HomeMy WebLinkAboutC-949 - Group health insurance0
• ETNA LIFE INSURANCE COMPANY
0 YOUR NEW GROUP POLICY
is presented on a modern format considerably different from that which
was formerly in use and may require a few words of explanation. This
• format has been designed to present now and in the future a clear de-
scription of the current provisions of the plan.
One of the most important features of this new format is that the policy
• ordinarily will be amended by the addition, deletion or substitution of
pages. The new pages will be accompanied by a rider face page and,
after the rider has been executed, it will be necessary merely to sub-
stitute the new pages for the old, attach the old pages to the rider face
• page and file them behind the Historical tab for use when necessary
to refer to provisions not currently effective.
The date of the addition or substitution of pages after the issuance of
the original policy will be shown at the bottom of the new page. The
• extent and effect of the various changes may be determined by refer-
ence to the riders and obsolete pages filed in the Historical Section.
• GR -23 -O
9-'68
Group Control No. 46443
.ae
• I (Herein called the Insurance Company)
Group Policy No.: GC -46443 Policy Delivered In: California
• Policyholder: CITY OF NEWPORT BEACH (State or other Jurisdiction)
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Policy Signed: November 17, 1964 To Take Effect: August 1, 1964
This policy is a contract between the Policyholder and the Insurance Company and shall be
construed in accordance with the law of the jurisdiction in which it is delivered.
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In consideration of the payment by the Policyholder of premiums in the amounts and at the
times hereinafter provided, the Insurance Company hereby agrees with the Policyholder, sub-
ject to the terms appearing on this and the following pages of this policy (including, if any,
the riders, endorsements, and amendments, to this policy which are signed by the Insurance
Company), to pay benefits in accordance with the terms of this policy. The obligations and
the rights of all persons under this policy shall be determined in accordance with the terms of
this policy.
• j In witness whereof the Insurance Company has signed this policy at Hartford, Connecticut.
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• Assistant Secretary President
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GROUP INSURANCE POLICY
• GR -23
Ed. 9267 Page 1 t t to
•
Section 3. Premiums, How Payable ...... ...............................
8 -A
Section 4. Grace Period ............................... .. ...
8 -A
INDEX
Article V— DISCONTINUANCE OF POLICY ..............................
9
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1 o
Article I— GENERAL PROVISIONS
Pape
10
Section 2. Employees' Certificates .... ... . .... ........
10
Section 3. Data Required— Clerical Error —Misst .tements.-
•
Section 1. General Definitions .......... ...............................
Non- Discrimination ... ............................... ......
3 -3 -A
Section 2. List of Participant Employers . ...............................
10
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Section 3. Employees to be Insured
Section 6. Proofs of Loss
11
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(I) Employee Coverage .......... ...............................
Section 8. Conversion Privilege ...............................
5
(II) Dependent Coverage ......... ...............................
5 -A -5 -B
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OPEN
Ed. 9257 Page 2
1202
Article II— BENEFITS
Title HEB - Hospital Expense Benefits ..........................
6 -
6 -A -
HEB
Title SEB - Surgical Expense Benefits ..........................
6 -
6 -C -
SEB
Title ANEB - Anesthesia Expense Benefits .......................
6 -
ANEB
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Title IHMEB - In- Hospital Medical Expense Benefits .............
6 -
6 -A -
IHMEB
Title LXEB - Laboratory and X -Ray Expense Benefits .............
6 -
6 -A -
LXEB
Title AEB - Accident Expense Benefits ..........................
6 -
AEB
Title HvEB - Major Medical Expense Benefits ....................
6 -
6 -F -
MMEB
Exclusions, Limitations and Provisions Applicable To All
•
Titles Under Article II ........ ...............................
6 -
6.2 -
ELP
•
• Article III — TERMINATION OF INSURANCE
Section 1. Employee and Dependent Coverage ...................... ..... 7
Section 2. Dependent Coverage Only .............................. ... 7 -A
• Article IV— PREMIUMS
Section 1. Premium Rates ...... ............................... ...... 8
Section 2. Premium Calculations and Experience Rating ................. 8 - 8 -A
•
Section 3. Premiums, How Payable ...... ...............................
8 -A
Section 4. Grace Period ............................... .. ...
8 -A
Article V— DISCONTINUANCE OF POLICY ..............................
9
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Article VI— MISCELLANEOUS PROVISIONS
Section 1. Assignment . ....... ... ... ................. . .......
10
Section 2. Employees' Certificates .... ... . .... ........
10
Section 3. Data Required— Clerical Error —Misst .tements.-
•
Non- Discrimination ... ............................... ......
10
Section 4. Entire Contract; Changes ......... ..........................
10
Section 5. Time Limit on Certain Defenses ................ .............
11
Section 6. Proofs of Loss
11
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Section 7. Payment of Claims ... .... ........... . .
11
Section 8. Conversion Privilege ...............................
12 -12 -A
COPY OF APPLICATION
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GR -23
OPEN
Ed. 9257 Page 2
1202
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Article I— GENERAL PROVISIONS
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Section 1. General Definitions
z As used in this policy:
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• (a) The term "Employee Coverage" means only insurance as to an employee.
