured;
4. the Policyholder fails to promptly furnish any information which the Company may reasonably require;
5. the Policyholder, without good cause, fails to perform its duties pertaining to this Policy in good faith,
6. the Company's liability is changed as a result of any change in federal, state or local law which affects this Policy;
7, the Policyholder or any covered division, subsidiary or affIliated company relocates;
8, the Policyholder or any covered subsidiary or affIliated company dissolves or merges;
9, a division, subsidiary or affIliated company is added to or removed from this Policy;
10. any coverage for one or more classes of Insured Employees ceases to be provided under this Policy;
11. the number of Insured Employees changes by 25% or more from the number of Insured Employees on the date
this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or
12. the Employer ceases to be covered under the state Workers' Compensation program or any other program oflike
intent.
After the premium rate has been in effect for at least 12 months, or any later Rate Guarantee D'ate agreed upon by the
Company; the Company may terminate this Policy on the due date of any premium, Such termination may be with respect
to the Policy as a whole, to any coverage(s) provided under it, or to any class of Insured Employees covered under it.
The Company will give the Policyholder at least 45 days' advance written notice of its intent to terminate this Policy.
POLICY TERMINATION BY THE POLICYHOLDER. The Policyholder may terminate this Policy at any time by giving the
~ompany written notice. This Policy will then terminate on:
1. the date the Company receives the notice; or
2. some later date on which the Policyholder and the Company have agreed,
However, termination will not become effective during any period for which premium has been paid to the Company. The
Policyholder remains liable for the payment of premiums to the date of termination,
AUTOMATIC POLICY TERMINATION. If any premium is not paid before the end of the Grace Period; then this Policy will
terminate at the end of the Grace Period, without any action on the Company's part. The Policyholder remains liable for
the payment of premiums to the date of termination.
POLICY TERMINATION DURING DISABILITY. Termination of this Policy or an Employer's participation during a Disability
shall have no effect on benefIts payable to the InsUred Employee for that period of Disability.
GL3001-LID-10 98 FL
16
01/01/01
CONVERSION PRIVILEGE
ELIGIBILITY, This Policy provides a conversion privilege, when an Insured Employee's insurance under this Policy ends
ecause he or she:
1. resigns from employment with the Employer;
2. is terminated from employment with tbe Employer, with or without cause;
3, goes on a lay-off or leave of absence; or
4. remains on a lay-off or leave of absence beyond the continuation period provided in the Individual
Termination section of this Policy,
The Insured Employee may obtain converted long term disability insurance, without medical evidence of insurability, To
be eligible for a converted policy, the Insured Employee must have been insured under the Employer's group plan for at
least 12 months in a row, just before his or her insurance under this Policy terminated. The 12 months can be a
combination of coverages under this Policy, and under any prior group long term disability plan which this Policy replaces.
APPLICATION, Application to convert must be made within 31 days after insurance under this Policy terminates. The
converted benefits and amount of insurance may differ from those under this Policy.
CONDITIONS AND LIMITATIONS. This conversion privilege is not available to any Insured Employee whose insurance
terminates because:
1, this Policy is terminated by the Employer or the Company;
2, this Policy is amended to exclude the class to which the Insured Employee belongs: .
3. the Insured Employee no longer belongs to a class eligible for coverage under this Policy;
4. the Insured Employee retires or dies;
5. the Insured Employee fails to pay the required premium; or
6. the Insured Employee is Disabled under the terms of this Policy.
Also, this conversion privilege is not available to an Insured Employee who becomes insured for long term disability
">enefits under any other group plan; unless the other coverage takes effect more than 31 days after his or her insurance
under this Policy terminates.
If an Insured Employee converts his or her Policy coverage, and later resumes active employment in an eligible class;
then the Insured Employee's conversion coverage will terminate on the day before he or she is re-enrolled under this
Policy, In no event will benefits be paid under both this Policy and the conversion coverage for the same period of
Disability .
Conversion Privilege
GL3001-L TD-10.1
17
01/01/01
PREMIUMS AND PREMIUM RATES
PA YMENT OF PREMIUM. No coverage provided by this Policy will be in effect until the fIrst premium for such coverage is paid.
for coverage to remain in effect, the Employer must pay each subsequent premium on or before its due date at the Company's Home
OffIce. The premium must be paid in U.S. dollars,
PREMIUM RATES. The initial premium rates for this Policy are shown on the Face Page of this Policy, Premium rates are subject
to change.
PREMIUM RATE CHANGE, The Company may change any premium rate:
1. when this Policy's terms are changed:
(a) as agreed upon by the Policyholder and the Company; or
(b) as a result of a change in federal, state or locallaw which affects this Policy;
2. when the Company's liability is changed as a result of a change in federal, state, or locallaw;
3. when the Policyholder or any covered division, subsidiary or affIliated company relocates;
4. when a division, subsidiary, or affIliated company is added to or removed from this Policy;
5. when the number of Insured Employees changes by 25% or more from the number of Insured Employees on the
date this Policy took effect or the most recent Rate Guarantee Date expired, if later;
6. when the Employer ceases to be covered by the state Workers' Compensation program or any other program of
like intent; or
7. on any premium due date on or after:
(a) this Policy's fIrst anniversary; or
(b) any later Rate Guarantee Date agreed upon by the Company,
Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days' advance written
notice of any increase in premium rates,
MONTHLY PREMIUM AMOUNT. The amount of monthly premium due on each due date will be the Total Covered Payroll
multiplied by the premium rate. Changes will not be pro-rated daily. Instead, premium will be adjusted as follows.
1. When an Insured Employee's insurance (or increased amount of insurance) takes effect, premium will be charged
from the monthly due date coinciding with or next following that change.
2. When all or part of an Insured Employee's insurance terminates, the applicable premium will cease on the
monthly due date coinciding with or next following that termination.
3. When premiums are paid other than monthly, increases or decreases will result in an adjustment from the
premium due date coinciding with or next following that change.
The above manner of charging premium is for accounting purposes only. It will not extend insurance coverage beyond a date it
would have otherwise terminated.
Each premium payment will include any adjustments in past premiums, which are needed due to changes that have not yet been taken
into account. If a premium adjustment involves a return of unearned premium, the amount of the return will be limited to the prior
12-month period.
GRACE PERIOD. A Grace Period of 31 days from the due date will be allowed for the payment of each premium after the fIrst.
This Policy will remain in effect during the Grace Period. The Policyholder will be liable to the Company for the payment of all
premiums due for the period this Policy remains in effect, however.
WAIVER OF PREMIUM. Premium will be administered as follows during any period for which benefIts are payable.
1. Long Term Disability premium payments are waived for an Insured Employee who is Disabled, during any
period for which benefIts are payable.
2. If coverage is to be continued following a period during which premiums were waived; then premium payments
must be resumed, as they become due.
GL3001-LTD-l1 98 FL
18
01/01/01
TOTAL DISABILITY MONTHLY BENEFIT
BENEFIT. The Company will pay a Total Disability Monthly BenefIt to an Insured Employee, after the completion of the
1limination Period; ifhe or she:
L is Totally Disabled;
2. is under the regular care of a Physician; and
3. at his or her own expense, submits proof of continued Total Disability and Physician's care fothe Company upon
request.
The Total Disability Monthly BenefIt will cease on the earliest of:
1. the date the Insured Employee ceases to be Totally Disabled or dies;
2. the date the Maximum BenefIt Period ends;
3, the date the Insured Employee is able, but chooses not to engage in Partial Disability Employment:
(a) in his or her regular occupation, during the Own Occupation Period; or
(b) in any gainful occupation, after the Own Occupation Period;
4. the date the Insured Employee fails to take a required medical exam, without good cause; or
5. the 60th day after the Company mails a request for additional proof, if not given,
AMOUNT, The amount of the Total Disability Monthly BenefIt equals:
1, the Insured Employee's Basic Monthly Earnings multiplied by the BenefIt Percentage (limited to the Maximum
Monthly BenefIt); minus
2. Other Income BenefIts.
The amount of the Total Disability Monthly BenefIt will not be less than the Minimum Monthly BenefIt. The BenefIt Percentage,
MaximumMonthly BenefIt, Minimum Monthly BenefIt and Maximum BenefIt Period are shown in the Schedule of BenefIts.
DEFINITION
"Total Disability" or "Totally Disabled" will be dermed as follows.
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured
Employee is unable to perform each of the substantial and material duties of his or her own occupation.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to
perform each of the main duties of any gainful occupation which his or her training, education or experience will
reasonably allow,
The loss of a professional license, an occupational license or certifIcation, or a driver's license for any reason does not, by itself,
constitute Total Disability.
BENEFIT PERIOD EXTENSION. The Maximum BenefIt Period is shown in the Schedule of BenefIts. However, benefIts will be
extended beyond the end of the Maximum BenefIt Period if a Totally Disabled Employee attains the age specifIed in the benefIt
duration and has not received twelve Monthly BenefIt payments. In this event, the benefIt period will be extended during the
continuance of Total Disability until twelve monthly payments have been paid.
GL3001-L TD-12A 98 FL
19
Standard Integration, Any Occ. Disability Definition
01/01/01
PARTIAL DISABILITY MONTHLY BENEFIT
BENEFIT. The Company will pay a Partial Disability Monthly BenefIt to an Insured Employee, after completion of the Elimination
'eriod; if he or she:
1. is Disabled;
2, is engaged in Partial Disability Employment;
3. is earning at least 20% of Pre disability Income when Partial Disability Employment begins;
4. is under the regular care of a Physician; and
5, at his or her own expense, submits proof of continued Partial Disability, Physician's care and reduced earnings to
the Company upon request.
The Insured Employee does not have to be Totally Disabled prior to receiving Partial Disability Monthly BenefIts. The Elimination
Period may be satisfIed by days of Total Disability, Partial Disability or any combination thereof.
The Partial Disability Monthly BenefIt will cease on the earliest of:
1. the date the Insured Employee ceases to be Partially Disabled or dies;
2. the date the Maximum Benefit Period ends;
3. the date the Insured Employee earns more than:
(a) 99% of Pre disability Income, until Partial Disability Monthly BenefIts have been paid for 24
months for the same period of Disability; or
(b) 85% of Predisability Income, after Partial Disability Monthly BenefIts have been paid for 24
months for the same period of Disability; *
4, the date the Insured Employee is able, but chooses not to work full-time:
(a) in his or her regular occupation, during the Own Occupation Period; or
(b) in any gainful occupation, after the Own Occupation Period;
5. the date the Insured Employee fails to take a required medical exam, without good cause; or
6. the 60th day after the Company mails a request for additional proof, if not given.
*If the Insured Employee's earnings from Partial Disability Employment fluctuate, the Company has the option to average the most
recent three months' earnings and continue the claim; provided that average does not exceed the percentage of Predisability Income
clllowed above. A Monthly BenefIt will not be payable for any month during which earnings exceeded that percentage, however.
DEFINITIONS
"Full-Time" means the average number of hours the Insured Employee was regularly scheduled to work, at his or her regular
occupation, during the month just prior to:
1. the date the Elimination Period begins; or
2. the date an approved leave of absence begins, if the Elimination Period begins while the Insured Employee is
continuing coverage during a leave of absence.
"Partially Disabled" or "Partial Disability" will be defmed as follows.
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured
Employee:
(a) is unable to perform one or more of the main duties of his or her regular occupation, or is unable
to perform such duties full-time; and
(b) is engaged in Partial Disability Employment.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee:
(a) is unable to perform one or more of the main duties of any gainful occupation which his or her
training, education or experience will reasonably allow; or is unable to perform such duties full-
time; and
(b) is engaged in Partial Disability Employment.
GL3001-LID-13A 98
20
Residual Disability, Any Occ. Disability Definition
01/01101
PARTIAL DISABILITY MONTHLY BENEFIT
(Continued)
1ENEFIT AMOUNT. The Partial Disability Monthly Benefit will replace the Insured Employee's Lost Income; provided it
does not exceed the Total Disability Monthly Benefit, which would otherwise be payable during Total Disability without the
Partial Disability Employment.
Thus, the amount of the Partial Disability Monthly Benefit will equal the lesser of A or B below,
A. LOST INCOME: The Insured Employee's Predisability Income, minus all Other Income Benefits
(including earnings from Partial Disability Employment).
B. TOTAL DISABILITY MONTHLY BENEFIT otherwise payable:
1 . The Insured Employee's Predisability Income multiplied by the Benefit Percentage
(limited to the Maximum Monthly Benefit); minus
2, Other Income Benefits, except for earnings from Partial Disability Employment.
The Partial Disability Monthly Benefit will never be less than the Minimum Monthly Benefit. The Benefit Percentage,
Maximum Monthly Benefit, Minimum Monthly Benefit, and Maximum Benefit Period are shown in the Schedule of Benefits,
Progressive Calculation
GL3001-LTD-13.4
21
01/01/01
OTHER INCOME BENEFITS
OTHER INCOME BENEFITS means those benefIts shown below:
1. Any temporary or permanent benefIts or awards for which the Insured Employee is paid under:
(a) Worker's or Workmen's Compensation Law;
(b) occupational disease law; or
(c) any other act or law of like intent.
2. Any disability income benefIts which the Insured Employee receives under any compulsory benefIt act or law,
3. Any disability income benefIts which the Insured Employee receives under:
(a) any other group plan, sick leave or salary continuance plan of the Employer; or
(b) any governmental retirement system as a result of the Insured Employee's job with the Employer.
4. Any Disability BenefIts or Retirement BenefIts the Insured Employee receives under a Retirement Plan.
5. Benefits under the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan or any
similar plan or act as follows:
(a) disability or unreduced retirement benefIts which the Insured Employee and any spouse or
child receives, because of the Insured Employee's Disability; or
(b) reduced retirement benefIts received by the Insured Employee and any spouse or child
because of the Insured Employee's receipt of reduced retirement benefits.
6. Earnings the Insured Employee earns or receives from any form of employment.
These Other Income BenefIts, except Retirement BenefIts, are benefIts resulting from the same Disability for which a Monthly BenefIt
is payable under this Policy.
An Insured Employee who may be entitled to some Other Income BenefIt is required to actively pursue it; if he or she does not,
Policy benefIts may be denied or suspended.
COST-OF-LIVING FREEZE. After the ftrst deduction for each of the Other Income BenefIts, the Monthly BenefIt will not be further
reduced due to any cost-of-living increases payable under these Other Income BenefIts. No reduction in benefIts shall be put into
effect because of an increase in Social Security disability benefIts during a benefIt period.
:"UMP SUM PAYMENTS. Other Income BenefIts which are paid in a lump sum will be prorated on a monthly basis over the time
period for which the sum is given. If no time period is stated, the sum will be prorated on a monthly basis over the time the Company
expects the Insured Employee to live.
ESTIMATED PAYMENTS, When the Insured Employee may qualify for certain Other Income BenefIts, the Company may estimate
the amount of such benefIts. The Company may reduce the Insured Employee's Monthly BenefIts by such estimated amounts, which:
1, have not yet been awarded or denied; or
2, have been denied, if the denial is being appealed,
If an Insured Employee's Monthly BenefIts have been reduced by an estimated amount; then such payments will be adjusted when the
Company receives proof:
1. of the amount actually awarded; or
2. that benefIts have been denied, and that any appeal the Company deems necessary has been completed. (In that
event, a lump sum will be refunded to the Insured Employee.)
