1. Linza Soasa
100 Montgomery St
Jersey City, NJ 07302
Welcome Linza Soasa,
Congratulations on your wise decision to enroll in this valuable insurance program
– from National Union Fire Insurance Company of Pittsburgh, Pa.
Welcome to the
Good news: we’ve made managing your Essential Protection Plan online safe and easy.
At www.EssentialProtectionPlans.com you can access your account anytime for instant Plan that provides
policy news, account updates, access claim forms, tips for healthy living, and information for:
about other Essential Protection products. Everything you need is available when you
need it, 24 hours a day, with advanced security for your peace of mind.
Hospital indemnity
We have enclosed your Insurance Documents. Please read them carefully so that you coverage for covered
understand the many benefits available to you. hospital stays
Your coverage starts at $400 a day to a maximum of 365 days for hospital stays due to
covered accidents or $200 a day for a covered illness, from the first day for each covered Cash benefits paid
illness that requires a hospital stay of three consecutive days or more. direct to you or
whomever you choose
Best of all, your coverage amounts automatically increase every
3 months for 10 years with no increase in plan cost – regardless of
whether or not you’ve used your coverage. Cash paid in addition
to any other insurance
Receive benefits for a covered extended hospital stay. you have
To help ease the financial impact of an extended hospital confinement, the plan pays
one of the following single lump-sum benefits in addition to your daily cash payouts: No restrictions on
$5,000 after a 30 consecutive day stay or $10,000 after a 60 consecutive day stay. hospitals or doctors
continued
Linza Soasa
Contact Us Member # 49956222
Insurance Claims: 1-866-960-0765
Insurance Customer Service: 1-877-219-1365
Discount Services Customer Service: 1-888-822-8906
24-Hour Nurse Line: 1-877-541-9189
DTC101BNJ-408-110-2 1 DTC101BNJ
2. You’ll also receive coverage for doctor visits, emergency room treatment and ambulances:
• $50 for each covered doctor visit
• $300 for each covered Emergency Room treatment
(this amount increases every 3 months you remain covered)
• $200 for each covered ambluance transportation
(this amount also increases every 3 months)
PLUS, save on prescriptions, doctor and dentist visits, eye care and get 24-hour nursing assistance.*
Your plan includes full access to discounts which can save you 5-50% on routine doctor, hospital and lab visits while
providing additional savings for prescription drugs, dentist and eye care at thousands of participating providers
nationwide. You also have access to our 24-hour Nurse Hotline for answers to your family health questions. Please read
the enclosed brochure to learn how to use this valuable benefit.
Affordable monthly plan costs.
Your affordable monthly plan cost will not increase due to your growing older, and cannot change due to the
number of claims you make or how often you use your plan benefits.
We want to be sure you make the most of your coverage.
Don’t forget: information and answers about your Essential Protection plan are always available at
www.EssentialProtectionPlans.com.
If you have any questions regarding your policy, call the Customer Service Department at one of the toll free numbers
in the box below. A Customer Service Representative will be available between the hours of 9 am and 10 pm Monday
through Friday, Saturday 7 am to 3 pm Eastern Standard Time.
We appreciate the opportunity to provide you with this valuable coverage and look forward to serving you.
Sincerely, Insurance Claims:1-866-960-0765
Insurance Customer Service:1-877-219-1365
Discount Services Customer Service:1-888-822-8906
24-Hour Nurse Line:1-877-541-9189
Jonathan Yee
Senior Vice President
AIU Holdings, Inc.
Customer Care: 1-888-822-8906 Monday - Friday 9 a.m. - 7 p.m. EST. Attention Participating Discount Medical Providers:
For all membership inquires or to locate participating providers. To locate participating Call 1-888-822-8906 if you have any questions. The member agrees to pay 100% of the allowable
providers online go to: www.mymemberinfo.com/EssentialHealth amount at the time of treatment. Please call to verify member eligibility and for repricing. Member
is directly responsible for payment to the Participating Provider.
24 Hour Nurse Care Hotline: 1-877-541-9189
For physicians and hospital use only: 1-866-643-2230 ext.3
Pharmacy Help Desk: 1-800-847-7147 Members also have access to Call to determine members’s discounted fee. Provide the
24/7 Agelity Help Desk: For pharmacist use only the following networks Member’s ID number, your Provider number and the CPT
Bin: 009265 codes. Collect full discounted payment at time of service
PCN: AG unless other arrangements are made.
Group: UH07
For ALL family members: Use person code 01 Through the use of this Membership, Member is acknowledging and accepting that he/she has
read and is bound by the TERMS AND CONDITIONS of membership.
C-139-062609-EH THIS IS NOT HEALTH INSURANCE THIS IS NOT HEALTH INSURANCE
3.