The term "Dependent Coverage" means insurance as to an employee's dependents.
• GR -23 OPEN
Ed. 9267 Page 3 1309
(b) The term "family member" means an employee or a dependent of the employee. A "de-
pendent" means
•
(1) with respect to coverage under Title MMEB only:
(i) the employee's wife or husband or
(ii) the employee's unmarried child under nineteen years of age
•
(twenty -three years of age with respect to an unmarried
child who is attending school regularly and depends solely
upon the Employee for support);
•
(2) with respect to coverage under all other Titles:
(i) the employee's wife or husband or
(ii) the employee's unmarried child at least fourteen days of age
•
but under nineteen years of age (twenty -three years of age
with respect to an unmarried child who is attending school
regularly and depends solely upon the Employee for support)
•
but any person who is insured (or eligible for benefits by reason of having been insured)
as an employee shall not be considered a dependent, and no person shall be considered
as a dependent of more than one employee.
•
The word "child" means, in addition to the employee's own or lawfully adopted child,
any step - child, foster child, or other child, who depends upon the employee for support and
lives with the employee in a regular parent -child relationship.
(c) For the purposes of any Title under Article II, the term "covered family member" means,
•
as of any given time, and as to any employee, a family member with respect to whom in-
surance is in force for the employee under such Title.
(d) The term "non- occupational disease" means a disease which does not arise, and which is
not caused or contributed to by, or as a consequence of, any disease which arises, out of
•
or in the course of any employment or occupation for compensation or profit; however
if evidence satisfactory to the Insurance Company is furnished that the individual con-
cerned is covered as an employee under any workmen's compensation law, occupational
disease law, or any other legislation of similar purpose, or under the maritime doctrine
of maintenance, wages, and cure, but that the disease involved is one not covered under
•
the applicable laws or doctrine, then such disease shall, for the purposes of this policy,
be regarded as a "non- occupational disease ".
(e) The term "non - occupational injury" means an accidental bodily injury which does not
•
arise, and which is not caused or contributed to by, or as a consequence of, any injury
which arises, out of or in the course of any employment or occupation for compensation or
profit.
• GR -23 OPEN
Ed. 9267 Page 3 1309
• Article I-- GENERAL PROVISIONS (Continued)
Section 1. General Definitions (Continued)
• (f) The term "hospital" means only an institution which meets fully every one of the
following.tests, namely, (a) it is primarily engaged in providing- -for compensa-
tion from its patients and on an inpatient basis -- diagnostic and therapeutic
facilities for the surgical and medical diagnosis, treatment, and care of injured
• and sick persons by or under the supervision of a staff of physicians, and (b) it
continuously provides twenty -four hour a day nursing service by registered graduate
nurses, and (c) it is not, other than incidentally, a place for rest, a place for
the aged, a place for drug addicts, a place for alcoholics, or a nursing home.
(g) The term "board and room" means not only the hospital's charges for board and room
but also charges, by whatever name called, which are made by the hospital at a
daily or weekly rate for other hospital services and supplies, or which are
regularly made by the hospital as a condition of occupancy of the class of accom-
modations occupied.
(h) An expense or charge shall be deemed to be incurred on the date on which the par-
ticular service or supply which gives rise to the expense or charge is rendered or
• obtained. In the absence of due proof to the contrary, when a single charge is
made for a series of services each service shall be deemed to bear a pro rata share
of the charge.
• (i) The term "date of issue" means the date this policy took effect as shown on Page 1
of this policy.
(j) The first "policy anniversary" shall be deemed to occur on October 14, 1964. The
next policy year shall extend from October 15, 1964 to October 31, 1965, and there-
after "policy anniversaries" shall be deemed to occur on each succeeding November 1.
(k) The term "policy year" means a period commencing with the date of issue of this
policy, or a policy anniversary, and terminating immediately prior to the next
• succeeding policy anniversary.
(1) A "policy month" shall commence on the date of issue. Each "policy month" there-
after shall be deemed to commence on the fourteenth day of the calendar month.
• (m) The term "physician" or "surgeon" means only a legally qualified physician.
(n) "Contributory insurance" means insurance for which an employee makes written re-
quest to his Participant Employer and agrees to make the required contributions to
. his Participant Employer. "Non- contributory insurance" is insurance for which an
employee does not make written request nor contribute toward the cost. This policy
provides insurance on the non - contributory basis with respect to Employee Coverage
and on the contributory basis with respect to Dependent Coverage.
• (o) The term "Plan A" means insurance with respect to one dependent.
(p) The term "Plan B" means insurance with respect to more than one dependent.
•
• GR -23 Page 3 -A
Article I— GENERAL PROVISIONS (Continued)
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Section 2. List of Participant Employers
• An Employer shall be eligible to be included in this list as a Participant Employer if such
inclusion is not contrary to any applicable insurance law of the state or other jurisdiction
in which this policy is delivered.