22
Full SS Integ,
01/01/01
GL3001-LTD-14 98 FL
I'
RECURRENT DISABILITY
"Recurrent Disability" means a Disability due to an Injury or Sickness which is the same as, or related to, the cause of a prior
'1isability for which Monthly BenefIts were payable, A Recurrent Disability will be treated as follows,
1. A Recurrent Disability will be treated as a new period of Disability, and a new Elimination Period must be
completed before further Monthly BenefIts are payable; if the Insured Employee returns to his or her regular
occupation on a full-time basis for six months or more.
2. A Recurrent Disability will be treated as part of the prior Disability, if an Insured Employee returns to his or her
regular occupation on a full-time basis for less than six months.
To qualify for a Monthly BenefIt, the Insured Employee must earn less than the percentage of Predisability Income specifIed in the
Partial Disability Monthly BenefIt section, Monthly BenefIt payments will be subject to all other terms of this Policy for the prior
Disability.
If an Insured Employee becomes eligible for coverage under any other group Long Term Disability policy, this Recurrent Disability
provision will cease to apply to that Insured Employee.
GL3001-LlD-1598
23
01101/01
EXCLUSIONS
GENERAL EXCLUSIONS. This Policy will not cover any period of Total or Partial Disability:
1. due to war, declared or undeclared, or any act of war;
2. due to intentionally self-inflicted injuries;
3, due to active participation in a riot;
4. due to the Insured Employee's committing of or the attempting to commit a felony or any type of assault or
battery;
5, during which the Insured Employee is incarcerated for the commission of a felony; or
6. during which the Insured Employee is not under the regular care of a Physician.
PRE-EXISTING CONDITION EXCLUSION, This Policy will not cover any Total or Partial Disability:
1. which is caused or contributed to by, or results from a Pre-Existing Condition; and
2. which begins in the fIrst 12 months after the Insured Employee's Effective Date,
"Pre-Existing Condition" means a Sickness or Injury for which the Insured Employee received treatment within 3 months prior to the
Insured Employee's Effective Date.
"Treatment" means consultation, care or services provided by a Physician. It includes diagnostic measures and the prescription, refIll
of prescription, or taking of any prescribed drugs or medicines.
,3001-LID-16.0 98
24
SPECIFIED INJURIES OR SICKNESSES LIMITATION
LIMITATION, If an Insured Employee is Disabled primarily due to one or more of the SpecifIed Injuries or Sicknesses defmed
below; then Partial or Total Disability Monthly BenefIts:
1, will be payable subject to the terms of this Policy; but _
2. will be limited to 24 months for anyone period of Disability; unless the Insured Employee is confmed to a
Hospital.
"SpecifIed Injuries or Sicknesses" include any Mental Sickness, or Substance Abuse, as defmed below.
CONDITIONS
I. If the Insured Employee is confmed in a Hospital at the end of the 24th month for which Policy benefIts are paid
for the SpecifIed Injury or Sickness; then benefIts will be payable until he or she is discharged from that facility.
2. In no event will the Monthly BenefIt be paid beyond the Maximum BenefIt Period shown in the Schedule of
Insurance, however.
DEFINITIONS
"Hospital," as used in this provision, means:
1, a general hospital which:
(a) is licensed, approved or certifIed by the state where it is located;
(b) is recognized by the Joint Commission on the Accreditation of Hospitals; or
(c) is operated to treat resident inpatients; has a registered nurse always on duty; and has a lab, x-ray
facility and place where major surgery is performed; and
2. a skilled nursing care facility or unit, which provides convalescent or nursing care; and which is recognized as a
skilled nursing care facility under Medicare.
The term Hospital also includes:
1. a Mental Hospital when treatment is for a Mental Sickness; and
2. a Treatment Center when treatment is for Substance Abuse.
~ental Hospital" means a health care facility (or its psychiatric unit) which:
1. is licensed, certified or approved as a mental hospital by the state where it is located;
2. is equipped to treat resident inpatients' mental diseases or disorders; and
3, has a resident psychiatrist on duty or on call at all times.
"Mental Sickness" means any emotional, behavioral, psychological, personality, adjustment, mood or stress-related abnormality,
disorder, disturbance, dysfunction or syndrome; regardless of its cause. It includes, but is not limited to:
1, schizophrenia or schizoaffective disorder;
2, bipolar affective disorder, manic depression, or other psychosis; and
3. obsessive-compulsive, depressive, panic or anxiety disorders.
These conditions are usually treated by a psychiatrist, a clinical psychologist or other qualifIed mental health care provider.
freatment usually involves psychotherapy, psychotropic drugs or similar methods of treatment.
1ental Sickness does not include irreversible dementia resulting from:
1. stroke, trauma, viral infection, Alzheimer's disease; or
2, other conditions which are not usually treated by a mental health care provider using psychotherapy, psychotropic
drugs, or similar methods of treatment.
ubstance Abuse" means alcoholism, drug abuse, or chemical dependency of any type,
reatment Center" means a health care facility (or its medical or psychiatric unit) which:
1, is licensed, certified or approved by the state where it is located;
2. has a program for inpatient treatment of substance abuse; and
3, provides such treatment based upon a written plan approved and supervised by a Physician.
01-L TD-17 98 FL
VOLUNTARY VOCATIONAL REHABILITATION BENEFIT PROVISION
BENEFIT, If an Insured Employee is Disabled and is receiving Policy benefIts; then he or she may be eligible for a Vocational
Rehabilitation BenefIt. This BenefIt consists of services which may include:
1, vocational evaluation, counseling, training or job placement;
2. job modifIcation or special equipment; and
3. other services which the Company deems reasonably necessary to help the Insured Employee return to work.
The Company will determine the Insured Employee's eligibility and the amount of any BenefIt payable.
ELIGIBILITY, An Insured Employee may be eligible for this BenefIt, if the Company fmds that he or she:
1. has a Disability that prevents the performance of his or her regular occupation; and, after the Own Occupation
Period, also lacks the skills, training or experience needed to perform any other gainful occupation;
2. has the physical and mental abilities needed to complete a Program; and
3, is reasonably expected to return to work after completing the Program; in view of his or her-degree of motivation
and the labor force demand for workers in the proposed occupation.
The Company must also fmd that the cost of the proposed services is less than its expected claim liability.
AMOUNT, The amount of any Vocational Rehabilitation BenefIt will not exceed the Company's expected claims liability. This
benefIt will not be payable for services covered under the Insured Employee's health care plan or any other vocational rehabilitation
program. Payment may be made to the provider of the services, at the Company's option.
CONDITIONS, Either the Company, the Insured Employee, or his or her Physician may ftrst propose vocational rehabilitation.
When a Program is approved by the Company, this Policy's defmition of "Disability" will be waived during the rehabilitation period;
but it will be reapplied after the Program ends. The Company will determine the amount and duration of any Long Term Disability
benefIts payable after the Program ends,
LIMITATION. This Policy will not cover any period of Disability for an Insured Employee who has received a Vocational
Rehabilitation BenefIt and has failed to complete the Program, without Good Cause.
BFINITIONS
"Good Cause", as used in this provision, means the Insured Employee's:
1. documented physical or mental impairments, which render the Insured Employee unable to take part in or
complete a Program;
2, involvement in a medical program, which prevents or interferes with the Insured Employee's taking part in or
completing a Program; or
3, participating in good faith in some other vocational rehabilitation program, which:
(a) conflicts with taking part in or completing a Program developed by the Company; and
(b) is reasonably expected to return the Insured Employee to work.
"Program" means a written vocational rehabilitation program:
1. which the Company develops with input from the Insured Employee; his or her Physician; and any current or
prospective employer, when appropriate; and
2. which describes the Program's goals; each party's responsibilities; and the times, dates and costs of the
rehabilitation services.
GL3001-L TD-17,3 98
Voluntary Rehab.
26
REASONABLE ACCOMMODATION BENEFIT
If an Insured Employee of the Employer is Disabled, and is receiving Policy benefits; then the Employer may be ~ligible for
a Reasonable Accommodation Benefit. This Benefit reimburses the Employer for 50% of the expense incurred for
reasonable accommodation services for the Insured Employee; but will not exceed:
1. a maximum benefit of $5.000 for anyone Insured Employee; or
2. the Company's expected liability for the Insured Employee's Long Term Disability claim (whichever is
less).
Such services may include:
1, providing the Insured Employee a more accessible parking space or entrance;
2. removing barriers or hazards to the Insured Employee from the worksite;
3, special seating, furniture or equipment for the Insured Employee's work station;
4, providing special training materials or translation services during the Insured Employee's training; and
5. other services the Company deems reasonably necessary to help the Insured Employee return to work
with the Employer.
ELIGIBILITY FOR BENEFIT, The Company will determine the Employer's eligibility to receive the Benefit. To qualify for
the Benefit, the Employer must have an Insured Employee:
(a) whose Disability prevents the performance of his or her regular occupation at the Employer's worksite;
(b) who has the physical and mental abilities needed to perform his or her own or another occupation at the
Employer's worksite; but only with the help of the proposed accommodation; and
(c) who is reasonably expected to return to work with the help of the proposed accommodation,
The Company must also find that the requested Reasonable Accommodation Benefit is less than the expected liability for
the Insured Employee's Long Term Disability claim.
WRITTEN PROPOSAL. The reasonable accommodation services must be provided in accord with a written proposal.
which is developed with input from:
1. the Employer;
2. the Insured Employee; and
3. his or her Physician. when appropriate,
The proposal must state the purpose of the proposed accommodation; and the times, dates and costs of the services.
CONDITIONS. Either the Company. the Employer, the Insured Employee, or his or her Physician may first propose an
accommodation,
The proposal must be approved by the Company in writing.
The Company will then reimburse the Employer, upon receipt of proof that the Employer:
1 . has provided the services for the Insured Employee; and
2. has paid the provider for the services.
301-L TD-17.3
PRIOR INSURANCE CREDIT UPON TRANSFER OF INSURANCE CARRIERS
To prevent loss of coverage for an Employee because of a transfer of insurance carriers, this Policy will provide Prior
Insurance Credit for employees insured under the prior carrier's policy on its termination date as follows.
FAILURE TO BE ACTIVEL Y-AT-WORK DUE TO INJURY OR SICKNESS, Subject to premium payments, this Policy will
provide coverage to an Employee:
1. who was insured by the prior carrier's policy at the time of transfer; and
2, who was not Actively-At-Work due to Injury or Sickness on this Policy's Effective Date.
The coverage will be that provided by the prior carrier's policy, had it remained in force. The Company will pay:
1. the benefit that the prior carrier would have paid; minus
2. any amount for which the prior carrier is liable.
DISABILITY DUE TO A PRE-EXISTING CONDITION, Benefits may be payable for a Total Disability due to a Pre-Existing
Condition for an Employee who:
1. was insured by the prior carrier's policy at the time of transfer; and
2. was Actively-At-Work and insured under this Policy on this Policy's Effective Date.
The benefits will be determined as follows:
1. The Company will apply this Policy's Pre-Existing Condition Exclusion. If the Insured Employee
qualifies for benefits, such Insured Employee will be paid according to this Policy's benefit schedule.
2., If the Insured Employee cannot satisfy this Policy's Pre-Existing Condition Exclusion, but can satisfy the
prior carrier's pre-existing condition exclusion giving consideration towards continuous time insured
under both policies; then he or she will be paid in accord with the benefit schedule and all other terms,
conditions and limitations of:
(a) this Policy without applying the Pre-Existing Condition Exclusion; or
(b) the prior carrier's policy;
whichever is less.
3, If the Insured Employee cannot satisfy the Pre-Existing Condition Exclusion of this Policy or that of the
prior carrier, no benefit will be paid,
Prior Insurance Credit
GL3001-LID-1899
28
01/01/01
FAMILY INCOME BENEFIT
The Company will pay a lump sum benefit to the Eligible Survivor, when proof is received that an Insured Employee died:
1. after Disability had continued for 180 or more consecutive days;
2. while receiving a Monthly Benefit; and
3. as a result of the Disability for which the Monthly Benefit was being paid, or as a result of an accident.
The benefit will be equal to three times the Insured Employee's Last Monthly Benefit. It will be paid in three monthly
installments.
"Last Monthly Benefit" means the gross Monthly Benefit payable to the Insured Employee immediately prior to death. Any
reductions for Other Income Benefits, or for earnings the Insured Employee received for Partial Disability Employment, will
not apply.
"Eligible Survivor" means the Insured Employee's:
1. surviving spouse; or, if none
2. surviving children who are under age 25 on the Insured Employee's date of death,
If payment becomes due to the Insured Employee's children; then payment will be made to:
1. the surviving children, in equal shares; or
2. a person named by the Company to receive payments on the children's behalf.
This payment will be valid and effective against all claims by others representing, or claiming to represent, the children.
If there are no Eligible Survivors, payment will be made to the Insured Employee's estate.
Three Month Survivor Benefit
i..3001-LTD-1994 FL
2g
..
Hi
JEFFERSON PILOT
FINANCIAL
Jefferson Pilot Financial Insurance Company
8801 lodan Hills Drive, Omaha NE 68114.4066
(402) 361-7300 A Stock COlTl>8ny
Group Policyholder
Florida - Dental PPO Specimen
In consideration of the Group Policyholder's application for this Policy and payment of all premiums when due,
Jefferson Pilot Financial Insurance Company agrees to make the payments provided in this Policy to the
persons entitled to them,
The fIrst premium for this Policy is due on its effective date. Subsequent premiums are due on October 1,2001, and
on the same day of each month after that. Policy anniversaries will be each September 1st; unless shown otherwise
on the Premium Rate Schedule inside.
The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited over the
signatures below,
, Jefferson Pilot Financial Insurance Company has executed this Policy at its Home OffIce in Omaha, Nebraska,
~~
Chief Executive Officer
~~
Secretary
TIDS POLICY CONTAINS A DEDUCTIBLE.