4. 1-866-960-0765
1-877-219-1365
1-888-822-8906
24-Hour Nurse Line: 1-877-541-9189
Coverage may not be available in all states.
This letter provides only a brief description of the insurance coverage available. The Policy contains reductions,
limitations, exclusions and termination provisions. Full details of the insurance coverage are contained in each Policy.
If there are any conflicts between this document and the Policy, the Policy (policy form numbers A30293NUFIC &
C11695DBG) shall govern. Coverage may not be available in all states. Insurance is underwritten by National Union
Fire Insurance Company of Pittsburgh, Pa., a Pennsylvania insurance company with its Administrative Offices at 80
Pine Street, New York, NY 10270. It is currently authorized to transact business in all states and the District of Columbia.
NAIC No.19445
National Union Fire Insurance Company of Pittsburgh, Pa., assumes no responsibility or liability for any of the listed
services, the providers of the services, the quality of the services, the delivery of the services, or the outcomes of the
services. Questions or concerns about the services should be addressed directly to the providers.
Note: If you are 70 years of age or older on the date of a covered accident for which benefits are payable, the benefits
listed below will be reduced by fifty percent (50%), except for the Physician’s Office Visits Indemnity Benefit. Benefit
amounts for dependents are lower than your benefit amounts.
*The Discount Medical Plans are provided by Patriot Health Florida, Inc., a discount medical plan organization. The
features are not health insurance policies and are not available in all areas. The features provide discounts at certain
health care providers for medical services and do not make payments directly to the providers of medical services. The
member is obligated to pay for all health care services but will receive a discount from those health care providers who
have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York 11791. 800-292-3797
Not available in AK, FL, MT, ND, SD and VT. Coming soon to FL.
5. E
NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH,PA.
Administrative Offices: 80 Pine Street, New York, NY 10005
(212) 770-7000
(a capital stock company, herein referred to as the Company)
Policyholder: Group Insurance Trust Delaware
Policy Number: 49956222
GROUP ACCIDENT INSURANCE CERTIFICATE
ABOUT THIS CERTIFICATE. This certificate describes accident insurance the Company provides to Insured
Persons under the Group Policy (herein called the Policy) issued to the Policyholder.
RIGHT TO EXAMINE THIS CERTIFICATE. This certificate of insurance is issued to You, the Insured, and can be
returned for any reason within the later of: (1) 30 days after it is received by You; or (2) 30 days after Your Coverage
Effective Date. The certificate should be returned by mail or in person to the Company. Any premium paid will be
refunded and the certificate will be treated as if it were never issued.
The President and Secretary of National Union Fire Insurance Company of Pittsburgh, Pa. witness this Certificate:
President Secretary
PLEASE READ THIS CERTIFICATE CAREFULLY.
THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CONTRACT. If you are eligible for Medicare, review
the Guide to Health Insurance for People with Medicare available from this Company.
A30298NUFIC - NJ 1 DTC101BNJ
6. TABLE OF CONTENTS
Schedule............................................................................................................................3
Classification of Eligible Persons .................................................................................3
Insured.........................................................................................................................3
Covered Activities ........................................................................................................3
Insured’s Coverage Effective Date ..............................................................................3
Premium Payments .....................................................................................................3
Benefit Schedule..........................................................................................................3
Definitions ........................................................................................................................10
Insured's Effective and Termination Dates ......................................................................10
Insured Dependent’s Effective and Termination Dates ...................................................10
Premium ..........................................................................................................................11
Benefits............................................................................................................................11
Maximum Amount ......................................................................................................11
Emergency Transportation and Treatment Benefit ....................................................11
In-Hospital Indemnity Daily Benefit ............................................................................12
In-Hospital Indemnity Single Payment Benefit...........................................................12
In-Hospital Indemnity Sickness Daily Benefit ............................................................13