• The Policyholder may act for and on behalf of any and all of the Employers included in
this list in all matters pertaining to this policy, and every act done by the Policyholder,
agreement made between the Insurance Company and the Policyholder, or notice given by
the Insurance Company to the Policyholder or by the Policyholder to the Insurance Com-
pany, shall be binding on all such Employers.
Any eligible Employer may be added to this list as a Participant Employer only upon
written agreement between the Policyholder and the Insurance Company and upon terms
mutually agreeable to them.
• An Employer shall be eliminated automatically from this list when this policy is discon-
tinued with respect to employees of such Employer, as provided for elsewhere in this
policy, but termination of an Employer's status as a Participant Employer shall not relieve
• such Employer from any obligations to the Insurance Company with respect to the time
such Employer was a Participant Employer under this policy.
Effective Date
Name of Participant Employer Principal Location of Inclusion
Policyholder See Application Date of Issue
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GR -23
Ed. 9-'67
Page 4
1413
Article I— GENERAL PROVISIONS (Continued)
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• Section 3. Employees to be Insured
3 (I) Employee Coverage
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A. Employees Eligible:
All employees of a Participant Employer shall be eligible for Employee Coverage ex-
cept employees in the following classes:
(a) temporary or substitute employees (i.e., employees who are not classified by such
. Employer as permanent employees) ;
(b) employees who are actively working for such Employer on a part -time basis, but
this exception shall not apply in the case of a regular, full -time, active em-
ployee of such Employer if and while he is only temporarily working for such
Employer on a part -time basis.
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Each employee in an eligible class whose employment commenced on or before the
date of issue shall become eligible for Employee Coverage on the date of issue, and
each other employee in an eligible class shall become eligible for Employee Cover-
. age on the date on which he completes two months of continuous service.
Anything to the contrary notwithstanding, if an individual is in the employ of or con-
nected with two or more Participant Employers, he shall not be eligible for multiple
coverage under this policy, but shall be treated the same as if he were in the employ
of or connected with a single Participant Employer; the amount of insurance for which
any such individual shall be eligible under this policy shall under no circumstances ex-
ceed the amount which would apply if all of the Participant Employers with which he
is employed or connected were a single Participant Employer and if the aggregate of
• the remuneration being paid to him by all such Participant Employers were being paid
to him by a single Participant Employer.
If any Participant Employer is a partnership, the natural- person partners thereof shall
be considered to be employees within the meaning of this policy if and while they are
actively engaged in and devoting their time on a substantially full -time basis to the
• conduct of the business of the partnership. If any Participant Employer is an indi-
vidual proprietorship, the natural- person proprietor thereof shall be considered to be
an employee within the meaning of this policy on the same terms as those applicable
to partners of a partnership.
• GR -23 New
Ed. 9-'57 Page 5 1503
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Article I— GENERAL PROVISIONS (Continued)
Section 3. Employees to be Insured (Continued)
(I) Employee Coverage (Continued)
B. Effective Dates of Insurance:
(1) As to contributory insurance, each employee who makes written request to his
Participant Employer for Employee Coverage and agrees to make the required con-
tributions therefor to his Participant Employer is to be insured for Employee Cov-
erage on the date he becomes eligible for Employee Coverage or on the date he
makes such request, whichever is later; provided, however, that
(a) the Employee Coverage of any employee who makes such written request after
thirty -one days from the date he becomes eligible, or who revokes any written
request previously made, shall become effective only if and when the Insur-
ance Company gives its written consent; and
(b) any employee who is both disabled (i.e., ill or injured) and away from work
on the date Employee Coverage is to become effective shall not be insured
until he actually returns to work on a full -time basis.
(2) As to non - contributory insurance, each employee is to be insured for Employee Cov-
erage on the date he becomes eligible therefor; provided, however, that any em-
ployee who is both disabled (i.e., ill or injured) and away from work on the date
Employee Coverage is to become effective shall not be insured until he actually re-
turns to work on a full -time basis.
GR -23 C —NC
Ed. 9257 Page 5- Continued 1536
Article I— GENERAL PROVISIONS (Continued)
Section 3. Employees to be Insured (Continued)
(II) Dependent Coverage
A. Employees Eligible:
• (1) Each employee who has one or more dependents shall be eligible for Dependent
Coverage on the date he becomes eligible for Employee Coverage, and
(2) each employee without a dependent at the date he becomes eligible for Employee
• Coverage shall be eligible for Dependent Coverage on the date he acquires a de-
pendent.
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• An employee who has only one dependent shall be eligible for Dependent Coverage
under Plan A. An employee who has more than one dependent shall be eligible
for Dependent Coverage under Plan B.