GROUP DENTAL INSURANCE POLICY
No. :xxxxxxxxxxxxx
GLll-I-FP FL
97
09/01/01
TABLE OF CONTENTS
Schedule of BenefIts "".,.,..,..,..,...",.,., ,.,.,. ",., "..,.".,...,., "." '" ..,., ,." "., "., ,., ,.,... ...."" ,.,.", ,., ,.,.......,.,.. .,."..., 3
DefIni tions ........,.."...................."",.,.............."..,.....",."",..,.",...,.,.""."..,..,..,.",.,......,.,."."". ..""".".,...., 4
General Provisions......,.,.....,.,.........,.",."".,.......""."",...""..,....,.,.,."",.,.....,....,.,.,.,.,..,.".,.,..."."".,.. ,'....., 8
Eligibility and Effective Dates for Employee Dental Coverage................................................................ 10
Termination of Employee Dental Coverage ,..............................,.................,...................,........,............... 11
Eligibility for Dependent Dental Coverage ......................,..,.............................................................,....... 13
Termination of Dependent Dental Coverage.................................,..............,..,......................................... 15
Premiums and Premium Rates ....... .................. ........................................."..,.. .........., ...., ,...............,...,..... 16
Policy Termination ................. ...........,...,.,..,....., "..................,....,...,.".,.....,.. "...,..... ,.. ..,..,...,." ......,...,., ,.", 17
Dental Expense BenefIts "..... ,..,., "..."" ,.,..., "."."....,. ..,.",. "." ,'....,.,.,.,.., ,.,..,........ ,.....,.,.. ,." ........,.."".,....,. 18
Alternative Procedures ......,.,.,.,',.,.......",..".,..,."...",.,...,.,.".,."....."...,..."...,.,.,..,....".,.,....,.,.",..,.......,.,.... 19
Limitations and Exclusions .,.,... "..,..... ,.., "..,."..., ..", ..,." ,..".. .".,."" ".,.,.,..,.., ,..., ,."" ,......, ...,. ,. .,... .,..., ..,.. ,. 20
Coordination of Dental Expense BenefIts ".".."".,......,......,.,.....,.,...".,....".,..".,.......,.,.,..,...,..".,...,...,....,.23
Claims Procedures for Dental Coverage.................................................................................................... 25
Predetermination of BenefIts".,..,..,.....""."."....,..,..,.,.,.... ........,.."....,.,.".,.......,..""........".",..,.........,....... 27
Dental Coverage Continuation "" ... ........"."." ,..,............, "..,.",..."..",.....,.,....,..., ,..,.,.", ",.. .,....,.,."" ..., ..", 28
Type I Procedures "."...............",......." ......,.....,.,..... .,.. ,....,..,.."" "...,...., ,....,.......,...,.,., '.,. .., ........,..,....".., ,. 31
Type II Procedures ,.,..,.,",....".,.,.,.,.,.".,.,..,....,..........,...,.,..",...,.....,....,.,..,..,.....",..,..,.......,..,.......,.....,...... 32
Type III Procedures .. ......,.,.,.,..........., ,.....,. ...." ,.."..".., ...,."..,....,.....,.".,.....,...., ,.,..."..,..., ,......, ...,..,.....,. .... 35
Prior Carrier Credit Provision. ..,.,........ ..........,...........". ,."....,...........,...,.....,..", ....,...., ,...,.,..,....,..,.., ,.,., ,.,., 37
GL11-2-TC
2
09/01/01
SCHEDULE OF BENEFITS
The amount of a Covered Employee's coverage is determined from the following table. The initial amount of coverage is the amount
.hich applies to a Covered Employee's ClassifIcation on the date his or her coverage takes effect. If a Covered Employee becomes
eligible for an increase, it will take effect on the later of:
(1) the fIrst day of the Coverage Month which coincides with or follows the date on which the Covered Employee
becomes eligible for the increase, provided he or she is Actively at Work on that day; or
(2) the day the Covered Employee resumes Active Work, if not Actively at Work on the day the increase would
otherwise take effect.
Any decrease will take effect on the day of the change, whether or not the Covered Employee is Actively at Work.
DENTAL PREFERRED PROVIDER ORGANIZATION (PPO), This plan is designed to provide high quality dental care while
controlling the cost of such care. To do this, the Policy encourages a Covered Person to seek dental care from Dentists who have
signed a contract with the dental network being offered by the Policy. These Dentists are called Participating Dentists.
Use of a Participating Dentist is voluntary. The Covered Person may receive treatment from any Dentist he or she chooses. And he
or she is free to change Dentists at any time. But, the Covered Employee's out-of-pocket expenses are usually lower when a
Participating Dentist is used. Conversely, out-of-pocket expenses are usually higher when treatment is provided by a Non-
Participating Dentist, even if the treatment was recommended or ordered by a Participating Dentist.
A listing of Participating Dentists is available from the Employer, Information about Participating Delltists may also be obtained
by:
(1) accessing the Company's web site at www.jpfmancial.com; or
(2) calling the Company's Client Services Department (800) 842 - 3729.
This information is included on the ID card provided to each Covered Employee, When the Covered Employee enrolls Eligible
Dependents, two ID cards will be provided.
When using a Participating Dentist, the Covered Person must present the ID Card. Most Participating Dentists prepare the
necessary claim forms, and submit them to the Company for the Covered Person. BenefIts are based on the terms of the Policy.
CLASSIFICA nON
Plan 1 - All Active Full-time Employees located in a PPO service area
Class I
All Full-Time Employees located in a PPO service area
Plan 2 - All Active Full-time Employees located outside a PPO service area
Class 2
All Full-Time Employees located outside a PPO service area
ELIGmILITY WAITING PERIOD (For date coverage begins, refer to "Effective Date" section)
(a) None for employees who were hired on or before the Policy issue date.
(b) 90 days of continuous Active Work for employees who were hired after the Policy issue date,
GLll-3-SB
3
09/01/01
.'
SCHEDULE OF BENEFITS (CONTINUED)
Plan 1 - All Active Full-time Employees located in a PPO service area
BENEFITS FOR CLASS 1
Eli~ible Class:
All Full-Time Employees located in a PPO service area
Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are
required to contribute to the cost for Dependent Dental Coverage,
BenefIt Waitin~ Period:
Type II Procedures:
Type III Procedures:
None
6 Months
The BenefIt Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the
Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the
Policy Effective Date.
Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes
Late Entrant Limitation (when lij)plicable):
Type II Procedures: 12 Months
Type III Procedures: 12 Months
DENTAL BENEFITS
PPO PLAN
In-Network
Services
PPO PLAN
Out-of-Network
Services
CALENDAR YEAR DEDUCTIBLE
for these Procedure Types (combined)
INDIVIDUAL
FAMILY
Types II & III
$50
$150
Types II & III
$50
$150
PERCENT PAYABLE
Type I - Diagnostic & Preventive Services
Type II - Basic Services
Type III - Major Services
100%
85%
55%
100%
75%
45%
CALENDAR YEAR MAXIMUM
for these Procedure Types (combined)
$2,000
Types I, II & III
, $2,000
Types I, II & III
Under the CLAIMS PROCEDURES provision, the paragraph captioned "TO WHOM PAYABLE" is amended to read as
follows.
TO WHOM PAYABLE. Dental Expense BenefIts generally will be paid to the Covered Employee; unless the Covered Employee
has assigned such benefIts to the Dentist, or an overpayment has been made. However, if services are provided by a Participating
Dentist, benefIts are automatically assigned to that Dentist, unless the bill has been paid,
GL 11-3-SB
3-2
09/01/01
SCHEDULE OF BENEFITS (CONTINUED)
Plan 2 - All Active Full-time Employees located outside a PPO service area
BENEFITS FOR CLASS 2
Elil:ible Class:
All Full-Time Employees located outside a PPO service area
Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are
required to contribute to the cost for Dependent Dental Coverage.
BenefIt Waitinl: Period:
Type II Procedures:
Type III Procedures:
None
6 Months
The BenefIt Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the
Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the
Policy Effective Date.
Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes
Late Entrant Limitation (when lij)J)licablc:):
Type II Procedures: 12 Months
Type III Procedures: 12 Months
DENTAL BENEFITS
CALENDAR YEAR DEDUCTIBLE
for Type II and III Procedures (combined)
INDMDUAL
F AMIL Y
$50
$150
PERCENT PAYABLE
Type I - Diagnostic & Preventive Services
Type II - Basic Services
Type III - Major Services
100%
80%
50%
CALENDAR YEAR MAXIMUM
for Type I, II and III Procedures (combined)
$2,000
GL 11-3-88
3-3
09/01/01
DEFINITIONS
\CTIVE WORK or ACTIVELY AT WORK means an employee's full-time performance of all customary duties of his or her
.Jccupation at:
(1) the Group Policyholder's place of business; or
(2) any other business location where the employee is required to travel.
Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following
days:
(1)
(2)
(3)
a Saturday, Sunday or holiday which is not a scheduled workday;
a paid vacation day, or other scheduled or unscheduled non-workday; or
an excused or emergency leave of absence (except a medical leave) of three days or less; or a leave of absence
which qualifIes under the Family and Medical Leave Act (FMLA) of 1993,
APPROPRIATE TREATMENT (includes APPROPRIATE) means the range of services and supplies by which a dental condition
may be treated, which falls within the accepted standards of dentistry. Appropriate Treatment may vary in techniques, materials
utilized and technical complexity, as well as cost.
BENEFIT WAITING PERIOD means the period of time a Covered Person must be covered for Dental Expense BenefIts -- or for a
specifIc Type of Dental Expense BenefIts -- under this Policy before that Type of Service becomes eligible for coverage,
COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home OffIce address is 8801
Indian Hills Drive, Omaha, Nebraska 68114-4066,
COVERAGE MONTH means that period of time:
(1) beginning at 12:01 A.M. on the same day of each month as this Policy's anniversary; and
(2) ending at 12:00 midnight on the day prior to the same day of the following month;
at the Group Policyholder's primary place of business.
COVERED EMPLOYEE means an eligible Employee for whom the coverage provided by this Policy is in effect.
COVERED EXPENSES, for Employees located in a PPO service area, means expenses incurred for Necessary Dental Procedures
shown on the List of Covered Dental Procedures contained in this Policy. Covered Expenses will not exceed:
(1) for a Participating Dentist, the Dentist's:
(a) fee, as allowed by the Dentist's contract with the dental network; or
(b) usual charge for a service;
whichever is less.
(2) for a Non-Participating Dentist, this Policy's Usual, Customary and Reasonable allowances.
These expenses must be Incurred for procedures performed by a Dentist or by a dental hygienist, under the direction of a Dentist The
expenses must be Incurred while covered by this Policy for those procedures for which a claim is being submitted. Covered Expenses
are subject to the terms and limitations of this Policy,
COVERED EXPENSES, for Employees located outside a PPO service area, means expenses which:
(1) are incurred for Necessary Dental Procedures shown on the List of Dental Procedures; and
(2) do not exceed the Company's Usual, Customary and Reasonable allowances.
These expenses must be Incurred for procedures performed by a Dentist or by a dental hygienist, under the direction of a Dentist The
expenses must be Incurred while cQvered by this Policy for those procedures for which a claim is being submitted. Covered Expenses
are subject to the terms and limitations of this Policy,
COVERED PERSON means an eligible Employee or an eligible Dependent for whom the coverage provided by this Policy is in
effect.
GL 11-4-DF
4
09/01/01
DEFINITIONS
(continued)
..>AY OR DATE means at 12:01 A.M" at the Group Policyholder's primary place of business; when used with regard to eligibility
dates and effective dates. It means 12:00 midnight, at the same place, when used with regard to termination dates.
DENTIST means a licensed doctor of dentistry, operating within the scope of his or her license, in the state in which he or she is
licensed, A Dentist does not include a Covered Person or a relative of the Covered Person. Relatives include spouses, siblings,
parents, children and grandparents.
DEPENDENT: See the Eligibility for Dependent Dental Coverage section of this Policy.
DEPENDENT DENTAL COVERAGE means the coverage provided by this Policy for eligible Dependents,
ELIGIBILITY WAITING PERIOD means the continuous period of time that an Employee must be employed in an eligible class
with the Group Policyholder, before he or she becomes eligible to enroll for coverage under this Policy.
This Eligibility Waiting Period may be waived for an Employee who qualifIes for reinstatement of his or her coverage, as provided in
this Policy,
EMPLOYEE means a full-time employee of the Group Policyholder:
(1) whose employment with the Group Policyholder is the employee's principal occupation;
(2) who is not a temporary or seasonal employee;
(3) who is regularly scheduled to work at such occupation at least 30 hours each week;
(4) who is a member of an employee class which is eligible for coverage under this Policy; and
(5) who is a citizen of the United States or who legally works in the United States.
EMPLOYEE DENTAL COVERAGE means the coverage provided by this Policy for eligible Employees.
EXPENSES INCURRED (includes INCURRED). An expense is Incurred at the time a service is rendered or a supply is furnished,
except that an expense is considered Incurred:
(1) for an appliance (or change to an appliance), at the time the impression is made;
(2) for a crown or bridge, at the time the tooth or teeth are prepared; and
(3) for root canal therapy, at the time the pulp chamber is opened;
provided the service is completed within 31 days from the date it is begun.
GL 11-4.1-DF FL
5
09/01/01
DEFINITIONS
(continued)
lROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy,
LATE ENTRANT means an eligible Employee who makes written application:
(1) more than 31 days after the Employee ftrst becomes eligible for Employee Dental Coverage;
(2) after Employee Dental Coverage has been cancelled; or
(3) after Employee Dental Coverage has been terminated due to failure to pay premiums when due.
LATE ENTRANT also means an eligible Dependent for whom written application is made:
(I) more than 31 days after he or she fIrst qualifIes for Dependent Dental Coverage;
(2) after the Covered Employee has requested to terminate Dependent Dental Coverage; or
(3) after Dependent Dental Coverage has been terminated due to failure to pay premiums when due.
A person will not be considered to be a Late Entrant if the Employee's spouse was covered under an employer's group dental plan; and
the spouse's dental coverage was terminated due to:
(1) termination of the dental plan by the spouse's employer; or
(2) loss of the spouse's eligibility due to termination of employment or change in the spouse's employment
classifIcation.
In order to qualify for waiving the Late Entrant Limitation, each person applying for coverage under the Group Policyholder's dental
plan must:
(1) provide proof of coverage under the spouse's prior dental plan; and
(2) enroll for coverage and pay premiums for the Group Policyholder's plan within 31 days following the loss of
coverage under the spouse's plan.
NECESSARY DENTAL PROCEDURE (includes NECESSARY and DENTAL NECESSITY) means a procedure, service or
mpply which the Company, or a qualifIed party selected by the Company, determines is:
(1) required by, and Adequate and Appropriate for the diagnosis or treatment ofa dental disease, condition or injury;
(2) Appropriate and consistent with the symptoms and fmdings, or with the diagnosis and treatment of the Covered
Person's dental disease, condition or injury;
(3) provided in accord with the generally accepted professional standards for dental practice;
(4) on the List of Dental Procedures contained in this Policy; and
(5) the most Appropriate and Professionally Adequate level of service or supply which can be provided on a cost
effective basis without adversely affecting the Covered Person's dental condition,
Necessary Dental Procedures include the Diagnostic and Preventive Services contained in the List of Dental Procedures contained in
this Policy,
The fact that a person's Dentist prescribes a service or supply does not automatically mean that such services or supplies are
considered as Necessary Dental Procedures and are covered by this Policy.
GL 11-4.2-DF
6
09/01/01
.'
DEFINITIONS
(continued)
iON-PARTICIPATING DENTIST means a Dentist who is not participating in the dental network being made available through
this Policy.
PARTICIPATING DENTIST means a Dentist who:
(1) has signed a contract with the dental network being made available through this Policy; and
(2) has agreed to abide by the rules of that network.
The Company will periodically provide the Group Policyholder with a listing of Participating Dentists for distribution to Covered
Employees, It is the Covered Employee's responsibility to verify whether the Dentist is a Participating Dentist at the time of service.
Participating Dentists are independent contractors; they are not employees or agents of the network or the Company, The Company
does not supervise, control or guarantee the services of the Participating Dentist or any other Dentist.
POLICY means this group dental policy issued by the Company to the Group Policyholder.
PROFESSIONALLY ADEQUATE (includes ADEQUATE) means the least expensive form of treatment, within the range of
Appropriate Treatments, for a given dental condition, that conforms to the accepted standards of dentistry,
TYPE (includes TYPE OF SERVICE) means a level of dental services, contained in the List of Dental Procedures and covered by
this Policy:
(1) TYPE I procedures are categorized as Diagnostic & Preventive Services, such as routine oral exams, dental x-
rays and cleanings;
(2) TYPE n procedures are categorized as Basic Services, such as fIllings, extractions and many oral surgeries;
(3) TYPE ill procedures are categorized as Major Services. Major services are generally considered the most
complex and expensive dental care, including crowns and dentures; and
(4) TYPE IV procedures provide Orthodontic Care,
USUAL, CUSTOMARY AND REASONABLE (VCR) means the allowable charge for a procedure which is the lesser of:
(1) the amount usually charged by that Dentist for the same or similar procedure(s); or
(2) the amount charged by most other Dentists, with similar training and experience within the same geographic area,
for a comparable service.