In-Hospital Indemnity Sickness Single Payment Benefit ...........................................14
Physician’s Office Visits Benefit.................................................................................14
Limitations........................................................................................................................14
Limitation on Multiple Covered Activities ...................................................................14
Reduction Schedule...................................................................................................15
Exclusions........................................................................................................................15
Claims Provisions ............................................................................................................15
General Provisions ..........................................................................................................16
A30298NUFIC - NJ 2 DTC101BNJ
13. 115-117 $9,750.00 $4,875.00 $1,950.00
118-120 $9,875.00 $4,937.50 $1,975.00
120+ $10,000.00 $5,000.00 $2,000.00
Physician’s Office Visits Benefit
Maximum Number of Visits Per Family: Months 1 to 36: 5 Visits
Maximum Number of Visits Per Family: Months 37+: 8 Visits
Maximum Number of Visits Per Calendar Quarter Per Family: 2
Policy Month in which Physician’s Office Visits occurs:
1-3 $50.00 $50.00 $50.00
4-6 $50.00 $50.00 $50.00
7-9 $50.00 $50.00 $50.00
10-12 $50.00 $50.00 $50.00
13-15 $50.00 $50.00 $50.00
16-18 $50.00 $50.00 $50.00
19-21 $50.00 $50.00 $50.00
22-24 $50.00 $50.00 $50.00
25-27 $50.00 $50.00 $50.00
28-30 $50.00 $50.00 $50.00
31-33 $50.00 $50.00 $50.00
34-36 $50.00 $50.00 $50.00
37-39 $50.00 $50.00 $50.00
40-42 $50.00 $50.00 $50.00
43-45 $50.00 $50.00 $50.00
46-48 $50.00 $50.00 $50.00
49-51 $50.00 $50.00 $50.00
52-54 $50.00 $50.00 $50.00
55-57 $50.00 $50.00 $50.00
58-60 $50.00 $50.00 $50.00
61-63 $50.00 $50.00 $50.00
64-66 $50.00 $50.00 $50.00
67-69 $50.00 $50.00 $50.00
70-72 $50.00 $50.00 $50.00
73-75 $50.00 $50.00 $50.00
76-78 $50.00 $50.00 $50.00
79-81 $50.00 $50.00 $50.00
82-84 $50.00 $50.00 $50.00
85-87 $50.00 $50.00 $50.00
88-90 $50.00 $50.00 $50.00
91-93 $50.00 $50.00 $50.00
94-96 $50.00 $50.00 $50.00
97-99 $50.00 $50.00 $50.00
100-102 $50.00 $50.00 $50.00
103-105 $50.00 $50.00 $50.00
106-108 $50.00 $50.00 $50.00
109-111 $50.00 $50.00 $50.00
112-114 $50.00 $50.00 $50.00
115-117 $50.00 $50.00 $50.00
118-120 $50.00 $50.00 $50.00
120+ $50.00 $50.00 $50.00
The Maximum Amounts are used to determine amounts payable under each Benefit. Actual amounts payable will not exceed
the maximums, and may be less than the maximums under circumstances specified in this Certificate.
The Maximum Amounts specified above for an Insured Person who is age 70 or older on the date of an accident for which
benefits are payable, except the Physician’s Office Visits Indemnity Benefit, will be reduced by 50%.
A30298NUFIC - NJ 9 DTC101BNJ
14. DEFINITIONS covered under the Policy solely as an Insured
Dependent.
Any capitalized terms in this Certificate and any riders,
endorsements, or other attached papers are to be given Insured Dependent – means Your Insured Spouse or
the meanings as ascribed in this section or as later Insured Dependent Child.
defined.
Insured Dependent Child - means Your Eligible
Age - means the age of the Insured Person on the Dependent Child: (1) whom You have elected to cover
Insured Person's most recent birthday, regardless of the under the Policy; (2) for whom premium has been paid
actual time of birth. when due; and (3) while covered under the Policy.
Covered Activity (ies) - means those activities set out Insured Person – means the Insured or an Insured
in the Covered Activities section of the Schedule with Dependent.
respect to which Insured Persons are provided accident
insurance under the Policy. Insured Spouse – means Your Eligible Spouse; (1)
whom You have elected to cover under the Policy; (2)
Eligible Spouse – means Your legal spouse. for whom premium has been paid when due; and (3)
while covered under the Policy.
Eligible Dependent – means an Eligible Spouse or
Eligible Dependent Child. Physician - means a licensed practitioner of the healing
arts acting within the scope of his or her license who is
Eligible Dependent Child – means Your unmarried not: 1) the Insured Person; 2) an Immediate Family
child(ren), including natural, step, foster or adopted Member; or 3) retained by the Policyholder.
children from the moment of placement in Your home,
under age 19 ( 23 if attending an accredited institution You, Your – means the Insured.
of higher learning on a full time basis) and primarily
dependent on You for support and maintenance. If the INSURED'S EFFECTIVE AND TERMINATION DATES
Insured has a court order to provide coverage under the
Policy to a child, the amount of support contributed by Effective Date. Your coverage under the Policy begins
the Insured for such child will not be used to determine on the latest of: (1) the Policy Effective Date; (2) the
whether or not such child is an “eligible dependent date for which the first premium for Your coverage is
child.” paid when due; (3) the date You become a member of
an eligible class of persons, as described in the
Immediate Family Member - means a person who is Classification of Eligible Persons section of the
related to the Insured Person in any of the following Schedule; (4) if individual enrollment is required, the
ways: spouse, brother-in-law, sister-in-law, son-in-law, date enrollment is received.