B. Effective Dates of Insurance:
• Each employee who makes written request for Dependent Coverage under the PIan for
which he is eligible and agrees to make the required contributions therefor to his Par-
ticipant Employer is to be insured for Dependent Coverage under that Plan from the
date he becomes eligible under that Plan or on the date he makes such request, which-
ever is later; provided, however, that
• (a) no employee shall become insured for Dependent Coverage at a time when he is
not insured for Employee Coverage;
(b) the Dependent Coverage of any employee who makes such written request after
• thirty -one days from the date he becomes eligible for Dependent Coverage, or
who revokes any written request previously made, shall become effective only if and
when the Insurance Company gives its written consent; and
(c) if an employee who is insured under one of the Plans makes written request for
• Dependent Coverage under another Plan after thirty -one days from the date the
employee becomes eligible for Dependent Coverage thereunder, the Insurance Com-
pany shall have the right to require evidence of insurability (without expense to the
Insurance Company) of each of such employee's dependents not covered under this
policy on the date of such written request; and insurance shall become effective
• with respect to a dependent of whom evidence of insurability is required only if
and when the Insurance Company gives its written consent.
GR -23 Page 5 -A As
Ed. 9 -157 (A & B) )56)
• I Article I— GENERAL PROVISIONS (Continued)
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Section 3. Employees to be Insured (Continued)
If on the date an employee would otherwise become insured with respect to a particular
dependent, the effective date of the Dependent Coverage under Title CMEB or Title
MMEB for that dependent would be deferred in accordance with the following para-
graph, then insurance under such Title shall be deferred until such time as neither the
terms of such paragraph nor the foregoing terms of this section require it to be de-
ferred:
In any instance in which a dependent —other than a child with respect to whom
• the employee becomes insured under Title CMEB or Title MMEB within thirty -one
days after the date of the child's birth —is confined, by reason of disease or injury,
at home, in a hospital, or elsewhere, on the date the employee would otherwise be-
come insured under Title CMEB or Title MMEB with respect to such dependent,
or in any instance in which a dependent has been confined in a hospital at any time
. during the thirty -one day period immediately preceding the date the employee
would otherwise become insured under Title CMEB or Title MMEB with respect to
such dependent, the effective date of the employee's insurance under such Title
with respect to any such dependent shall be deferred until the earlier to occur of
• (a) the end of a thirty -one day period during which there has been no confinement
of any kind, and
(b) the date the Insurance Company is furnished with evidence satisfactory to it
that the dependent has completely recovered from all such diseases and in-
juries.
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• GR -23 Page 5 -B BIRTH
Ed. 9257 (A & B) 15'72
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• Classification
All employees
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Article II— BENEFITS
TITLE HEB— HOSPrI'AL EXPENSE BENEFITS
Schedule of Insurance
Maximum Rate of Factor For
Daily Benefit Benefit Clause (a)
$20
70
Factor For
Benefit Clause (b
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Section 1. Hospital Expense Benefit
• If, solely because of any non - occupational disease or non - occupational injury, a covered family
member becomes confined in a hospital, the Insurance Company shall, subject to the terms of
this policy, pay:
(a) a benefit in an amount equal to the actual charges made by the hospital, in its own
• behalf, for board and room of the covered family member during such confinement,
but in no event shall the aggregate benefit payable under this benefit clause (a) in
connection with all hospital confinements commencing during any one continuous
period of disability exceed the amount determined by multiplying the applicable
Maximum Rate of Daily Benefit by the lesser of (i) the number of days of confine-
ment for which such charges are made and (ii) the applicable Factor for Benefit
Clause (a);
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• GR -23
Ed. 4 -'59 Page 6 — HEB 4132
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Article II— BENEFITS
TITLE HEB— HOSPITAL EXPENSE BENEFITS (Continued)
Section 1. Hospital Expense Benefit (Continued)
• (b) a benefit in an amount equal to the actual charges other than those for board and
room, for the services of any physician or intern, and for any private duty or special
nursing services, regardless of whether the services are rendered under the direction
of the hospital or otherwise —made by the hospital, in its own behalf, for services and
• supplies required for and rendered to the covered family member in direct con-
nection with the treatment of the covered family member; but in no event shall the
aggregate benefit payable under this benefit clause (b) in connection with all hos-
pital confinements commencing during any one continuous period of disability exceed
the amount determined by multiplying the applicable Maximum Rate of Daily Bene-
fit by the applicable Factor for Benefit Clause (b) ; moreover, no benefit shall be
payable under this benefit clause (b) with respect to any charges incurred during
any period for which a board and room benefit is not payable under the foregoing
benefit clause (a), except when the only hospital charge either is in connection with
. and for services rendered on the day of a surgical procedure or is for emergency
treatment required as a result of a non - occupational injury and rendered on the day
of the injury or the day next following.
No benefit shall be payable under this section under any of the circumstances for which no
! insurance is afforded as stated in the provision of this Article entitled Exclusions, Limitations,
And Provisions Applicable To All Titles Under Article II.
All hospital confinements of a covered family member shall be considered as commencing dur-
ing one continuous period of disability (whether or not there has been any interruption in the
• continuity of insurance as to such family member), except that if evidence satisfactory to the
Insurance Company is furnished
(a) that the cause or causes of the latest hospital confinement cannot be connected with
the cause or causes of any of the prior hospital confinements, or
• (b) that a connection with the cause or causes of any one or more of the prior hospital
confinements can be established but that between the date of the last of the previous
hospital confinements which are connected and the latest one the family member
either has recovered completely from all of the causes of such prior hospital con-
finements or, if he is the employee, has returned to active work for at least one full
day or, if he is other than the employee, a period of at least ninety days free of hos-
pital confinement has intervened,
the latest hospital confinement will not be considered as having commenced during the same
• period of disability.