The Company will determine the size of the area needed to obtain an accurate cross-section of dental charges data. "Area" means a
city, a county, a metropolitan area or a greater area, if needed to frod a cross section of Dentist performing the same or similar
procedure.
If Covered Expenses are Incurred outside of the United States, the UCR allowance will be the amount that would be allowed for that
procedure if it had been performed at the Company's Home Office in Omaha, Nebraska.
GL 11-4,3-DF
7
09/01/01
GENERAL PROVISIONS
~NTIRE CONTRACT. The entire contract between the parties consists of:
(1) this Policy and the Group Policyholder's application (a copy of which is included with this Policy);
(2) the Participating Employer's Participation Agreement, if any; and
(3) the Covered Employees' enrollment forms, if any,
All statements made by the Group Policyholder, Participating Employers, if any, and Covered Employees are representations and not
warranties, No statement made by a Covered Employee will be used to contest the coverage provided by this Policy; unless:
(1) it is contained in a written statement signed by the Covered Employee; and
(2) a copy of the statement is furnished to the Covered Employee.
AUTHORITY TO AMEND CONTRACT. Only an OffIcer of the Company located in the Company's Home OffIce, may change
this Policy or extend the time for payment of any premium, No change will be valid unless it is made in writing and signed by the
Company OffIcer,
No person other than a Company OffIcer, or a Home OffIce employee designated by the OffIcer, has the authority, expressed or
implied, to:
(I) determine the insurability of a group or any individual within the group;
(2) make a contract in the name of the Company; or
(3) amend or waive any provision of this Policy,
INCONTESTABILITY. Except for the non-payment of premiums, the Company may not contest the validity of this Policy as to
any Covered Person after his or her coverage has been in force for two years during his or her lifetime,
NONPARTICIPATION. This Policy will not be entitled to share in the surplus earnings of the Company,
INFORMATION TO BE FURNISHED. The Group Policyholder may be required to furnish any information needed to administer
this Policy, Clerical error by the Group Policyholder will not:
(1) affect the amount of coverage which would otherwise be in effect; or
(2) continue coverage which otherwise would be terminated.
Once an error is discovered, an equitable adjustment in premium will be made, If a premium adjustment involves the return of
unearned premium, the amount of the return will be limited to the three month period which precedes the date the Company receives
proof such an adjustment should be made,
The Company may inspect any of the Group Policyholder's records which relate to this Policy,
MISSTATEMENT OF AGE. If a Covered Person's age has been misstated, premiums will be subject to an equitable adjustment. If
the amount of benefIt depends upon age; then the benefIt will be that which would have been payable, based upon the person's correct
age,
CERTIFICATES. The Group Policyholder will be furnished with individual certifIcates of coverage for delivery to each Covered
Employee. These certifIcates summarize the benefIts provided by this Policy. If tlrere is a conflict between this Policy and the
certifIcate, this Policy will control.
GL11-5-GP
8
09/01/01
CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable state law, the provision
will be deemed to conform to the minimum requirements of the law.
NORKERS' COMPENSATION, This Policy is not to be construed to provide benefIts required by Workers' Compensation laws.
COMPANY'S DISCRETIONARY AUTHORITY, By purchasing this Policy, the Group Policyholder grants the Company the
discretion and fmal authority to resolve all questions arising from the administration, interpretation and application of this Policy,
This authority includes the right to determine:
(1) eligibility for coverage;
(2) entitlement to benefIts;
(3) the amount of benefIts payable; and
(4) the amount and sufficiency of information reasonably required to make such decisions,
In making any decision, the Company may rely on the accuracy and completeness of any information furnished by the Group
Policyholder or any Covered Person. Decisions made by the Company in the exercise of its discretionary authority shall be
conclusive and binding, Failure by the Company to enforce any provision of this Policy does not render that provision unenforceable.
The Group Policyholder, as plan sponsor, agrees that the Group Policyholder retains full responsibility for the legal and tax status of
its benefIts program; and releases the Company from all responsibility for the reporting and the design of the program; and from all
other responsibilities not accepted in writing by a designated Officer in the Company's Home Office,
CURRENCY. All premiums and all claims will be payable in United States dollars.
GLI1-5-GP
9
09/01/01
ELIGffiILITY AND EFFECTIVE DATES
FORE~LOYEEDENTALCOVERAGE
ELIGffiILITY. An Employee becomes eligible for the coverage provided by this Policy on the later of:
(1) the Policy's date of issue; or
(2) the completion of the Eligibility Waiting Period as a full-time Employee,
The Eligibility Waiting Period is shown in the Schedule of BenefIts,
EFFECTIVE DATE, Employee Dental Coverage becomes effective on the latest of:
(1) the fIrst day of the Coverage Month coinciding with or next following the date the Employee becomes eligible for
the coverage;
(2) the date the Employee resumes Active Work, if not Actively at Work on the day he or she becomes eligible, The
Employee will be deemed Actively at Work on any regular non-working day, if he or she:
(a) is not totally disabled or hospital confmed on that day; and
(b) was Actively at Work on the regular working day before that day;
(3) if the Employee contributes to the cost of the Employee Dental Coverage, the fIrst day of the Coverage Month
coinciding with or next following the date the Employee makes written application for coverage; and signs:
(a) a payroll deduction order, if Covered Employees pay any part of the Policy premium for
Employee Dental Coverage; or
(b) an order to pay premiums from the Employee's Section 125 Plan account, if any contributions are
paid through a Section 125 Plan; or
(4) the fIrst day of the Coverage Month coinciding with or next following the date the Company approves a Late
Entrant's application,
GL1l-6-ELE
10
09/01/01
TERMINATION OF
EMPLOYEE DENTAL COVERAGE
fERMINATION. An Employee's coverage will terminate on the earliest of:
(1) the date this Policy is terminated (see the Policy Termination section);
(2) the last day of the Coverage Month in which the Covered Employee requests termination;
(3) the last day of the last Coverage Month for which premium payment is made on the Covered Employee's behalf;
(4) the last day of the Coverage Month in which the Covered Employee ceases to be in a class of Employees which is
eligible for coverage under this Policy;
(5) with respect to a benefIt for a specifIc Type of dental care, the date the portion of this Policy providing benefIts
for that Type of care terminates; or
(6) the last day of the Coverage Month in which the Covered Employee's employment with the Group Policyholder
terminates.
CONTINUATION OF COVERAGE. Ceasing Active Work results in termination of coverage; but Employee and Dependent Dental
Coverage may be continued as follows.
DISABILITY. If the Covered Employee is disabled due to illness or injury; then coverage may be continued until the earliest of:
(1) the date coverage has been continued for three Coverage Months after the disability begins:
(2) the date the Covered Employee is no longer disabled; or
(3) the date coverage would otherwise terminate, if the Covered Employee had remained an Active Employee;
provided premium payments are made on the Covered Employee's behalf,
LAY-OFF OR LEAVE OF ABSENCE. If the Covered Employee ceases work due to a temporary layoff or an approved leave of
absence; then coverage may be continued:
(1) for three Coverage Months after the layoff or leave of absence begins;
(2) provided premium payments are made on the Covered Employee's behalf.
If an Employee's coverage is continued as provided above, but Dependent Dental Coverage is terminated; then any Dependents who
are re-enrolled at a later date will be treated as Late Entrants,
MILITARY LEAVE OF ABSENCEffERMINATION OF EMPLOYMENT DUE TO MILITARY SERVICE. If a Covered
Employee goes on leave for military service of more than 30 days, Dental Coverage may be continued for up to 18 Coverage Months,
subject to payment of premiums.
REINSTATEMENT OF COVERAGE. The Company will reinstate Dental Coverage and waive any Eligibility Waiting Period,
new Late Entrant Limitation, or new BenefIt Waiting Period if:
(1) a Covered Employee's coverage ends due to termination of employment, reduction of hours, or going on an
approved leave of absence; and he or she returns to qualifying full-time employment within six months of that
event; or
(2) a Covered Employee's coverage ends due to military service of more than 30 days; and he or she applies for or
returns to qualifying full-time employment:
( a) by the 14th day after completing military service of31 to 180 days;
(b) by the 90th day after completing military service of 181 days or longer; or
(c) within 2 years if disabled upon completing such military service.
The Employee's accumulated leave for military service may not exceed 5 years; except as provided by federal
law.
To reinstate coverage, the Employee must enroll within 31 days after resuming Active Work; and must sign a payroll deduction order
or Section 125 Plan election, if required. An Employee who resumes Active Work or enrolls later will be treated as a new Employee.
GLlI-7-TE 98 FL
11
09/01/01
EXTENDED DENTAL BENEFITS. Extended Dental BenefIts will be paid if, on the date this Policy terminates, the Covered
Employee requires dental services due to an injury which occurred or a sickness which was diagnosed before his or her coverage
~nded, In that event, benefIts will be continued as ifhis or her coverage remained in force; provided:
( I) the attending Dentist or Physician must recommend the course of treatment or dental procedures to the Covered
Employee in writing, and start treatment while Policy coverage is in effect;
(2) the services must be other than routine exams, prophylaxis, x-rays, sealants or orthodonti<;services;
(3) the Covered Expenses are incurred within 90 days after Policy termination; and
(4) policy termination must not occur due to the Covered Employee's failure to pay premiums or request to cancel
coverage,
GLll-7-TE 98 FL
12
09/01/01
ELIGmILITY FOR
DEPENDENT DENTAL COVERAGE
JEPENDENT means a person who is a Covered Employee's:
(1) legal spouse, who is not legally separated from the Covered Employee;
(2) unmarried natural and adopted child until the end of the calendar year in which the child reaches 25 years of age,
if the child:
(a) is dependent on the Covered Employee for support;
(b) is living in the Covered Employee's household; or
(c) is a full-time or part-time student.
This includes:
(a) a child placed with Covered Employee for adoption; or
(b) a child named in a court order for which the Covered Employee is required by law to provide
dental benefIts;
(3) unmarried child age 25 years or older, who is incapable of self-sustaining employment by reason of mental
retardation or physical handicap; and who is chiefly dependent upon the Covered Employee for support and
maintenance, The child must be covered by the dental plan on the day before coverage would otherwise end due
to his or her age. Proof of the continuing handicap must be sent to the Company when a claim is denied due to
the fact the child has attained a limiting age;
(4) stepchild or foster child, who resides in the Covered Employee's household; and who is chiefly dependent upon
the Covered Employee for support; or
(5) grandchild, who is newly born to the Covered Employee's covered dependent.
ELIGmILITY. A Covered Employee becomes eligible for Dependent Dental Coverage on the latest of:
(1) the date the Covered Employee becomes eligible for Employee Dental Coverage;
(2) the effective date of this dental plan; or
(3) the date the Covered Employee fIrst acquires a Dependent.
An Employee must be covered for Employee Dental Coverage to cover his or her dependents.
When a child's parents are both Covered Employees under this Policy, the child can be covered as a Dependent of only one parent. A
spouse or child who is eligible as an Employee and a Dependent can be covered under this Policy for either Employee Dental
Coverage or Dependent Dental Coverage; but not both at the same time.
GL11-8-ELD FL
13
09/01/01
ELIGmILITY FOR
DEPENDENT DENTAL COVERAGE
ii:FFECTIVE DATES, Except as provided in the NEW DEPENDENTS section, Dependent Dental Coverage will become effective
on the latest of:
(1) the ftrst day of the Coverage Month coinciding with or next following the date the Covered Employee becomes
eligible for Dependent Dental Coverage;
(2) the ftrst day of the Coverage Month coinciding with or next following the date the Covered Employee makes
written application for Dependent Dental Coverage; and, if additional premium is required, the Employee signs:
(a) a payroll deduction order, if the Covered Employee pays any part of the premium for Dependent
Dental Coverage; or
(b) an order to pay premiums from the Employee's Section 125 Plan account, if any contributions for
Dependent Dental Coverage are paid through a Section 125 Plan account; or
(3) the fIrst day of the Coverage Month coinciding with or next following the date the Company approves a Late
Entrant application for each Dependent applying for Dependent Dental Coverage.
COURT ORDERED COVERAGE. If coverage is provided to a child based on a court order which requires the Covered Employee to
provide dental benefIts for the child, the coverage will become effective on the date stated in the court order; subject to payment of
any additional premium.
NEW DEPENDENTS. If a Covered Employee acquires a new Dependent while covered under this Policy, coverage will become
effective for the Covered Employee's Spouse or stepchild on the date the Covered Employee is married or takes custody of the child.
If additional premium is required, a written application, and a payroll deduction order or Section 125 Plan election, must be made
within 31 days of the date the Dependent is acquired.
Coverage for a Covered Employee's newborn child will be effective from the moment of birth.
Coverage for a newborn child born to any family member while this Policy is in force will be effective from the moment of birth and
will terminate 18 months after the birth of the child.
Coverage for a Covered Employee's adopted child, foster child or other child in court-ordered custody, placed in compliance with
Chapter 63, will be effective from the moment of placement in the Covered Employee's home. In the case of a newborn child,
coverage will be effective from the moment of birth if the Covered Employee has entered into such a written agreement to adopt prior
to the birth, whether or not such agreement is enforceable, However, coverage for such child shall not be required in the event that
the child is not ultimately placed in the Covered Employee's home,
Written notice of a newly acquired Dependent may be given to the Company within 31 days of the birth or placement of a child. If
timely notice is given, additional premium will not be charged for the notice period, If timely notice is not given, any applicable
additional premium will be charged from the date of birth for newborns or the date of placement in the home for an adopted child.
Coverage will not be denied for a child due to the Covered Employee failing to notify the Company, within the 3 I-day notice period,
of the birth of the child,
GL11-8-ELD FL
14
09/01/01
TERMINATION OF
DEPENDENT DENTAL COVERAGE
fERMINATION, Dental coverage on a Dependent will cease on the date he or she ceases to be an eligible Dependent, as defmed in
this Policy.
Dependent Dental Coverage will cease for all of the Covered Employee's Dependents:
(1) when the Covered Employee's Dental Coverage terminates;
(2) when Dependent Dental Coverage is discontinued under this Policy;
(3) when the Covered EOlployee ceases to be in a class of employees eligible for Dependent Dental Coverage;
(4) when the Covered Employee requests that the Dependent Dental Coverage be terminated; or
(5) on the last day of the premium paying period for which the Covered Employee has made any required
contribution toward the cost of the Dependent Dental Coverage.
SURVIVING DEPENDENTS. If Employee Dental Coverage terminates due to the Covered Employee's death, Dependent Dental
Coverage may be continued:
(1) for three Coverage Months; or any longer period, if required by state or federal law;
(2) provided the Group Policyholder submits the premium on behalf of the surviving Dependents; and this Policy
remains in force.