daughter-in-law, mother-in-law, father-in-law, parent
(includes stepparent), grandparent, brother or sister Termination Date. Your coverage under the Policy ends
(includes stepbrother or stepsister), or child (includes on the earliest of: (1) the date the Policy is terminated
legally adopted or stepchild). (unless the Company and the Policyholder agree, in
writing, to permit coverage to continue to the end of the
Injury - means bodily injury: (1) which is sustained as a period for which premiums have been paid in lieu of a
direct result of an unintended, unanticipated accident return of unearned premiums); (2) the premium due date
that is external to the body and that occurs while the if premiums are not paid when due; (3) the date You
injured person's coverage under the Policy is in force; cease to be a member of any eligible class(es) of
(2) which directly (independent of sickness, disease, persons, as described in the Classification of Eligible
mental incapacity, bodily infirmity or any other cause) Persons section of the Schedule; (4) the date You
causes a covered loss; and (3) which occurs while such request that Your coverage be terminated; or (5) the
person is participating in a Covered Activity. date You attain Age 85.
Insured - means a person: (1) who is a member of an Termination of coverage will not affect a claim for a
eligible class of persons as described in the covered loss that occurred while Your coverage was in
Classification of Eligible Persons section of the force under the Policy.
Schedule; (2) for whom premium has been paid when
due; (3) while covered under the Policy; and (4) who has INSURED DEPENDENT’S EFFECTIVE AND
enrolled for coverage under the Policy, if required. TERMINATION DATES
However, an Insured does not include any person
10
DTC101BNJ
15. Effective Date. Your Eligible Dependent’s coverage Person’s class in the Benefit Schedule, subject to the
under the Policy begins on the latest of: (1) the date Reduction Schedule shown in the Limitations section.
Your coverage under the Policy begins, (2) the date the
first premium for the Eligible Dependent’s coverage is
paid when due; (3) the date the person becomes an
Eligible Dependent; or 4) if individual enrollment is Emergency Transportation and Treatment Benefit
required, the date Your enrollment is received.
Emergency Transportation Benefit. If an Insured
Termination Date. An Insured Dependent’s coverage Person suffers an Injury that requires Emergency
under the Policy ends on the earliest of: (1) the date Treatment within 24 hours of the date of the accident
Your coverage under the Policy ends; (2) the premium that caused the Injury and it is determined that it is
due date if premiums for the Insured Dependent are not Medically Necessary that such Insured Person be
paid when due; (3) the date You request that coverage transported to a Hospital or a Satellite Emergency
for the Insured Dependent be terminated; or (4) the date Center by Ambulance, the Company will pay 100% of
the Insured Dependent ceases to meet the definition of the Emergency Transportation Maximum Amount shown
an Eligible Dependent. in the Benefit Schedule. Only one Emergency
Transportation Benefit is payable for any one accident
Termination of coverage will not affect a claim for a per Insured Person. The maximum number of
covered loss that occurred while the Insured Emergency Transportation Benefits payable per
Dependent’s coverage was in force under the Policy. calendar year per Insured Person regardless of the
number of accidents incurred, is shown in the Benefit
PREMIUM Schedule.
Premiums. The Company provides insurance in return Emergency Treatment Benefit. If an Insured Person
for premium payments. The premium shown in the suffers an Injury that, within 24 hours of the date of the
Schedule is payable to the Company in the manner accident that caused the Injury, requires him or her to
described in the Schedule. The Company may change receive Medically Necessary Emergency Treatment in a
the required premiums due by giving the Policyholder at Hospital emergency room or a Satellite Emergency
least 31 days advance written notice. The Company Center, the Company will pay 100% Emergency
may also change the required premiums at any time Treatment Benefit Maximum Amount shown in the
when any coverage change affecting premiums is made Benefit Schedule. Only one Emergency Treatment
in the Policy. Benefit is payable for any one accident per Insured
Person. The maximum number of Emergency Treatment
Grace Period. A Grace Period of 31 days will be Benefits payable per calendar year per Insured Person
provided for the payment of any premium due after the regardless of the number of accidents incurred, is shown
first. An Insured Person’s coverage will not be in the Benefit Schedule.
terminated for nonpayment of premium during the Grace
Period if all premiums due are paid by the last day of the Definitions
Grace Period. An Insured Person’s coverage will
terminate on the last day of the period for which all Ambulance – means any publicly or privately owned
premiums have been paid if all premiums due are not surface, water or air vehicle, including a helicopter, that
paid by the last day of the Grace Period. is specifically designed and constructed or modified and
equipped to be used, maintained or operated primarily
If the Company expressly agrees to accept late payment for the transportation of individuals who are sick, injured
of a premium without terminating coverage under the or wounded. Ambulance does not include a surface,
Policy, the Company does so in accordance with the water or air vehicle that is owned and operated to
Noncompliance with Policy Requirements provision of accommodate an incapacitated or disabled person who
the General Provisions section. does not require medical monitoring, care or treatment
during transport.