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GR -23
Ed. 4259 Page 6 -A — HEB 4191
Article II— BENEFITS
• TITLE SEB— SURGICAL EXPENSE BENEFITS
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Schedule of Insurance
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• Schedule of Basic Maximum
Classification Procedures Surgical Unit Benefit
All employees K $16 $480
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• Section 1. Specific Definitions
As used in this Title:
• (a) the term `operation" means the performance of one or more surgical procedures
during a single operating period and shall, in any event, include all surgical pro-
cedures performed during any one continuous period of anesthetization;
(b) the term "surgical procedure" means any procedure specifically listed in the appli-
cable Schedule of Procedures, and any other surgical procedure in the categories
listed below:
(1) the incision, excision, or electrocauterization of any organ or part of the body;
(2) the manipulative reduction of a fracture or dislocation;
• (3) the suturing of a wound;
(4) the removal by endoscopic means of a stone or other foreign object from the
larynx, bronchus, trachea, esophagus, stomach, urinary bladder, or ureter.
• Section 2. Surgical Expense Benefit
If, solely because of any non - occupational disease or non - occupational injury, a surgical pro-
cedure is .performed on a covered family member, the Insurance Company shall, subject to
the terms of this policy, pay a benefit in an amount equal to the total surgical fees actually
is charged by the operating physicians (but not including any fee charged by a resident physi-
cian or intern of a hospital), for their professional services in performing such surgical pro-
cedure but not exceeding the amount obtained by multiplying the applicable Basic Surgical
Unit by the factor determined for such procedure in accordance with the applicable Schedule
of Procedures.
• No benefit shall be payable under this section
(1) with respect to any medical treatment (whether involving injury or disease) other
than the performance of surgical procedures, whether or not the alternative treat-
ment is in lieu of or accomplishes the same result as the performance of the corres-
• ponding surgical procedures; or
• GR -23 K 480
Ed. V59 Page 6 — SEB 4614
• Article II— BENEFITS
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• TITLE SEB— SURGICAL EXPENSE BENEFITS (Continued)
Y Section 2. Surgical Expense Benefit (Continued)
(2) under any of the circumstances for which no insurance is afforded as stated in the
provision of this Article entitled Exclusions, Limitations, And Provisions Applicable
to All Titles Under Article II, or for dental work or oral surgery, except oral sur-
gery for (a) excision of partially or completely unerupted impacted teeth, (b) ex-
cision of tooth root without extraction of entire tooth, (c) closed or open reduction
of fractures or dislocations of the jaw, and (d) other incision or excision procedures
on the gums and tissues of the mouth when not performed in connection with the
extraction of teeth —for the purposes of the oral surgery recognized by the terms of
this paragraph, the term "physician" shall be deemed to include a duly licensed
• dentist.
Two or more surgical procedures performed during the course of a single operation either
through the same incision, or through the same natural body orifice, or in the same opera-
tive field, shall, except to the extent, if any, that this provision is specifically contradicted by
the provisions of the applicable Schedule of Procedures, be considered as one surgical proced-
ure and the factor applicable shall be the greatest of the factors determined for such surgical
procedures in accordance with the applicable Schedule of Procedures. Otherwise, payment
will be made for each surgical procedure as indicated in the preceding paragraph unless the
• applicable Schedule of Procedures specifies to the contrary.
The aggregate benefit payable with respect to all surgical procedures performed during one
continuous period of disability shall not exceed the Maximum Benefit.
• All surgical procedures which are performed on a covered family member shall be considered
as having been performed during one continuous period of disability (whether or not there
has been any interruption in the continuity of insurance as to such family member), except
that if evidence satisfactory to the Insurance Company is furnished
• (a) that the cause or causes of the latest surgical procedure cannot be connected with
the cause or causes of any of the prior surgical procedures, or
(b) that a connection with the cause or causes of any one or more of the prior surgical
procedures can be established but that between the date of the last of the previous
• surgical procedures which are connected and the latest one the family member either
has recovered completely from all of the causes of such prior surgical procedures or,
if he is the employee, has returned to active work for at least one full day or, if he
is other than the employee, a period of at least ninety days free of surgery has in-
tervened,
the latest surgical procedure will not be considered as having been performed during the
same period of disability. However, in any instance in which the applicable Schedule of Pro-
cedures provides either (i) for a single factor to be applicable to a particular series of pro-
cedures or to several stages of a procedure or (ii) for a lesser factor to be applicable to the
• second and subsequent procedures of a particular series of procedures than would apply to the
first procedure in the series, then the provisions of the applicable Schedule of Procedures shall
apply whether the procedures are performed during the same or different periods of disability.