REINSTATEMENT OF DEPENDENT COVERAGE. If a Dependent's Dental Coverage ends due to the Employee's termination
of full-time employment, approved leave of absence, or military leave; then the Company will reinstate'Dependent coverage and
waive any Eligibility Waiting Period, new BenefIt Waiting Period, or new Late Entrant Limitation; provided the Employee:
(1) returns from termination of employment or an approved leave of absence to qualifying full-time employment
within six months; or
(2) returns to qualifying full-time employment following a military leave of up to fIve years, as provided under the
Reinstatement of Employee Coverage section,
The Covered Employee must enroll eligible Dependents within 31 days after resuming Active Work; and sign a payroll deduction
)rder or Section 125 Plan election, if required,
EXTENDED DENTAL BENEFITS. Extended Dental BenefIts will be paid if, on the date this Policy terminates, the Covered
Employee's Dependent requires dental services due to an injury which occurred or a sickness which was diagnosed before his or her
coverage ended. In that event, benefIts will be continued as ifhis or her coverage remained in force; provided:
( 1 ) the attending Dentist or Physician must recommend the course of treatment or dental procedures to the Covered
Employee's Dependent in writing, and start treatment while Policy coverage is in effect;
(2) the services must be other than routine exams, prophylaxis, x-rays, sealants or orthodontic services;
(3) the Covered Expenses are incurred within 90 days after Policy termination; and
(4) policy termination must not occur due to the Covered Employee's failure to pay premiums or request to cancel
coverage.
GL-9- TO 98 FL
15
09/01/01
PREMIUMS AND PREMIUM RATES
OAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the fIrst premium for such coverage is
t>aid. For coverage to remain in effect, each subsequent premium must be paid on or before its due date. The Group Policyholder is
responsible for paying all premiums as they become due, Premiums are payable on or before their due dates at the Company's Home
OffIce.
GRACE PERIOD. A grace period of 31 days from the due date will be allowed for the payment of each premium after the fIrst.
During the grace period, the Policy will remain in effect. However, the Group Policyholder will remain liable for payment of a pro
rata premium for the time this Policy remained in force during the grace period.
PREMIUM RATE CHANGE, The Company may change any premium rate:
(1) when this Policy's terms are changed:
(a) as agreed upon by the Group Policyholder and the Company; or
(b) as a result of a change in federal, state or local law which affects this Policy;
(2) when a division, subsidiary or affIliated company is added or removed from this Policy;
(3) when the Group Policyholder or division, subsidiary or affIliates company relocates;
(4) when the number of Covered Employees changes by 15% or more from the number covered on this Policy's
effective date or the most recent anniversary; or
(5) on any premium due date after this Policy's fIrst anniversary, or later Rate Guarantee Date agreed upon by the
Company.
Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days advance written notice of
any increase in premium rates,
PREMIUM AMOUNT. The amount of premium due on each due date will be the total of the premium amounts obtained by
multiplying:
(1) each rate shown in the Premium Rate Schedule; by
(2) the number of employee and family units covered;
and then adding the monthly billing fee, if any.
For premium purposes, the effective date of any change in coverage is the fIrst day of the Coverage Month which coincides with or
follows the change. Changes will not be pro-rated daily,
PREMIUM RATE SCHEDULE
Monthly Dental Rates
Employee Only Coverage
Employee and one Dependent
Employee and two or more Dependents
$20.93 per employee
$41.29 per family unit
$60.34 per family unit
The above rates are guaranteed until September 1, 2003, unless any of the Policy's terms or the Company's liability are
changed, as described in parts 1 through 4 of the PREMIUM RATE CHANGE section, above.
After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group Policyholder
a renewal letter prior to each Policy anniversary.
GL11-10-PR FL
16
09/01/01
POLICY TERMINATION
TERMINATION BY THE COMPANY, When terminating this Policy for a reason other than nonpayment of premium, the
Company must give the Group Policyholder at least 45 days' advance written notice of cancellation, nonrenewal or expiration of this
Policy, The Group Policyholder shall forward, as soon as practical, the notice of cancellation, nonrenewal or expiration to each
Covered Person. Until the premium rate has been in effect for at least twelve months, the Company can terminate coverage only if:
(1) the number of Covered Employees is less than ten;
(2) part of the premium is paid by Covered Employees or through a Section 125 plan; and
(a) for Employee Dental Coverage, less than 75% of the eligible Employees are covered; and/or
(b) for Dependent coverage, less than 60% of eligible Employees with dependents, are covered for
Dependent Dental Coverage;
(3) all of the premium is paid from the Group Policyholder's general funds:
(a) for Employee coverage; and less than 100% of eligible Employees are covered by the Policy; or
(b) for Employee and Dependent Coverage; and less than 100% of eligible Employees and
Dependents are covered by this Policy;
(4) the Group Policyholder fails to promptly furnish any information which the Company may reasonably require;
(5) the Group Policyholder, without good cause, fails to perform its duties pertaining to this Policy in good faith;
(6) this Policy's terms are changed as a result ofa change in federal, state or local law which affects this Policy;
(7) a division, subsidiary or affiliated company is added or removed from this Policy;
(8) the Group Policyholder or a division, subsidiary or affiliates company relocates; or
(9) when the number of Covered Employees changes by 15% or more from the number covered on this Policy's
effective date or the most recent anniversary,
In determining the above participation rates, "eligible employees" will not include any employee who declines to enroll, because it
would result in duplicate coverage:
(1) under this Policy as an Employee and a Dependent at the same time; or
(2) under this Policy and another group dental plan with his or her spouse's employer.
After the premium rate has been in effect for at least 12 months, the Company can terminate coverage on any premium due date, by
giving the Group Policyholder at least 45 days advance written notice.
TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any time by giving the
Company advance written notice. Coverage will then terminate:
(1) on the date the Company receives the notice; or
(2) any later date the Group Policyholder and the Company have agreed upon,
The Group Policyholder remains responsible for the payment of premiums to the date of termination.
AUTOMATIC TERMINATION. This Policy will terminate without any action on the part of the Company on the day before the
due date of any premium which remains unpaid at the end of the grace period,
17
(10 lives)
09/01/01
GL11-11-PT FL
DENTAL EXPENSE BENEFITS
'"\ENEFIT, The Company will pay Dental Expense BenefIts if a Covered Person incurs Covered Expenses in excess of the
..Jeductible during a Calendar Year. The Company will pay the Percentage Payable shown in the Schedule of BenefIts for that Type
of service; provided any BenefIt Waiting Period is satisfIed. BenefIts will be paid up to the Maximum shown in the Schedule of
BenefIts for each Covered Person.
BENEFIT DETERMINATION. The amount of benefIts payable for Type I, II and III Procedures will be determined as follows:
(1) Dates of service are reviewed and categorized by:
(a) services prior to effective date;
(b) services after termination date; and
(c) covered services by benefIt period or calendar year.
(2) Each procedure, service or supply is evaluated to ensure that it qualifIes as a Necessary Dental Procedure which is
determined to be Professionally Adequate under the terms of the Policy.
(3) Covered Expenses are determined, then grouped by Type of dental service. The Covered Expenses for each Type
are added,
(4) The total for each Type of dental service is reduced by any unmet Deductible amount. The total is reduced:
(a) for Type I Procedures fIrst, if the Deductible applies to Diagnostic and Preventive Procedures;
(b) for Type II Procedures next; and for Type III, last.
(5) Then, each remaining amount is multiplied by the Percent Payable for that Type of Service, to determine the
Dental Expense BenefIts payable, subject to Policy provisions, maximums, limitations and exclusions.
BenefIts for Covered Expenses are based on Dental Necessity, Services which are determined to be not Necessary are not covered by
this Policy, even if they are recommended or provided by a Dentist.
DEDUCTIBLE. The Deductible shown in the Schedule of BenefIts is the amount of Covered Expenses which must be incurred
before benefIts are payable, The Deductible applies separately to the Covered Expenses incurred by each Covered Person, BenefIts
will be based on those Covered Expenses which are in excess of the Deductible,
After Covered Expenses Incurred by all covered family members combined exceed the Family Deductible shown in the Schedule of
BenefIts, no additional Covered Expenses will be applied toward the Deductible in that Calendar Year.
BENEFIT WAITING PERIOD. The BenefIt Waiting Period is shown on the Schedule of BenefIts page of this Policy,
LATE ENTRANT LIMITATION. For a Late Entrant, Dental Expense BenefIts will be limited to Type I benefIts only; until the
Late Entrant has completed the Late Entrant Limitation, for each Type of service shown on the Schedule of BenefIts page.
GL11-12-DB
18
09101/01
ALTERNATIVE PROCEDURES
There may be two or more methods of treating a dental condition, The amount of Covered Expense will be limited to the charge for
the least costly procedure or treatment which:
(1) the dental profession recognizes to be Professionally Adequate, in accord with widely accepted standards of
dental practice; and
(2) the Company determines to be both Adequate and Appropriate, in view of the Covered Person's total current oral
condition.
To determine its liability for a dental procedure submitted for consideration, the Company may request the pre-operative dental x-rays
and any other pertinent information. Based on its review of this information, the Company will decide which procedure would
provide Professionally Adequate restoration, replacement or treatment.
The Covered Person may receive the more expensive procedure or treatment. However, the Company's liability for Covered Expense
will be limited to the least expensive procedure which it determines to be Professionally Adequate care.
To frod out in advance what charges or alternative procedures will be considered Covered Expenses, a Covered Employee may use
the Dental Claim Procedure for Predetermination of BenefIts, described in this Policy,
GLll-13-AP
19
09/01/01
LIMITATIONS AND EXCLUSIONS
'::overed Expenses will not include, and Dental Expense BenefIts will not be payable, for:
(1) any procedure begun:
(a) before the Covered Person was covered under this Policy, subject to the Prior Carrier Credit
Provision, if included in this Policy; or
(b) after termination of the Covered Person's coverage under this Policy,
(2) treatment or service which:
(a) is not recommended by a Dentist or is not provided by or under the direct supervision of a Dentist;
(b) is not a Necessary Dental Procedure, required for the care and treatment of a dental condition, as
determined by the Company;
(c) is not specifIcally listed as covered by this Policy;
(d) does not meet accepted standards of dental practice;
(e) is considered experimental or unproven in nature; or
(f) is provided by a physician or other health care provider, but is beyond the scope of his or her
license,
(3) charges which exceed Covered Expenses, as defmed in this Policy. BenefIts will not be payable when:
(a) total benefIt payments would exceed the annual maximum benefIts payable under this Policy; or
(b) services exceed the frequency limitations contained in this Policy.
(4) procedures which are subject to a BenefIt Waiting Period or a Late Entrant Limitation, until that BenefIt Waiting
Period or Late Entrant Limitation has been satisfIed.
(5) Orthodontic Procedures.
(6) any treatment or services which:
(a) are for mainly cosmetic purposes (facings or veneers on crowns or pontics distal to the second
bicuspid will be considered cosmetic); or
(b) are related to the repair or replacement of any prior cosmetic procedure,
(7) services related to the repair or replacement of third molars (wisdom teeth) with prostheses,
(8) bone grafts or any regenerative procedure in an extraction site.
(9) any procedure related to a dental disease or injury to natural teeth or bones of the jaw, which is considered a
covered service under any group medical plan,
(10) orthognathic recording, orthognathic surgery, osteoplasty, osteotomy, LeFort procedure, stomatoplasty or
magnetic resonance imaging (MRIs),
(11) initial placement of any prosthetic appliance or fIxed bridge; unless such placement is needed to replace one or
more functioning natural teeth extracted while the Covered Person is covered under this Policy, subject to the
Prior Carrier Credit Provision, if included in this Policy. Any such appliance or fIxed bridge must include the
replacement of the extracted tooth or teeth.
20
Has TMJ, (I-ill)
09/01/01
GL11-16B-EX FL
(12) the retreatment or adjustment, recementation, reline, rebase, replacement or repair of cast restorations, crowns and
prostheses, when made by the same Dentist or dental office which provided the initial service, within 6 months of
the completion of the service,
(13) the replacement of:
(a) any full or partial denture, within fIve years; or
(b) fIXed prosthetic (crown, inlay or onlay restoration, or fIxed bridge) within eight years;
of the date of the last placement of these items, If a replacement is required because of an accidental dental injury
sustained while the Covered Person is covered under this Policy, it will be a Covered Expense. (Damage
resulting from biting food or other objects is not considered to be an accidental injury.)
(14) the insertion, maintenance or removal of implants, and any related expenses.
(15) specialized procedures, including:
(a) precision or semi-precision attachments;
(b) precious metals for removable appliances;
(c) overlays and overdentures; or
(d) personalization or characterization,
(16) duplicate prosthetics, or for initial placement or replacement of athletic mouth guards, bruxism appliances or any
appliance to correct harmful habits; and for replacement of:
(a) space maintainers; or
(b) misplaced, lost or stolen dental appliances,
(17) appliances, restorations or procedures, or their modifIcations, that:
(a) alter vertical dimension;
(b) restore or maintain occlusion or for occlusal adjustment or equilibration; or
(c) splint teeth or replace tooth structure lost as a result of erosion, abfraction, abrasion or attrition,
(18) charges for services provided by:
(a) an ambulatory surgical facility;
(b) a hospital;
(c) any other facility; or
(d) an anesthesiologist.
(19) analgesia, sedation, hypnosis or acupuncture, for anxiety or apprehension.
(20) any medications administered outside the dentist's office or for prescription drugs.
(21) charges which do not directly provide treatment for a dental injury or condition, such as:
(a) the completion of claim forms;
(b) broken appointments;
(c) interest or collection charges;
(d) sales or other taxes or surcharges;
(e) education, training and supplies used for dietary or nutritional counseling, personal oral hygiene
or dental plaque control;
(f) caries susceptibility tests, bacteriologic studies, histopathologic exams or pulp vitality testing; or
(g) duplication ofx-.rays or other dental records.
GLll-16B-EX FL
21
Has TMJ, (I-ill)
09/01/01
(22) itemized or separated charges for dental services, supplies or materials when those services, supplies and
materials may be combined into a single, more comprehensive procedure payable under this Policy. This also
includes itemized charges which are routinely included in the Dentist's charge for the primary service, such as:
(a) sterilization or asepsis charges;
(b) a charge for local anesthesia;
(c) charges for pre- and post-operative care;
(d) temporary dental services (for example, a temporary crown), which are considered to be part of
the permanent service. If the temporary service is billed separately, benefIts for the temporary
service will be deducted from the amount payable for the permanent service.
(23) duplication of services.
(24) charges for which the Covered Person is not liable, or which would not have been made had no coverage been in
force.
(25) a Covered Person's dental injury or condition:
(a) for which he or she is paid under Workers' Compensation or any similar law; or
(b) sustained while performing military service,
(26) services received for dental conditions caused directly or indirectly by:
(a) war or an act of war;
(b) intentionally self-inflicted injury;
(c) engaging in an illegal occupation;
(d) commission or attempt to commit a felony; or
(e) a Covered Person's active participation in a riot.
(27) treatment rendered by a Dentist or dental hygienist:
(a) who ordinarily resides in the Covered Person's household; or
(b) who is related to the Covered Employee or Dependent by blood, marriage or legal adoption,
"Related" persons include the Employee's or Dependent's spouse, siblings, parents, children and
grandparents.
(28) root planing; unless the presence of periodontal disease (bone and attachment loss of 4mm or more) is confmned
by x-rays and pocket depth charting of each tooth involved.