No Grace Period will be provided if the Company
receives notice to terminate the Insured Person’s Emergency Treatment – means treatment for a medical
coverage under the Policy prior to a premium due date. condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
BENEFITS prudent layperson with average knowledge of health and
medicine could reasonably expect the absence of
Maximum Amount. As applicable to each Benefit immediate medical attention to result in:
provided by the Policy for each Insured Person, 1. Placing the health of the person (or with respect to a
Maximum Amount means the amount shown as the pregnant woman, the health of her unborn child) in
maximum amount for that Benefit for the Insured serious jeopardy;
2. Serious impairment to bodily functions; or
11
DTC101BNJ
16. 3. Serious dysfunction of any bodily organ or part. Day(s) of Confinement - means a day of Hospital
confinement as an Inpatient.
Hospital - means a facility which: (1) is operated
according to law for the care and treatment of injured Hospital - means a facility which: (1) is operated
and sick people; (2) has organized facilities for diagnosis according to law for the care and treatment of injured
and surgery on its premises or in facilities available to it and sick people; (2) has organized facilities for diagnosis
on a prearranged basis; (3) has 24 hour nursing service and surgery on its premises or in facilities available to it
by registered nurses (R.N.’s); and (4) is supervised by on a prearranged basis; (3) has 24 hour nursing service
one or more Physicians. A Hospital does not include: by registered nurses (R.N.’s); and (4) is supervised by
(1) a nursing, convalescent or geriatric unit of a hospital one or more Physicians. A Hospital does not include:
when a patient is confined mainly to receive nursing (1) a nursing, convalescent or geriatric unit of a hospital
care; or (2) a facility that is, other than incidentally, a rest when a patient is confined mainly to receive nursing
home, nursing home, convalescent home or home for care; or (2) a facility which is, other than incidentally, a
the aged; nor does it include any ward room, wing, or rest home, nursing home, convalescent home or home
other section of the hospital that is used for such for the aged; nor does it include any ward room, wing, or
purposes. other section of the hospital that is used for such
purposes.
Medically Necessary – means an Emergency
Treatment or Transportation is: (1) essential for the Inpatient - means a person: (1) who is confined in a
diagnosis, treatment and care of the Injury; (2) meets Hospital as a registered bed patient; and (2) for whom at
generally accepted standards of medical practice; (3) is least one day's room and board is charged by the
ordered by a Physician and performed under the Hospital unless the Insured Person is confined as an
Physician’s care, supervision or order; or (4) with regard Inpatient in any military, veterans or other government
to Emergency Transportation, is subsequently supported or sponsored Hospital for which a charge for
authorized by a Physician as appropriate due to the room and board is not made.
nature of the Injury.
Medically Necessary – means that confinement as an
Satellite Emergency Center - means a licensed facility In-patient in a Hospital is (1) essential for the diagnosis,
providing outpatient care under the direction of a treatment and care of the Injury; (2) in accordance with
Physician on a 24 hour basis. Available services must generally accepted standards of medical practice; and
include: (1) diagnostic care, including laboratory services (3) ordered by a Physician.
and diagnostic x-rays; and (2) treatment or medical care,
including availability of the means for stabilization of Period of Confinement - means a period of
emergency medical conditions. A Satellite Emergency consecutive Days of Confinement as an Inpatient for all
Center does not include a Hospital or an office Injuries caused by the same accident. However,
maintained by a Physician for the practice of medicine or successive confinements as an Inpatient for all Injuries
dentistry. caused by the same accident are considered to be part
of the same Period of Confinement, unless the
In-Hospital Indemnity Daily Benefit discharge date for the prior confinement is separated
from the admission date for the next confinement by at
If an Insured Person suffers an Injury that, within 90 least 60 days.
days of the date of the accident that caused the Injury,
requires him or her to be confined in a Hospital as an In-Hospital Indemnity Single Payment Benefit
Inpatient, the Company will pay a benefit after 1 Day of
Medically Necessary Confinement due to that Injury, If an Insured Person suffers an Injury that, within 90
retroactive to the first Day of Confinement. No benefit is days of the date of the accident that caused the Injury,
provided for any Day(s) of Confinement that are not requires him or her to be confined in a Hospital as an
Medically Necessary. The amount of the benefit is equal Inpatient, the Company will pay a benefit after 30
to 100% of the Daily Maximum Amount shown for the In- consecutive Day(s) of Medically Necessary Confinement
Hospital Indemnity Daily Benefit in the Benefit Schedule due to that Injury. No benefit is provided if the Insured
per day of Medically Necessary Inpatient confinement Person is confined for less than 30 consecutive
due to that Injury. It is payable monthly up to the Medically Necessary Days of Confinement. The amount
Maximum Number of Days shown for the In-Hospital of the benefit is equal to 100% of the Maximum Amount
Indemnity Daily Benefit in the Benefit Schedule during shown for the In-Hospital Indemnity Single Payment
any one Period of Confinement. Only one benefit is Benefit in the Benefit Schedule. Only one benefit is
provided for any one Day of Confinement, regardless of provided for any one accident per Insured Person
the number of Injuries for which the confinement is regardless of the number of Injuries for which the
required. confinement is required or the number of times the
Insured Person must be confined due to Injuries
resulting from the same accident.