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GR -23 K
Ed. V59 Page 6 -A — SEB 4676
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Article II — BENEFITS
TITLE SEB —SURGICAL EXPENSE BENEFITS (Continued)
Schedule of Procedures K
GENERAL Factor
Accidental lacerations of skin structures,
suture of
Face, neck, genitalia and hands, all
lacerations combined 1 inch or less .
More than 1 inch up to 2 inches
Other body areas, all lacerations
combined
1 inch or less . . . . . .
More than 1 inch up to 2 inches
Bronchoscopy — Diagnostic, with or
withoutbiopsy .
— Operative removal of
tumors or foreign
bodies . . . . . .
Cystoscopy
Diagnostic, with or without biopsy
Without ureteral catheterization
With ureteral catheterization
Operative — Transurethral resection
of bladder neck or bladder tumors or
crushing of bladder stones .
— Fugguration of bladder
tumors or removal of bladder stones,
without crushing. . .
Cysts, excision of - - Pilonidal cyst . .
-- Sebaceous cyst .
Mammary glands
Excision of benign tumors or cysts
— Unilateral . . . . .
— Bilateral . . . . .
Mastectomy -- Total . . . .
— Radical with axillary
node dissection
Skin abscess, superficial, incision and
drainage .— One . . . .
-- Each additional . . .
— Maximum . . . . .
Thyroid gland
Thyroidectomy, total or subtotal
Thyroid lobectomy,
hemithyroidectomy
Excision of thyroid adenoma or cyst .
Tumors, benign, superficial
Excision from face, neck, genitalia,
hands, or feet -- One .
— Each additional
Excision from other body areas
— One . . .
— Each additional .
Electrocauterization or fulguration,
with or without curettage, per day
of such treatment
One tumor, except plantar wart
More than one tumor, or each
plantar wart . . . . . .
MUSCULOSKELETAL
Amputations
Finger, thumb, or toe (one or more
phalanges) — One . .
-- Each additional . .
Thigh, through femur . . . . .
GR -23
Ed. 4 -'59
1.5
2
0.75
1
4.5
7.5
2.5
3.5
11
5
9
1.5
5
7.5
10
20
0.75
0.40
2.5
17.5
15
12.5
1
0.5
0.5
2.5
1.5
15
MUSCULOSKELETAL (Continued) Factor
Closed Open
Reduc- Reduc-
Dislocations tion tion
Elbow . . . . . . . 4 10
Shoulder 3.5 12.5
Fractures, simple or
compound
Ankle — Malleolus of
tibia or fibula . . . . 5 10
— Bimalleolar
(Potts) . . . 6 15
Clavicle . . 3 10
Elbow, distal end of
humerus or proximal end
of radius or ulna, one or
more bones . . 6 15
Femur (except knee) 12 24
Fibula (except ankle) 4 8
Finger, thumb or toe
— One 2 4
— Each additional 1 2
Humerus (except elbow) 7.5 15
Knee, distal end of femur
or proximal end of tibia,
one or both bones 7.5 15
Radius, including Colles'
(except elbow) 5 10
Radius and ulna (except
elbow) . . . . . . 7 14
Ribs, one or more 2
Tibia (except ankle and
knee) 7.5 15
Tibia and fibula (except
ankle) . . 10 20
Ulna (except elbow) . . 4 10
Closed reduction is correction of displace-
ment by manipulation without incision in-
cluding application of casts or traction and
including debridement at fracture site. For
closed reduction of a fracture with skeletal
pinning and external fixation, the factor
amount is one and one -half times the factor
for closed reduction.
Open reduction is correction of displace-
ment by manipulation and incision with or
without skeletal traction or metallic fixation.
Intervertebral disc, excision of
— Without spinal fusion 22.5
— With spinal fusion 30
Tendons — Excision of ganglion . . . 4
Suture of tendon laceration
— One . . . 5
— Each additional . . . 2.5
EYE, EAR, NOSE, AND THROAT
Chalazion, excision or curettage
— Single . . . . . . 1.5
— Multiple . . . . . . 2.5
Extraction of lens for cataract . . . . 20
Strabismus, operation for -- One eye 13.5
— Both eyes 17.5
Page 6 -B —SEB
K
4801
•
Article II —
BENEFITS
TITLE SEB — SURGICAL EXPENSE BENEFITS (Continued)
m
Schedule of Procedures
Iti (Continued)
$
EYE, EAR, NOSE, AND THROAT
PROCTOLOGY AND UROLOGY
(Continued) Factor
(Continued) Factor
Each additional operation, one or both
Proctectomy, complete, combined
eyes . . . . . . . . . . .
7.5
abdominal — perineal procedure, one
o
Fenestration operation for otosclerosis .
30
or more stages . . . . . . .
30
Myringotomy or tympanotomy . . .
1.5
Prostatectomy — Suprapubic, one or
V
Nasal polyps, removal of one or more,
more stages . . .
25
•
one or more stages
— Transurethral, one or
Unilateral . . . . . . . . .
1.5
more stages including
Bilateral . .