22
Has lMJ, (I-Ill)
09/01/01
GLll-16B-EX FL
COORDINATION OF DENTAL EXPENSE BENEFITS
-";FFECT ON BENEFITS, If a Covered Person is covered by another Plan, the Dental Expense BenefIts under this Policy and
JenefIts under the other Plan( s) will be coordinated for the Claim Period. The Order of BenefIt Determination Rules on the next page
decide which Plan pays fIrst.
(1) Primary Benefits, When this Plan must pay its full benefIts fIrst, the Dental Expense BenefIts under this Policy
will be paid as if the other coverage did not exist.
(2) Secondary Benefits. When another Plan must pay its full benefIts fIrst, the Dental Expense BenefIts under this
Policy:
(a) will be calculated as if the other coverage did not exist; and then
(b) will be reduced so that total benefIts, from all Plans combined, will not exceed 100% of the
Allowable Expenses incurred by the Claimant during that Claim Period,
BenefIts will be coordinated with any benefIt amounts that would be payable for the Allowable Expenses under the other Plan(s),
whether or not claim is actually made. When this Plan's benefIts are reduced, each benefIt is reduced in proportion, Then, the
reduced benefIt payments are applied towards the Maximums of this Plan.
BENEFIT SAVINGS, The amount by which this Plan's benefIts have been reduced due to such coordination will accrue during the
Claim Period. This amount will be used to pay any Allowable Expenses which:
(I) are incurred by that Claimant during the same Claim Period; and
(2) are not otherwise paid by any Plan,
DEFINITIONS. The following definitions apply only to this coordination provision.
"Plan" means any group hospital, surgical, medical or dental expense policy, group health care services plan, or group type self-
insurance plan that provides protection or insurance against hospital, surgical, medical or dental expenses or services, including:
(I) Blue Cross and Blue Shield group plans;
(2) Health Maintenance Organization (HMO) and Dental Maintenance Organization (DMO) plans; and
(3) other prepayment, group practice and individual practice plans.
It also includes any coverage under a government medical or dental plan required or provided by law; except Medicaid, This Plan
must pay its benefIts before Medicaid pays. Coordination with Medicare will be in accord with federal law.
Each of the above coverages is a separate Plan. If an arrangement has two or more parts, and its coordination provision applies only
to some benefIts or services; then each part is a separate plan,
"Allowable Expense" means any necessary, reasonable and customary expense for dental care, which is at least partly covered under
at least one of the Plans covering the Claimant. When a Plan provides benefIts in the form of services rather than cash payments, the
reasonable cash value of each service rendered during the Claim Period will be considered Allowable Expense.
"Claimant" means the Covered Person for whom claim is made,
"Claim Period" means a calendar year (or part of a calendar year) during which the Claimant has been covered under this Policy.
23
Savings
09/01/01
GL11-17-COB FL
ORDER OF BENEFIT DETERMINATION RULES, To decide which Plan pays fIrst, the Company will use the fIrst of the
following rules which applies.
(1) Noncoordinated/Coordinated Plan. A Plan without a coordination provision will pay its benefIts before a Plan
which includes a coordination provision.
(2) Nondependent/Dependent. A Plan covering the Claimant as an employee, member or subscriber will pay its
benefIts before a Plan covering the Claimant as a dependent.
(3) Child of Parents Not Separated or Divorced, If the Claimant is a dependent child whose parents are not
separated or divorced, the Plan of the parent whose birthday falls earlier in the calendar year will pay fIrst.
However:
(a) if both parents have the same birthday, the Plan which has covered the parent longer will pay fIrst;
and
(b) if the Plan coordinates benefIts based upon the sex of the parents, the male parent's plan will pay
fIrs t.
(4) Child of Separated or Divorced Parents. If the Claimant is a dependent child whose parents are separated or
divorced, then:
(a) the Plan of the parent who is required by court decree to pay the child's dental expenses will pay
fIrst;
(b) provided the Plan receives notice of the court decree before paying or providing benefIts.
If there is no notice of a court decree requiring payment of such expense, then:
(a) the custodial parent's Plan pays fIrst;
(b) the Plan of the custodial parent's spouse pays next (if the custodial parent is remarried); and
(c) the noncustodial parent's Plan pays last.
When a noncustodial parent is responsible for the Claimant's dental expenses, benefIts may be paid
directly to the provider, if the custodial parent requests this.
(5) Active/Inactive Employee, A Plan covering the Claimant as a laid off or retired employee (or a dependent of
such an employee) will pay after a Plan covering the Claimant on some other basis; provided the other Plan:
(a) includes this coordination rule for laid off or retired employees; or
(b) is issued in a state which requires this rule by law,
A Plan covering the Claimant pursuant to federal COBRA Continuation law will pay after a Plan
covering the Claimant as an employee (or a dependent of an employee).
(6) Leneth of Coveraee. If none of the above rules apply, then the Plan which has covered the Claimant longer will
pay fIrst.
RIGHT TO EXCHANGE DATA. To determine the benefIts payable under this section, the Company has the right to exchange
information with any insurance company, organization or person. Such data may be exchanged without the consent of (or any notice
to) the Covered Person, A Covered Person who claims benefIts under this Policy must provide the Company with the data required to
apply this Section,
PAYMENT AND OVERPAYMENT. Other Plans may make payments which this Plan should have made in accord with this
Section, In that event, the Company has the right to reimburse any amount it deems necessary to satisfy the intent of this Section, If
the Company pays such benefIts to an organization in good faith, it will not be liable to the extent of the payment.
The Company also has the right to recover any overpayment it makes because of coverage under another Plan, The Company may
recover the amounts needed to satisfy the intent of this Section from any insurance company, organization or person to or for whom
Policy benefIts were paid.
24
Savings
09/01/01
GL11-17.1 COB
CL~SPROCEDURES
FOR DENTAL COVERAGE
80TICE OF CLAIM, Written notice of a claim for Dental Expense BenefIts must be given within 20 days after the claim occurs.
The notice must be sent to the Company's Home Office and should include:
(1) the Group Policyholder's (or Participating Employer's) name and Policy number;
(2) the Covered Employee's name, address and certifIcate number, if available; and
(3) the name and relationship of the claimant.
If it is not reasonably possible to send notice in the time required, the claim will not be reduced or denied solely for this reason;
provided notice is sent as soon as reasonably possible,
CLAIM FORMS, When notice of claim is received, the Company will send forms for fIling the required proof to the Covered
Employee. If the Covered Employee does not receive these forms within 15 days, the proof of claim requirement may be met by
giving the Company a written statement of the nature and extent of the claim within the time limit stated in the Proof of Claim
provision,
PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the date of services. If it is not
reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason; provided
proof is fIled as soon as reasonably possible. In any event, proof of the claim must be given no later than one year from such time,
unless the claimant was legally incapacitated.
Proof of claim may include:
(1) a description of the services provided and the Dentist's charges for those services;
(2) study models, treatment records or charting; and
(3) copies of x-rays or other diagnostic materials.
APPEAL PROCEDURE. The Covered Employee may request a claim review or appeal a claim decision within 60 days after
receiving the written notice; by sending the Company a written request, along with any written comments or other items to support the
appeal.
The Company will make its decision within 60 days of its receipt of the appeal; or within 120 days, if an unusual circumstance
requires an extension of time to investigate and consider the appeal.
TIME OF PAYMENT, The Company will pay any Dental Expense BenefIts within 45 days after receipt of acceptable Proof of
Loss. If benefIts have not been assigned, the Company has the option either to pay the Covered Employee or the provider of services,
unless prior to payment the Covered Employee requests otherwise in writing. The Covered Employee or any assignee will be notifIed
in writing within 45 days after receipt of a claim if the claim or any part of it is contested or denied. The notice will identify the
contested portion of the claim and the reasons for the contest or denial. The Company will payor deny any claim within 120 days of
its receipt and payor deny any contested claim within 60 days after receipt of any additional information requested from the Covered
Employee or his assignees. Upon written notice, the Company will investigate a Covered Employee's claim of improper billing by a
provider of services. If the Company determines the billing was improper, the Company will notify the provider, make an appropriate
reduction in the amount of the payment to the provider and pay the Covered Employee the lesser of 20% of the reduction or $500,
GLlI-18-CP FL
25
09/01/01
TO WHOM PAYABLE. Dental Expense BenefIts will be paid to the Covered Employee; unless such benefIts have been assigned or
an overpayment has been made.
fHIRD PARTY RESPONSIBILITY. If a Covered Person is injured through the act or omission of a third party, and benefIts are
paid by this Policy due to that injury; then the Company is entitled to a refund of such benefIts paid, to the extent any recovery is
made by the Covered Person.
Upon request, the Covered Person must complete and sign any recovery forms requested by the Company.
The Company may fIle a lien for this refund of benefIts,
LEGAL ACTIONS. No legal action to recover any benefIts may be brought until 60 days after the required written Proof of Claim
has been submitted. No legal action may be brought after the expiration of the applicable statute oflimitations from the time written
Proof of Claim is required to be given.
PHYSICAL EXAMINATIONS. While a dental claim is pending, the Company may (at its expense):
(I) examine any pre-operative dental x-rays and any other pertinent information; and
(2) have the Covered Employee or covered Dependent examined, as often as is reasonably necessary,
GLll-18-CP FL
26
09/01/01
DENTAL CLADM PROCEDURE
for
PREDETERMINATION OF BENEFITS
If a Covered Person is advised to have non-emergency dental treatment which will cost $300 or more, he or she should fmd out in
advance what charges may be considered Covered Expenses under this Policy.
To use this procedure:
(1) the Covered Employee should request a claim form and take it to the Dentist;
(2) the Dentist will list the proposed procedures and fees on the claim form and return it to the Company; and
(3) the Company will verify current eligibility and determine what benefIts would be payable for the procedures
listed.
GL11-19B-PD
')7
OQ/01/01
DENTAL COVERAGE CONTINUATION
"lbe following provisions comply with the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended,
fhese provisions apply when Dental Coverage is provided by a private Employer with 20 or more employees (as dermed by
COBRA), Any further changes made to the COBRA continuation requirements will automatically apply to these continuation
provisions.
RIGHT TO CONTINUE, Insurance may be continued in accord with the following provisions when:
(1) a Covered Person becomes ineligible for Policy coverage due to a Qualifying Event shown below; and
(2) this Policy remains in force,
"Qualifying Event" means one of the following events, if it would otherwise result in a QualifIed COBRA BenefIciary's loss of
Policy coverage:
(1) the Covered Employee's termination of employment or hours reduction;
(2) the Covered Employee's death, divorce or legal separation;
(3) the Covered Employee's becoming entitled to Medicare benefIts; or
(4) a child's ceasing to be an eligible Covered Dependent, under the terms of this Policy.
"Qualified Beneficiary" means the Covered Employee and any Covered Dependent who is entitled to continue insurance under this
Policy, from the date of the Covered Employee's fIrst Qualifying Event. It also includes the Covered Employee's natural child, legally
adopted child or child placed for the purpose of adoption; when the new child:
(1) is acquired during the Covered Employee's 18- or 29-month continuation period; and
(2) is enrolled for insurance in accord with the terms of this Policy.
But it does not include the Covered Employee's new spouse, stepchild or foster child acquired during that continuation period;
whether or not the new Dependent is enrolled for Policy coverage.
CONTINUATION PERIODS. The maximum period of continued coverage for each Qualifying Event shall be as follows,
Termination of Employment. When eligibility ends due to the Covered Employee's termination of employment; then coverage for
the Covered Employee and any Covered Dependents may be continued for up to 18 months, from the date employment ended.
Termination of employment includes a reduction in hours or retirement. Exceptions:
(1) Misconduct. If the Covered Employee's termination of employment is for gross misconduct, coverage may not
be continued for the Covered Employee or any Covered Dependents,
(2) Disability, "Disability" or "Disabled" as used in this section, shall be as dermed by Title II or XVI of the Social
Security Act and determined by the Social Security Administration,
If the Covered Employee:
(a) becomes disabled by the 60th day after his or her employment ends; and
(b) is covered for Social Security Disability Income benefIts;
then coverage for the Covered Employee and any Covered Dependents may be continued for up to 29
months, from the date the Covered Employee's employment ended,
If the Covered Employee's Dependent:
(a) becomes disabled by the 60th day after the Covered Employee's employment ends; and
(b) is covered for Social Security Disability IDcome benefIts;
then coverage for that Covered Dependent may be continued for up to 29 months, from the date the
Covered Employee's employment ended.
GLll-20-COBRA
28
09/01/01
. .
The Covered Employee must send the Company a copy of the Social Security Administration's notice of
disability status:
(a) within 60 days after they fmd that the Covered Person is disabled, and before the I8-month
continuation period expires; and again
(b) within 30 days after they fmd that he or she is no longer disabled.
(3) Subsequent Qualifyin(: Event. If the Covered Employee's Dependent:
(a) is a QualifIed BenefIciary; and
(b) has a subsequent Qualifying Event during the 18- or 29-month continuation period;
then coverage for that Covered Dependent may be continued for up to 36 months, from the date the
Covered Employee's employment ended.
Loss of Dependent Eli&ibility. If a Covered Dependent's eligibility ends, due to a Qualifying Event other than the Covered
Employee's termination of employment; then that Dependent's coverage may be continued for up to 36 months, from the date of the
event. Such events may include:
(1) the Covered Employee's death, divorce, legal separation, or Medicare entitlement; and
(2) a child's reaching the age limit, getting married or ceasing to be a full-time student.
One or more subsequent Qualifying Events may occur during the Covered Dependent's 36-month period of continued coverage; but
coverage may not be continued beyond 36 months, from the date of the fIrst event.
Medicare Entitlement. If the Covered Employee's eligibility under this Policy ends when he or she becomes entitled to Medicare
benefIts; then coverage may not be continued for the Covered Employee, But coverage may be continued for any Covered
Dependents for up to 36 months, from the Covered Employee's Medicare entitlement date.
If the Covered Employee's eligibility under this Policy continues beyond Medicare entitlement, but later ends upon termination of
employment or retirement; then any Covered Dependents may continue coverage for up to:
(1) 36 months from the Covered Employee's Medicare entitlement date; or
(2) 18 months from the date the Covered Employee's employment ended (whichever is later),
NOTICE REQUIREMENTS. The Group Policyholder is required by law to notify the Company within 30 days after the following
Qualifying Events:
(1) the Covered Employee's termination of employment, hours reduction or retirement; and
(2) the Covered Employee's death or becoming entitled to Medicare benefIts,
The Covered Employee:
(1) must notify the Group Policyholder within 60 days of a divorce; a legal separation; or a child's ceasing to be an
eligible Dependent, as defmed by this Policy; and
(2) must notify the Company within 60 days of the Social Security Administration's fInding that a Covered Person
was disabled within 60 days after the Covered Employee's termination of employment.
ELECTION. To continue Dental Insurance, the Covered Person must notify the Group Policyholder of such election within 60 days
from the latest of:
(1) the date of the Qualifying Event;
(2) the date coverage would otherwise end due to the Qualifying Event; or
(3) the date the Group Policyholder sends notice of the right to continue,
Payment for the cost of the insurance for the period prior to the election must be made to the Group Policyholder, within 45 days after
the date of such election, Subsequent payments are to be made to the Group Policyholder, in the manner described by the Group
Policyholder. The Group Policyholder will remit all payments to the Company.