12
DTC101BNJ
17. provided for any Day(s) of Confinement that are not
If an Insured Person suffers an Injury that, within 90 Medically Necessary. The amount of the benefit is equal
days of the date of the accident that caused the Injury, to 100% of the In-Hospital Indemnity Sickness Daily
requires him or her to be confined in a Hospital as an Benefit shown in the Benefit Schedule per day of
Inpatient, the Company will pay a benefit after 60 Medically Necessary Inpatient confinement due to that
consecutive Day(s) of Medically Necessary Confinement Sickness. The benefit is payable monthly up to the
due to that Injury. No benefit is provided if the Insured Maximum Number of Days shown for the In-Hospital
Person is confined for less than 60 consecutive Indemnity Sickness Daily Benefit in the Benefit Schedule
Medically Necessary Days of Confinement. The amount during any one Period of Confinement. Only one benefit
of the benefit is equal to 100% of the Maximum Amount is provided for any one Day of Confinement, regardless
shown for the In-Hospital Indemnity Single Payment of the number of Sicknesses for which the confinement
Benefit in the Benefit Schedule. Only one benefit is is required.
provided for any one accident per Insured Person
regardless of the number of Injuries for which the Day(s) of Confinement - means a day of Hospital
confinement is required or the number of times the confinement as an Inpatient.
Insured Person must be confined due to Injuries
resulting from the same accident. Hospital - means a facility which: (1) is operated
according to law for the care and treatment of injured
Day(s) of Confinement - means a day of Hospital and sick people; (2) has organized facilities for diagnosis
confinement as an Inpatient. and surgery on its premises or in facilities available to it
on a prearranged basis; (3) has 24 hour nursing service
Hospital - means a facility which: (1) is operated by registered nurses (R.N.’s); and (4) is supervised by
according to law for the care and treatment of injured one or more Physicians. A Hospital does not include:
and sick people; (2) has organized facilities for diagnosis (1) a nursing, convalescent or geriatric unit of a hospital
and surgery on its premises or in facilities available to it when a patient is confined mainly to receive nursing
on a prearranged basis; (3) has 24 hour nursing service care; or (2) a facility which is, other than incidentally, a
by registered nurses (R.N.’s); and (4) is supervised by rest home, nursing home, convalescent home or home
one or more Physicians. A Hospital does not include: for the aged; nor does it include any ward room, wing, or
(1) a nursing, convalescent or geriatric unit of a hospital other section of the hospital that is used for such
when a patient is confined mainly to receive nursing purposes.
care; or (2) a facility which is, other than incidentally, a
rest home, nursing home, convalescent home or home Inpatient - means a person: (1) who is confined in a
for the aged; nor does it include any ward room, wing, or Hospital as a registered bed patient; and (2) for whom at
other section of the hospital that is used for such least one day's room and board is charged by the
purposes. Hospital unless the Insured Person is confined as an
Inpatient in any military, veterans or other government
Inpatient - means a person: (1) who is confined in a supported or sponsored Hospital for which a charge for
Hospital as a registered bed patient; and (2) for whom at room and board is not made.
least one day's room and board is charged by the
Hospital unless the Insured Person is confined as an Medically Necessary – means that confinement as an
Inpatient in any military, veterans or other government In-patient in a Hospital is (1) essential for the diagnosis,
supported or sponsored Hospital for which a charge for treatment and care of the Sickness; (2) in accordance
room and board is not made. with generally accepted standards of medical practice;
and (3) ordered by a Physician.
Medically Necessary – means that confinement as an
In-patient in a Hospital is (1) essential for the diagnosis, Period of Confinement - means a period of
treatment and care of the Injury; (2) in accordance with consecutive Days of Confinement as an Inpatient for the
generally accepted standards of medical practice; and same Sickness. However, successive confinements as
(3) ordered by a Physician. an Inpatient for the same Sickness are considered to be
part of the same Period of Confinement, unless the
In-Hospital Indemnity Sickness Daily Benefit discharge date for the prior confinement is separated
Not applicable to Insured Persons Age 75 or older from the admission date for the next confinement by at
least 60 days.