2.5
control of postoper-
Nasal septum, submucous, resection of.
10
ative bleeding
20
Tonsillectomy with or without
GYNECOLOGY
adenoidectomy . . . . .
4
Conization of cervix . . . . . . .
3
•
HEART AND BLOOD VESSELS
Cystocele, repair of . . . . . . .
10
Commissurotomy or valvotomy .
30
Rectocele, repair of . . . . .
7.5
Saphenous vein, long, ligation with or
Cystocele and rectocele, repair of . . .
14
without retrograde injection or distal
Dilation of cervix and curettage of
interruptions
uterus, non - puerperal, with or without
•
Without stripping — Unilateral
7.5
electrocautenzation, conization or
— Bilateral
11
polypectomy . . . . . .
4
With stripping on same or sub-
Electrocauterization of cervix,
sequent days — Unilateral
10
non - puerperal . . . . . . .
Hysterectomy, with or without dilation
1.5
•
— Bilateral
CHEST
15
and curettage
Lobectomy — Total, subtotal or
Complete (pan - hysterectomy), with or
without adnexa . . . . . . .
18
segmental
30
Subtotal or supracervical, with or
-- Wedge resection . . .
22.5
without . . . . . .
15
Thoracotomy, for drainage of empyema .
r mall
Radical, for malignancy
25
•
Without rib resection . , ,
5
Saboth, ctomy oo or
With rib resection . . . . .
10
ra bilateral .
both, unilateral or bilateral .
12.5
ABDOMEN
Uterus, suspension of, any type, with or
Appendectomy, with or without incision
without dilation and curettage or
and drainage of appendiceal abscess .
11
surgery on tubes or ovaries . . . .
12.5
•
Cholecystectomy, with or without ex-
NEUROSURGERY
ploration of comon duct . . . . .
17.5
Craniotomy (other than trephination
Colon resection — Partial, with or with-
only)
out colostomy . . .
25
Decompression, unilateral or
— Total . . .
30
bilateral . . .
17.5
•
Gastrectomy, with or without
vagotomy — Partial
25
Excision of brain cyst, neoplasm, or
abscess
30
— Total . .
30
Lumbar sympathectomy - Unilateral
15
Herniotomy, inguinal or femoral
— Bilateral
22.5
— Single . . . . .
11
Trephination
— Bilateral . . . . . .
15
Drainage of subdural, epidural or
•
PROCTOLOGY AND UROLOGY
brain abscess or hematoma
Fistulectomy or fistulotomy — Single
6.5
Initial trephination
15
Multiple
9
--Subsequent needling
3
Fistulectomy or fistulotomy (single or
Pneumoventriculography . . . . .
10
multiple), with incision and drainage
of ischiorectal abscess . .
9
Hemorrhoidectomy, by excision, internal
only or both internal and external
Without fistulectomy
8
— With fistulectomy . . .
10
Hydrocele or varicocele, excision of
•
— Unilateral
7.5
— Bilateral . . . .
10
Ischiorectal abscess, incision and
drainage . . .
3.5
Nephrectomy or heminephrectomy
22.5
•
The Insurance Company will determine a
factor consistent with the factors listed, for a surgical
pro-
cedure not listed in the foregoing Schedule
— such determination, in each case, to take into account
the
nature and complexity of the procedure involved
and
the exclusions and other restrictions applicable.
GR -23
K
—XO8
Ed. 4 -'59
Page 6 -C—SEB
4803
n
u
Article II— BENEFITS
N
• TITLE ANEB— ANESTHESIA EXPENSE BENEFITS
Schedule of Insurance
• Classification Maximum Anesthesia Benefit
All employees The greater of
(i) 5cle of the applicable Maximum
Benefit under Title SEB of Arti-
cle II
(ii) 20% of the total surgical allow-
ance under Title SEB for all sur-
gical procedures with respect to
which anesthesia was adminis-
tered
0
• if anesthesia, other than local infiltration anesthesia, is administered to a covered family mem-
ber in connection with a surgical procedure for which Surgical Expense Benefits are payable
under Title SEB and if the anesthesia is administered and charged for by a physician who is not
the operating surgeon or his assistant, then the Insurance Company shall, subject to the terms
of this policy, pay a benefit in an amount equal to the actual charges made by the physician,
• but not exceeding the applicable Maximum Anesthesia Benefit; provided, however, that the
aggregate benefit payable with respect to any one continuous period of disability (as defined
in Title SEB), whether such disability be from one or more causes, shall be 20% of the ap-
plicable Maximum Benefit under Title SEB.
r1
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•
is
•
40
GR -23
Ed. 4253 Page 6 —ANEB 5106
Article II— BENEFITS
. TITLE IHMEB —IN- HOSPITAL MEDICAL EXPENSE BENEFITS
Schedule of Insurance
! Daily Total Maximum Period
Classification Maximum Maximum of Payment (in Days)
! All employees $5 $350 70
Section 1.