GL11-20-COBRA
29
09/01/01
TERMINATION, Continued coverage will end at the earliest of the following dates:
(1) the end of the maximum period of continued coverage shown above;
(2) the date this Policy or the Employer's participation under this Policy terminates;
(3) the last day of the period of coverage for which premium has been paid, if any premium is not paid when due;
(4) the date on which the Covered Person:
(a) again becomes covered under this Policy;
(b) becomes eligible for benefIts under Medicare; or
(c) becomes covered under any other group dental plan, as an employee or otherwise.
OTHER CONTINUATION PROVISIONS. If any other continuation privilege is available to the Covered Person under this
Policy, it will apply as follows.
(1) EMLA. If a Covered Employee continues coverage during leave subject to the Family and Medical Leave Act
(FMLA); then COBRA continuation may be elected from the day after the FMLA continuation period ends.
(2) .Q1bu, If a Covered Person continues coverage under any other continuation privilege under this Policy; then
that continuation period will run concurrently with any COBRA continuation period provided above.
Another continuation privilege may provide a shorter continuation period, for which the Employer pays all or part of the premium, In
that event, the Covered Person's share of the premium may increase for the rest of the COBRA continuation period provided above,
GL11-20-COBRA
30
09/01/01
LIST OF DENTAL PROCEDURES
TYPE I PROCEDURES
DIAGNOSTIC & PREVENTIVE SERVICES
DIAGNOSTIC SERVICES
ORAL EXAMINATIONS
- up to two per calendar year
DENTAL X-RAYS
- x-rays taken for orthodontia or for the diagnosis and treatment of craniomandibular or
temporomandibular (TMJ) joint disorders are not covered under this provision of this Policy
Bitewing films
- up to four per calendar year, including any bitewings taken as part of a full mouth or panoramic series
Panoramic x-rays, including bitewings; or
Full mouth x-rays, with periapical x-rays and bitewings
- one complete full mouth or panoramic series in any fIve consecutive years
Other dental x-rays, needed to diagnose a specific dental condition
- maximum of 6 per calendar year
PREVENTIVE CARE
PROPHYLAXIS (Routine Cleanings)
- up to two per calendar year
- includes scaling, removal of stain and polishing of teeth
FLUORIDE TREATMENTS
- one treatment per calendar year
- for Dependent children through age 15
SPACE MAINT AlNERS (passive Appliance)
- for Dependent children through age 15
- for the purpose of maintaining spaces created by the premature loss of primary teeth
- includes all adjustments within six months after installation
- does not include repairs and replacement costs
GL11-DP.l
31
09/01/01
TYPE II PROCEDURES
BASIC SERVICES
SEALANTS:
- for Dependent children through age 15
- for the occlusal surface ofunrestored and non-decayed fIrst and second permanent molars only
- one treatment per tooth in any 36 consecutive months
BASIC RESTORATIONS
Fillings: amalgam, silicate or composite
- benefIts for composite fIllings of posterior teeth will be limited to the amount payable for an
equivalent amalgam fIlling
- multiple restorations on the same tooth will be treated as one restoration with multiple surfaces; and
multiple restorations on one surface or adjacent surfaces will be treated as one restoration
Prefabricated stainless steel or resin crowns
- for covered Dependent children through age 15
- one per tooth, in any 5 consecutive years
ORAL SURGERY
- oral surgery includes local anesthesia and routine post operative visits
Simple extraction
Surgical removal of erupted tooth
Removal of impacted tooth (soft tissue, partially or completely bony)
Surgical exposure of impacted or unerupted tooth, to aid eruption
- extractions of asymptomatic teeth, except third molars (wisdom teeth), are not covered
- where related to orthodontic treatment, extractions and surgical exposure of teeth are not covered
under this provision
Removal of exposed roots
Surgical removal of residual tooth roots
Excision of lesions, malignant or benign tumors
Radical resection of bone for tumor with bone graft
Incision and removal of foreign body from soft tissue
Removal of foreign body from bone
Maxillary sinusotomy for removal of tooth fragment or foreign body
Suture of soft tissue wound
- excludes closure of surgical incisions
Incision and drainage of abscess, intraoral or extraoral
Frenulectomy
Sialolithotomy and Sialodochoplasty
Dilation of salivary duct
Sequestrectomy for osteomyelitis or bone abscess
Closure of fistula, salivary or oroantral
Reimplantation of tooth or tooth bud
GLII-DP.2h
32
09/01101
TYPE n PROCEDURES (continued)
PATHOLOGY
Biopsy and examination of oral tissue
ADMINISTRATION OF ANESTHESIA
General anesthesia or I.V. sedation
- administered in the Dentist's offIce by the Dentist or other person licensed to administer anesthesia
payable in connection with a Necessary complex oral surgery procedure
payable when underlying medical condition, age or health factors render anesthesia medically
necessary
not covered when benefIts for the accompanying surgical procedure are not payable
not covered when administered due to patient anxiety
anesthesia for orthodontic procedures (or for procedures to treat craniomandibular or
temporomandibular joint disorders where required by state law) is not covered under this provision of
this Policy
EMffiRGENCYTREATMffiNT
Emergency examination and palIiative treatment
Palliative treatment is limited to:
opening and drainage of a tooth when no endodontics is to follow
- smoothing down a chipped tooth
- drysockettreatment
- pericoronitis treatment
- treatment for apthous ulcers
BenefIts for emergency treatment are payable only if services are rendered in order to relieve dental pain or
dental injury
CONSULTATIONS
Diagnostic services
- provided by a Dentist other than the Dentist providing any treatment
- payable if no other services are rendered
ENDODONTICS (treatment of diseases of root canal, periapical tissue and pulp chamber)
Pulpotomy
- primary teeth only
Root canal therapy
- permanent teeth only
- includes necessary x-rays and cultures
Apexification
Apicoectomy
Root amputation
Hemisection
OTHER BASIC SERVICES
Injection of antibiotics
- by the Dentist, in the Dentist's office
GL11-DP.2
33
09/01/01
TYPE n PROCEDURES (continued)
PERIODONTICS (treatment of disease of the soft tissue or bone surrounding the tooth)
- periodontal therapy is not covered unless bone and attachment loss is 4 mm or greater, by quadrant;
and confIrmed by x-rays and pocket depth charting for each tooth
- surgical treatment includes post operative visits
- benefIts for multiple periodontal surgeries within the same quadrant on the same day will be paid
based on the most comprehensive procedure provided that day
Gingivectomy or gingivoplasty, by tooth or quadrant
Osseous or mucogingival surgery
- one per quadrant in each 36 consecutive months
Soft tissue graft
Bone replacement graft
Subepithial connective tissue graft
Guided tissue regeneration, per tooth
Crown lengthening, per tooth
Scaling and root planing, per quadrant, for pathological alveolar bone loss
- one treatment per quadrant in each 24 consecutive months
Periodontal maintenance c1eanings
- following active periodontal therapy
- four per calendar year; but no more than two in any calendar year if benefIts are paid for two routine
c1eanings in that same calendar year
Chemotherapeutics, for areas of refractory disease
localized delivery of chemotherapeutic agent by means of a controlled release vehicle
- following active periodontal therapy which has failed to resolve the condition
- does not include irrigation
REPAIR of PROSTHETICS
- no benefIts are payable within six months of installation if the repair is provided by the same Dentist
who installed the prosthetic
Repair of dentures
- Repair of complete denture includes repair of broken base and replacement of missing or broken teeth
- Repair of partial dentures includes repair of acrylic saddles on base, cast framework, repair or
replacement of broken clasp, and replacement of missing or broken teeth
Repair or recementation of inlays, crowns and bridges
GL11-DP,2
34
09/01/01
TYPE III PROCEDURES
MAJOR SERVICES
MAJOR RESTORATIONS
Inlays and onlays
Crowns and posts
- not covered for claimants prior to age 16
Crown build-up, in conjunction with a crown
Cast post and core, in conjunction with a crown
Cast post, as part of a crown
- Inlays, onlays and crowns are covered only when needed due to substantial loss of tooth structure
caused by decay or accidental injury to teeth, which cannot be repaired by fIllings
- replacement of inlays, onlays and crowns is limited to one time in any eight years
ORAL SURGERY - ALVEOLAR OR GINGIVAL RECONSTRUCTION
Alveolectomy (with or without extractions)
Vestibuloplasty
Removal of exostosis of the maxilla or mandible
- includes removal of tori
Excision of hyperplastic tissue
PROSTHODONTICS - Fixed or Removable
Services to replace teeth extracted or accidentally lost while covered under, this Policy
- precision attachments, overdentures, specialized techniques and characterizations are not covered
Bridge abutments and pontics
- replacement is limited to one time in any eight consecutive years
Dentures
- includes adjustments, within six months of placement
- replacement is limited to once in any fIve consecutive years, per denture
- fees for partial dentures include all conventional clasps, rests and teeth
Complete denture - upper or lower
Partial denture - upper or lower
- acrylic base or predominantly base cast with acrylic saddles
Removable unilateral partial denture
- one piece, predominantly base casting, clasp attachments (including pontics)
Adjustments to dentures, more than six months after installation
Special tissue conditioning
- one per arch per calendar year
Reline of complete or partial denture
- once in any 36 consecutive months, per denture
Rebase of complete or partial denture
- once in any fIve consecutive years, per denture
Addition of teeth or c1asp(s) to existing partial denture to replace natural teeth extracted or accidentally lost while
covered under this Policy
GL11-DP.3
35
09/01/01
TYPE III PROCEDURES (continued)
SURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINT
- includes anesthesia and postoperative care
- reduction of dislocation, open or closed
- manipulation under general anesthesia
- condylectomy
- excision or repair of disc
- synovectomy
- myotomy
- joint reconstruction
- arthrotomy
- arthroplasty
- arthrocentesis
- arthroscopy
GL11-DP.3
36
09/01/01
AMENDMENT TO BE ATIACHED TO AND MADE PART OF GROUP POLICY NO.: XXXXXXXXXXX
ISSUED TO: Florida - Dental Specimen
PRIOR CARRIER CREDIT PROVISION. This provision applies when:
(1) the Schedule of BenefIts shows that the Prior Carrier Credit Provision applies; and
(2) the Covered Person:
(a) is covered under the Group Policyholder's prior group dental plan on the day before Dental
Expense BenefIts under this Policy take effect; and
(b) immediately becomes covered under this dental plan on the day the Group Policyholder's Dental
Expense BenefIts under this Policy take effect.
If this provision applies, then the Covered Person's Dental Expense BenefIts will be payable as follows,
(1) Any amounts used to satisfy the Covered Person's Deductible under the prior plan will be credited towards the
satisfaction of his or her Deductible under this Policy; provided:
(a) the expenses would be Covered Expenses under this Policy;
(b) the expenses are incurred during the same Calendar Year in which Dental Expense BenefIts under
this Policy take effect; and
(c) the Covered Person sends the Company a claim worksheet explaining the benefIts paid by the
prior plan.
(2) The Covered Person's continuous months of coverage under the prior plan just before it terminated will count
towards this Policy's BenefIt Waiting Period for Type II Procedures (Basic Care) or Type III Services (Major
Care), ifany.
(3) Expense that the Covered Person incurs for initial placement of a prosthetic appliance or fIxed bridge will be
covered; provided:
(a) the placement is needed to replace one or more natural teeth extracted while insured for Dental
Expense BenefIts under this Policy or under the prior plan;
(b) the replacement would have been covered under the prior plan; and
(c) the extracted teeth are not third molars (wisdom teeth),
This amendment takes effect on the day the Group Policyholder's Dental Expense BenefIts under this Policy take effect. In all other
respects, this Policy remains the same.
Jefferson Pilot Financial Insurance Company
Error! Not a valid rIlename.
GL11-R-PIC.2
37
09/01/01
Presented to City of Sunny Isles Beach
EYEMED VISION CARE in conjunction with FIDELITY SECURITY UFE INSURANCE COMPANY
Premier-Plus Benefit
Funded Vision Benef"rt with a $100 Frame Allowance and $115 Contact Lens Allowance
2 Tier Rates
Groups of 10 - 500 Eligible Employees
Non-Voluntary Rates valid with a Minimum of 10 Enrolled Employees
24 Month Contract Term
Valid for Groups Domiciled in the State of:
Florida
Beneftt Design Summary:
(See attached detailed benefit design summary for description of Lens Options, Laser Vision Discount and Out of Network Benefits)
Exam with dilation as necessary
$100 Frame Allowance
Standard Plastic Lenses
$115 Contact Lens Allowance
Once every 12 months
Once every 24 months
Once every 12 months
Once every 12 months
Member Co-pay at time of Service:
$10 Exam Co-pay
$25 Lens Co-pay
Monthly Fee:
Employee Only
Employee + Family
$4.79 per month
$11A2 per month
Plan Terms and Conditions:
. Fees quoted are valid for plan start dates of 10/1/01 through 1211102.
. The above selected plan requires a 24 month contract term and the rates are guaranteed for 24 months.
. Non-Voluntary Rates assume 100% employer contribution for employees and dependents or that the vision
program is bundled with medlcaVdental benefit. Minimum 10 enrolled employees required.
. Children eligible as dependents included in coverage are defined as unmarried children up to age 19 and full time students
up to age 25 who are primarily dependent on subscriber for support.
. Rates are valid for groups with 10 - 500 eligible employees.
. Rates are valid for commercial groups, government agencies, municipalities, churches, school districts, public or private
colleges, unions and charitable organizations.
. Vision plan is underwritten by Fidelity Security Life Insurance Company of Kansas City Missouri,
If City of Sunny Isles Beach has chosen this benefit design, stated monthly rates, plan frequency and co-pay
options, attach this document to the group application and sign here:
City of Sunny Isles Beach Representative
Signature:
Date:
Print Name:
Internal Plan Code:
131 N14B-2T
EyeM~d.___.____..
The Eye Care Plan of America..
Exhibit "B"
I ~ It") I ~\ (),' ( '( ) 11 t ~\ 11 t ~
3. . . . . . . . . . . . . . . . . . . . . An Introduction to EyeMed
What makes us different?
4..................... The EyeMed Provider Network
Member choices and services
5. . . . . . . . . . . . . . . . . . . . . Accessing Member Benefits
Using benefits is as easy as 1,2,3
6. . . . . . . . . . . . . . . . . . . . . EyeMed Quality Assurance
Credentialing, contracting and evaluations
7.................... . EyeMed's Thorough Eye Exam Services
Comprehensive eye exam
8......... ..... ...... . EyeMed Quality Products
Frames, lenses and laboratory services
9. . . . . . . . . . . . . . . . . . . . . Plan Administration
Services and benefits to Administrators
11. . . . . . . . . . . . . . . . . . . . Frequently Asked Questions
888-4-EYEMED
www.eyemedvisioncare.com
2
/\ 11 III t r u d LI C t i u 11 t \,) I \ \..' 1\ h: d \. i '-, i \,) 11 ( '~l r l\ , . ,
What Makes Us Different?
EyeMed Vision Care is a managed vision care program that delivers more choices and _better
quality to you and your members. And EyeMed provides an overall value that'both you and your
members will appreciate.
Choice in Providers...
EyeMed's integrated network gives members a true choice in provider selection, with an
extensive resource base of private practice optometrists, ophthalmologists, and opticians, along
with the nation's leading optical retailer, LensCrafters.
Quality Care...
EyeMed has a firm commitment to quality and patient satisfaction. Our providers are contracted
and credentialed to provide only the best in quality care for our members.
Wide Selection of Quality Product...