If, after an Insured Person has been covered under the
Policy for at least 0 consecutive months and that Insured If the same Insured Person is again confined due to the
Person suffers a Sickness that requires him or her to be same Sickness or a new Sickness and such successive
confined in a Hospital as an Inpatient, the Company will confinement is separated from the admission date for
pay a benefit after 3 consecutive Day(s) of Medically the first confinement by at least 60 days and the Insured
Necessary Confinement due to that Sickness, Person has not been paid the Maximum Number of
retroactive to the first Day of Confinement. No benefit is Days shown in the In-Hospital Indemnity Sickness Daily
13
DTC101BNJ
18. Benefit for previous Medically Necessary Days of and sick people; (2) has organized facilities for diagnosis
Confinement, benefits will continue to be payable under and surgery on its premises or in facilities available to it
this benefit for the same Sickness or a new Sickness in on a prearranged basis; (3) has 24 hour nursing service
accordance with the requirements specified above until by registered nurses (R.N.’s); and (4) is supervised by
the Maximum Number of Days shown in the In-Hospital one or more Physicians. A Hospital does not include:
Indemnity Sickness Daily Benefit in the Benefit (1) a nursing, convalescent or geriatric unit of a hospital
Scheduled have been paid for that Insured Person. when a patient is confined mainly to receive nursing
Once the maximum has been reached, no benefits are care; or (2) a facility which is, other than incidentally, a
payable for any additional confinements due to Sickness rest home, nursing home, convalescent home or home
for the lifetime of the Insured Person. for the aged; nor does it include any ward room, wing, or
other section of the hospital that is used for such
Sickness – means an illness or disease which is purposes.
diagnosed or treated by a Physician after the effective
date of coverage under this Policy. Inpatient - means a person: (1) who is confined in a
Hospital as a registered bed patient; and (2) for whom at
Any exclusion within the Exclusions section regarding least one day's room and board is charged by the
sickness or disease; stroke or cerebrovascular accident Hospital unless the Insured Person is confined as an
or event; cardiovascular accident or event; myocardial Inpatient in any military, veterans or other government
infarction or heart attack; coronary thrombosis or supported or sponsored Hospital for which a charge for
aneurysm is hereby waived for this benefit. room and board is not made.
In-Hospital Indemnity Sickness Single Payment Medically Necessary – means that confinement as an
Benefit In-patient in a Hospital is (1) essential for the diagnosis,
Not applicable to Insured Persons Age 75 or older treatment and care of the Sickness; (2) in accordance
with generally accepted standards of medical practice;
If, after an Insured Person has been covered under the and (3) ordered by a Physician.
Policy for at least 0 consecutive months and that Insured
Person suffers a Sickness that requires him or her to be Sickness – means an illness or disease which is
confined in a Hospital as an Inpatient, the Company will diagnosed or treated by a Physician after the effective
pay a benefit after 30 consecutive Day(s) of Medically date of coverage under this Policy.
Necessary Confinement due to that Sickness. No benefit
is provided if the Insured Person is confined for less than Any exclusion within the Exclusions section regarding
30 consecutive Medically Necessary Days of sickness or disease; stroke or cerebrovascular accident
Confinement. The amount of the benefit is equal to or event; cardiovascular accident or event; myocardial
100% of the Maximum Amount shown for the In-Hospital infarction or heart attack; coronary thrombosis or
Indemnity Sickness Single Payment Benefit in the aneurysm is hereby waived for this benefit.
Benefit Schedule. The maximum number of In-Hospital
Indemnity Sickness Single Payment Benefits payable is Physician’s Office Visits Indemnity Benefit
shown in the Benefit schedule.
If the Insured visits a Physician’s office for treatment of
If, after an Insured Person has been covered under the Routine Well Care, an Injury or Sickness while the
Policy for at least 0 consecutive months and that Insured Insured’s coverage under this Benefit is in force, the
Person suffers a Sickness that requires him or her to be Company will pay a benefit equal to the Per Visit Benefit
confined in a Hospital as an Inpatient, the Company will shown in the Benefit Schedule, subject to Maximum
pay a benefit after 60 consecutive Day(s) of Medically Number of Visits and the Maximum Benefit Amount
Necessary Confinement due to that Sickness. No benefit shown in the Benefit Schedule.
is provided if the Insured Person is confined for less than
60 consecutive Medically Necessary Days of Definitions
Confinement. The amount of the benefit is equal to
100% of the Maximum Amount shown for the In-Hospital Routine Well Care - means a physical examination or
Indemnity Sickness Single Payment Benefit in the appropriate immunization. Service must be under the
Benefit Schedule. The maximum number of In-Hospital supervision of or recommended by a Physician.