EyeMed provides your members with choice in quality product when selecting eyeglass frames
that are right for them. Whereas some other plans may limit your members' selection to a few
choice frames, EyeMed members may choose from any frame available at our provider
locations, Additionally, most independent providers and all LensCrafters locations carry name
brand frames by Luxottica such as vogue@, Brooks Brothers@, Anne Klein@, and more.
The Best Value in Vision Care...
EyeMed offers total value in vision care that is unmatched in the industry. You and your
members will benefit from our vertical integration with Luxottica, the world's leading eyeglass
frame manufacturer, LensCrafters, the nations # 1 optical retailer and our wide and diverse
network of independent providers.
888-4-EYEMED
www.eyemedvisioncare.com
3
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Assuring your members maximum access to quality eye care is more than a matter of numbers.
It's also a matter of providing them with ::I. diverse network of providers along with convenience
and availability.
Integrated Network
EyeMed's nationwide, accessible network gives your members real options in eye care, starting
with their choice of private practice optometrists, ophthalmologists, or opticians, and
LensCrafters, the nation's largest optical retailer. Because many providers including all
LensCrafters stores offer extended office hours and service without an appointment, EyeMed's
integrated network means members receive eye care when and where they need it.
Having over 800 LensCrafters retail locations in our network means members have these
additional benefits:
o Convenient mall or near-mall locations
o 7 day doctor availability
o Evening and weekend hours
o 30 day, no-risk guarantee
o Service in "about an hour"
o Choice of thousands offashionable frames
888-4-EYEMED
www.eyemedvisioncare.com
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EyeMed is concerned with the visual health of your employees. That's why EyeMed encourages
them to use their benefits, And, we make it easy for your members to access their benefits.
Members do not need to request or fill out claim forms of any kind when visiting a participating
provider. Using their EyeMed Vision Care benefit is easy...
1. Find a Provider - To locate a nearby provider, members have three
options:
Cl Our web site, www.eyemedvisoncare.com. features a convenient Provider Locator, which
helps pinpoint providers according to the member's home zip code,
Cl Members can refer to their membership packets, which provide the names and locations of
nearby providers.
Cl A quick toll-free call to our Member Services Department (1-866-9EYEMED) puts members
in touch with a live operator, Also, by calling the same number, members can access our 24-
hr. automated provider locator. EyeMed offers member service hours that are unparalleled in
the industry:
Mon - Sat. 8 a.m. - 11 p.m. and Sun. 11 a.m. - 8 p.m.
2. Schedule an Appointment
All LensCrafters stores and many independent providers accept walk-ins, but it's recommended
that a prior appointment be made to schedule an eye exam. Many providers have convenient
evening and weekend hours.
3. Provide ID
Members should give providers their name, employer name, and Social Security number. They
should also present their EyeMed ill card at the time of service,
4. Receive Services
Members may choose to receive all services at one provider location, or may opt to receive an
exam at one location and purchase materials at another. All our plan designs, however, assume a
one-time use of benefit, providing no remaining balance for future use within the same benefit
period.
Out of Network Benefits
Your plan may offer an out-of-network option. In these instances, members will need to obtain a
claim form, attach their receipts, and submit these to EyeMed. Out-of-network claims are
processed weekly, and typical payment time to members is 10 business days. See plan details for
more information.
888-4-EYEMED
www.eyemedvisioncare.com
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Provider Credentialing
EyeMed providers offer quality eye care and eyewear for your members. Our detailed
credentialing and contracting process verifies that providers meet or exceed all requirements for
panel participation.
Once approved for participation in the EyeMed panel, providers must sign the EyeMed
Professional Provider Agreement. Only then does EyeMed supply the provider with the
materials necessary to properly administer our vision care program to members. All providers
are subject to a re-credentialing process every two years. This ensures that providers continue to
meet EyeMed panel admission standards.
EyeMed's Quality Assurance Program
An independent Peer Review Panel, consisting of an established group of optometrists,
ophthalmologists, and opticians from EyeMed's own provider panel, as well as industry experts
will administer EyeMed's Quality Assurance Program. This panel will monitor standards of
quality according to these criteria:
Annual Instrumentation and Office Evaluations, ensuring uniform quality standards in office and
instrumentation sanitation and safety.
o Process Evaluations, to ensure providers properly document case histories, exam results,
and management plans.
o Outcome Evaluations, ensuring providers achieve correct diagnoses and provide proper
treatment
o Referral Evaluations, to ensure providers provide appropriate referrals when necessary.
o Participating Provider Review Process, to ensure the resolution of member grievances.
888-4-EYEMED
www.eyemedvisioncare.com
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Comprehensive Eye Exam
EyeMed's panel of optometrists and ophthalmologists conduct comprehensive eye examinations
to diagnose or detect existing conditions of the eye and vision system. Eye examinations may
lead to the detection of health and vision-related medical conditions, including hypertension,
arteriosclerosis, glaucoma, macular degeneration and diabetes. The specific tests performed for
each patient may vary according to the age of the individual, type and severity of the conditions
present or other contributing factors. A summary of the tests and procedures that are used to
arrive at a member's personal diagnosis are included below. A more detailed description is listed
on our website at www.eyemedvisioncare.com.
Q Case History
Q Evaluation of the Visual System's Health Status
External Evaluation
Internal Evaluation
Neurological Evaluation
Tonometry
Perimetry
Visual Acuity
Q Refractive Status
- Objective Refraction
- Subjective Refraction
- Accommodative Flexibility
Q Binocular Function
Q Assessment, Diagnosis, and Treatment Plan
Q Contact Lens Evaluation (Exam) Protocol
888-4-EYEMED
www.eyemedvisioncare.com
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Choice in Frames
EyeMed provides your members with total flexibility in choosing eyeglass frames that meet their
own tastes, needs, and lifestyles. They may choose from any frame available atthe provider
location. Additionally, most EyeMed providers including all LensCrafters locations offer
quality, fashionable frames by Luxottica, the world leader in eyeglass design and manufacturing.
The Luxottica collection of eyewear includes the most reputable and prestigious names in the
optical fashion world, such as Vogue., Anne Klein., Perso.., Brooks Brothers., Georgia
Armani., Moschino., Sergio Tacchini., and more.
Choice in Lenses
EyeMed providers are given the freedom to recommend whichever lens brands or options they
believe offer members the best ocular clarity. They are also free to choose a fabrication
laboratory they trust to provide the best quality, service and convenience. Providers are required,
however, to dispense only lenses that adhere to ophthalmic industry standards (ANSI Z-80.s),
and all laboratory work dispensed by EyeMed providers must meet fabrication standards (ANSI
Z-80.5).
EyeMed Offers Superior Value in Vision Care
Only EyeMed can offer you and your members the benefits of our relationship with industry
leaders Luxottica and LensCrafters. EyeMed is part of the family ofLuxottica corporations, the
world's leading frame manufacturer. LensCrafters, the nation's leading optical retailer, is also a
part ofLuxottica. This vertical integration is strengthened by our relationship with independent
providers that offer Luxottica products. This unique structure enables EyeMed to achieve
economies of scale that deliver unparalleled vision care value.
EyeMed - Providing the Best Value in Vision Care
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Leader in Frames
Manufacturing
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Nation's #1
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retailer
8
888-4-EYEMED
www.eyemedvisioncare.com
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EyeMed is committed to quality and convenience not only for our members, but for you, our
client, as well. EyeMed is focused on delivering hassle-free service to benefit administrators,
giving you more time to concentrate on other, more complex benefit programs.
Easy Administration
Administering the EyeMed plan is refreshingly simple. You can expect detailed billing and
reporting, and exceptional account service from a dedicated team.
Implementing Your Plan
It's also an easy matter to implement your EyeMed Vision care program. Just complete the
application supplied by your EyeMed Sales Representative, and we'll send you an
implementation kit with all the information you need.
EyeMed will implement your plan once you've taken these easy steps:
Q Complete the application form
Q Submit member eligibility data or demographic data
Q Complete and execute the contract
Q Distribute member materials, including ill cards
Your EyeMed representative will gladly help you with any process-related questions you might
have. Your representative will also be happy to coordinate assistance at open enrollment
meetings where attendance will be 100 or more employees.
Integrated Administrative Systems
EyeMed's Administrative System's integrity is maintained through a comprehensive database
system that automatically updates all related files to include changes in member and provider
information.
To maintain the integrity of your organization's own vision care program, EyeMed requests
montWy updates of member eligibility. EyeMed's customer service department is available to
help you with formatting the data layout form, or to assist you with any questions related to our
eligibility process and systems.
888-4-EYEMED
www.eyemedvisioncare.com
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Electronic Claim Submission
When receiving services from a network provider, EyeMed members never need to request claim
forms, or file a claim for reimbursement. EyeMed providers can submit claims instantly - online.
Instantaneous transmission means EyeMed can begin processing member claims without delay.
All confidential member data transmitted online to EyeMed is protected by a special security
function.
Utilization Reporting
EyeMed can provide you with utilization reports at your request. We can provide accurate
membership, utilization and discount information including, but not limited to, the following:
Q Number of members covered
Q Number of patients serviced during the specified period
Q Number of exams, lenses, frames, and contact lenses dispensed
Q Total transactions during specified period
Q Total claims dollars processed
Q Savings realized vs. retail dollars
Your group may request customized reporting as well. This service mayor may not result in
additional charges.
Flexibility and Value
EyeMed Vision Care plans offer superior value along with the flexibility you need. EyeMed
plans include scheduled discount and comprehensive benefit options, with the ability to add
copayments, or to vary the frequency of service. We also offer plans on either a contributory or
non-contributory basis.
Access to Information
The EyeMed Sales Representative in your area is available to help you determine which EyeMed
plan is best for you, or for more information, visit our web site at www.eyemedvisioncare.com.
888-4-EYEMED
www.eyemedvisioncare.com
10
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Please provide a brief overview of the ownership and history of your
company.
EyeMed Vision Care is an integral part of the family ofLuxottica Corporations. Luxottica is the
world leader in eyeglass frame designs and manufacture. LensCrafters, the nation's leading
optical retailer, with over 17 years experience, is a wholly owned subsidiary ofLuxottica Group.
LensCrafters and the doctors of optometry next to LensCrafters are providers on EyeMed Vision
Care's panel. This unique vertical integration enables EyeMed to provide a vision care value
unmatched in the industry.
Do you conduct customer satisfaction surveys?
EyeMed has an independent research firm conduct a montWy Member Satisfaction Survey
(MSA T) that collects quantitative, reliable data about the service members receive at provider
locations. We use this information to determine the best ways to constantly improve customer
service and satisfaction levels.
Describe the procedures members must follow to access benefits through your
network providers?
The process for members to access their EyeMed Vision Care benefit is simple. First, the
member will locate the nearest participating provider, either by calling our toll-free locator
service (1-866-9EYEMED), visiting our web site (www.eyemedvisioncare.com). or by referring
to the provider listings in their membership kits. Second, the member will schedule an
appointment with the provider of choice, and third, present the member ill card at the time of
service. Eligibility verification and claim forms are handled entirely by the provider. This
means no paper work for members when utilizing participating providers.
What frames are covered under your plans?
Members may choose from any frame available at an EyeMed provider location. This allows the
members to select the style that best suits their personality and lifestyle needs. It also guarantees
members are getting the best value in eyewear. Most independent providers and all LensCrafters
locations carry quality brand name frames from Luxottica including Brooks Brothers., Anne
Klein., Vogue., and others. Additionally, Luxottica frames are fully guaranteed against defects
in material and/or workmanship for two full years.
888-4-EYEMED
www.eyemedvisioncare.com
11
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How can I determine the access members will have to the network providers?
EyeMed can perform an access analysis based upon the zip co<!es of the members. This analysis
will allow us to determine accessibility of members to our providers. When requesting an access
analysis, please include a listing of the member zip codes and a standard for the evaluation (i.e.,
one provider within 15 miles). If standards are not included, EyeMed will determine a
reasonable standard and indicate that on the report. Also, EyeMed has the capability to quickly
add providers in areas where additional coverage is needed. If members would like to request a
specific provider to be added to our network, we would be happy to extend them an application
as well.
How often and in what format will you accept eligibility information?
Eligibility data should be forwarded to EyeMed on at least a monthly basis to ensure we have up-
to-date information on all members. Your Account Management Team and Database
Coordinator assigned to your account will work closely with you on the submission of the data.
We can accept eligibility data in a variety of formats via electronic mail, diskette, or cartridge.
The following details the file formats preferred:
Q Microsoft Excel
Q Lotus 123
Q Comma Separated, PC Text File
Q 181 Byte Fixed Length Record Format
What type of communication material do you provide to members?
All new members will receive a comprehensive informational brochure, which contains
everything they will need to properly access quality eye care through the plan. Included are a
member ill card, a prioritized listing of nearby EyeMed Vision Care providers, specifics of the
plan, and an explanation of the discounts or the dollar amounts that are covered for eye exams,
eyewear, and laser vision correction.
Who will be the primary EyeMed contact?
EyeMed will dedicate an Account Management Team to work cooperatively with you to assist in
the implementation of the plan and to provide the ongoing service you need. This Account
Management Team is your primary contact, and will work closely with you, answering any
questions and helping you resolve any problems you may have. This team consists of the
Regional Sales Manager and the Account Service Manager for your area.
888-4-EYEMED
www.eyemedvisioncare.com
12
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What benefits are available to patients seeking laser vision correction?
Members utilizing their EyeMed Vision Care benefit will receive a 15% discount off the retail
price for LASIK or PRK treatments through the U.S. Laser Network, which is owned and
administered by LCA- Vision, a leader in laser vision correction. Members may also receive a
5% off promotional pricing, whichever is the greater benefit.
What information is available to callers via an automated voice response
system?
EyeMed Vision Care's toll-free line, 1-866-9EYEMED, is available 24-hours a day and will
provide members with the following options:
Q Locate the nearest participating provider location to the members' home zip code
Q Request or check the status of an out-of-network claim form
Q Speak to a Member Services Representative during operating hours
Do you have an optical retailer on your panel?
Yes, EyeMed Vision Care has the LensCrafters retail optical chain represented on our panel. As
the nation's largest optical retailer, with over 800 locations nationwide, LensCrafters is able to
provide your members with many services typically not available to the managed care patient. In
addition, they provide service in "about an hour" .
What types of reporting capabilities do you provide?
EyeMed provides a variety of comprehensive management reports and encounter data based on
eligibility data and the information from processed claims. The standard utilization reports
provided by EyeMed have been designed to meet the most requested needs of our clients,
however, we do have the capability to produce customized reports, if requested.
888-4-EYEMED
www.eyemedvisioncare.com
13
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Limitations and exclusions to the EyeMed Vision Care program include:
Q Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing
Q Aniseikonic lenses
Q Medical and/or surgical treatment of the eye, eyes, or supporting structures
Q Corrective eyewear required by an employer as a condition of employment
Q Services provided as a result of any Worker's Compensation law, or similar legislation, or
required by any governmental agency or program whether Federal, State, or subdivision
thereof
Q Piano, non-prescription lenses and non-prescription sunglasses (except for the 20% discount)
Q Two pair of glasses in lieu of bifocals (does not apply to Primary-Plus Plan members)
Q Services or materials provided by any other group benefit providing for vision care
Q Benefit allowances provide no remaining balance for future use within same benefit period
888-4-EYEMED
www.eyemedvisioncare.com
14