Indemnity Sickness Single Payment Benefits payable is
shown in the Benefit schedule. Sickness – means an illness or disease which is
diagnosed or treated by a Physician after the effective
Day(s) of Confinement - means a day of Hospital date of coverage under the Policy.
confinement as an Inpatient.
The Sickness exclusions in the Exclusions section of the
Hospital - means a facility which: (1) is operated Certificate or as amended shall not apply with respect to
according to law for the care and treatment of injured
14
DTC101BNJ
19. benefits payable under the Physician’s Office Visits (Loss caused while on short-tem National Guard or
Indemnity Benefit. reserve duty for regularly scheduled training
LIMITATIONS purposes is not excluded).
8. travel or flight in or on (including getting in or out of,
Reduction Schedule. The Maximum Amount used to or on or off of) any vehicle used for aerial navigation,
determine the amount payable for a loss will be reduced if the Insured Person is:
if an Insured Person is age 70 or older on the date of the a. riding as a passenger in any aircraft not
accident causing the loss with respect to any of the intended or licensed for the transportation of
following Benefits provided by the Policy: Emergency passengers; or
Transportation and Treatment Benefit, In-Hospital b. performing, learning to perform or instructing
Indemnity Daily Benefit, In-Hospital Indemnity Single others to perform as a pilot or crew member
Payment Benefit, In-Hospital Indemnity Sickness Daily of any aircraft; or
Benefit, In-Hospital Indemnity Sickness Single Payment c. riding as a passenger in an aircraft owned,
Benefit. The Maximum Amount is reduced to a leased or operated by the Policyholder or
percentage of the Maximum Amount that would be used the Insured’s employer;
if the Insured Person were under age 70 on the date of 9. the Insured Person being under the influence of
the accident, according to the following schedule: intoxicants.
10. the Insured Person being under the influence of
AGE ON DATE PERCENTAGE OF UNDER- drugs unless taken under the advice of and as
OF ACCIDENT AGE-70 MAXIMUM AMOUNT specified by a Physician.
11. the medical or surgical treatment of sickness,
70 or older 50% disease, mental incapacity or bodily infirmity whether
the loss results directly or indirectly from the
Premium for an Insured Person age 70 or older is based treatment.
on 100% of the coverage that would be in effect if the 12. stroke or cerebrovascular accident or event;
Insured Person were under age 70. cardiovascular accident or event; myocardial
infarction or heart attack; coronary thrombosis;
EXCLUSIONS aneurysm.
13. any condition for which the Insured Person is
No coverage shall be provided under the Policy and no entitled to benefits under any Worker’s
payment shall be made for any loss resulting in whole or Compensation Act or similar law.
in part from, or contributed to by, or as a natural and
probable consequence of any of the following excluded 14. the Insured Person riding in or driving any type of
risks even if the proximate or precipitating cause of the motor vehicle as part of a speed contest or
loss is an accidental bodily Injury. scheduled race, including testing such vehicle on a
track, speedway or proving ground.
1. suicide or any attempt at suicide or intentionally self- 15. any loss incurred while outside the United States, its
inflicted Injury or any attempt at intentionally self- Territories or Canada.
inflicted Injury or autoeroticism.
2. sickness, disease, mental incapacity or bodily CLAIMS PROVISIONS
infirmity whether the loss results directly or indirectly
from any of these Notice of Claim. Written notice of claim must be given
3. the Insured Person's commission of or attempt to to the Company within 20 days after an Insured Person's
commit a felony. loss, or as soon thereafter as reasonably possible.
4. infections of any kind regardless of how contracted, Notice given by or on behalf of the Insured Person to the
except bacterial infections that are directly caused Company at LOTSolutions, Claims Department, P. O.
by botulism, ptomaine poisoning or an accidental cut Box 2066, Jacksonville, FL 32203-2066, with information
or wound independent and in the absence of any sufficient to identify the Insured Person, is deemed
underlying sickness, disease or condition including notice to the Company.
but not limited to diabetes.
5. declared or undeclared war, or any act of declared Claim Forms. The Company will send claim forms to
or undeclared war, except if specifically provided by the claimant upon receipt of a written notice of claim. If
the Policy. such forms are not sent within 15 days after the giving of
6. participation in any team sport or any other athletic notice, the claimant will be deemed to have met the
activity, except participation in a Covered Activity. proof of loss requirements upon submitting, within the
7. full-time active duty in the armed forces, National time fixed in the Policy for filing proofs of loss, written
Guard or organized reserve corps of any country or proof covering the occurrence, the character and the
international authority. (Unearned premium for any extent of the loss for which claim is made. The notice
period for which the Insured Person is not covered should include Your name, the Insured Person’s name, if
due to his or her active duty status will be refunded)
15
DTC101BNJ