If, solely because of any non - occupational disease or non - occupational injury, medical treat-
ment is rendered to a covered family member while confined to a hospital as an inpatient, the
Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal
to the actual charges made by the physicians for such medical treatment; provided, however,
that
(a) as to charges with respect to all treatments rendered prior to the date of any sur-
gical procedure that may be performed, whether or not surgical expense benefits are
payable under this policy, not more than an amount equal to the applicable Daily
Maximum multiplied by the number of calendar days of such confinement prior to
the date of such surgical procedure shall be payable;
. (b) as to charges with respect to all treatments rendered on any calendar day on and
after the date of the first of any such surgical procedures, not more than the appli-
cable Daily Maximum shall be payable for any such calendar day on which treat-
ment is received; and
(c) the aggregate benefit payable with respect to all treatments rendered in connection
• with all hospital confinements commencing during any one continuous period of dis-
ability shall not exceed the applicable Total Maximum.
No benefit shall be payable under this section
(1) with respect to a surgical procedure, whether or not surgical expense benefits are
payable under this policy, or with respect to treatments rendered on or after the date
of such a surgical procedure, except for treatments rendered by physicians other than
the physicians who performed the surgical procedure; or
(2) for any dental work or treatment, or for eye examinations or the fitting of glasses,
or for diagnostic x -rays, or for drugs or medicines; or
! (3) with respect to charges incurred for medical treatment rendered to a, covered family
member during a period of hospital confinement which commenced prior to the date
this Title became applicable to him; or
(4) with respect to charges incurred during any one continuous period of disability after
. the expiration of the number of days of hospital confinement shown as the applicable
Maximum Period of Payment; or
(5) under any of the circumstances for which no insurance is afforded as stated in the
provision of this Article entitled Exclusions, Limitations, And Provisions Applicable
To All Titles Under Article I1.
• GR -23
Ed. 4 -'59 Page 6 — IHMEB 5410
Article II —BENEFITS
TITLE IHMEB — IN- HOSPITAL MEDICAL EXPENSE BENEFITS (Continued)
All hospital confinements of a covered family member shall be considered as commencing during one
• continuous period of disability (whether or not there has been any interruption in the continuity of
insurance as to such family member), except that if evidence satisfactory to the Insurance Company is
furnished
(a) that the cause or causes of the latest hospital confinement cannot be connected with the
cause or causes of any of the prior hospital confinements, or
(b) that a connection with the cause or causes of any one or more of the prior hospital confine-
ments can be established but that between the date of the last of the previous hospital con-
finements which are connected and the latest one the family member either has recovered
completely from all of the causes of such prior hospital confinements or, if he is the em-
ployee, has returned to active work for at least one full day or, if he is other than the em-
ployee, a period of at least ninety days free of hospital confinement has intervened,
the latest hospital confinement will not be considered as having commenced during the same period of
disability.
GR -23
Ed. 4259 Page 6 -A -- IHAIEB 5446
Article II —BENEFITS
• TITLE LXEB —LABORATORY AND X -RAY EXPENSE BENEFITS
N
o Schedule of Insurance
� Maximum
> Classification Benefit
•
All employees
$50
• Section 1.
If, solely for diagnosis of any non - occupational disease or non - occupational injury, a laboratory or
x -ray examination of a covered family member is made, the Insurance Company shall, subject to
• the terms of this policy, pay a benefit in an amount equal to the actual charges made with respect
to such examination, but not exceeding the maximum amount determined for such examination in
accordance with the Schedule of Laboratory and X -Ray Benefits.
No benefit shall be payable under this Title
• (1) with respect to an examination received in or through a hospital except in connection with
out - patient care for which no hospital expense benefit of any kind is payable under this
policy on account of such examination; or
(2) with respect to any dental x -ray except in connection with a non - occupational injury; or
• (:,) under any of the circumstances for which no insurance is afforded by this Title as stated
in the provision of this Article entitled Exclusions, Limitations, And Provisions Applica-
ble To All Titles Under Article II.
. If two or more such examinations are involved, payment shall be made for each examination in
accordance with the foregoing paragraphs, but not more than the applicable Maximum Benefit shall
be payable for all examinations made during any one calendar year, whether involving related or
unrelated causes.
•
•
•
0
•
GR -23 YR -SCHED S 12
Ed. 4259 Page 6 — LXEB 5601
11
Article II —BENEFITS
•
TITLE LXEB —LABORATORY AND X -RAY EXPENSE BENEFITS (Continued)
Schedule of Laboratory and X -Ray Benefits
— X -2
•
Maximum
Amount for
LABORATORY EXAMINATIONS
Examination
•
Bacteria Test: Smear (sputum, feces, etc.) .
Basal Metabolism Test . . . . . . . . . . .
$ 3.00
. . . . 7.50
Blood Count: Hemoglobin, Red Cells, White Ce, fferential
1.50
All four counts
5.00
Electrocardiogram or Ballistocardiogram, with interpretation and report
12.50
•
Malignancy Test: Papanicolaou Smear — initial
5.00
— each additional
2.50
Spinal Fluid: cell count and protein .
5.00
Sugar Determination, Blood
5.00
•
Sugar Tolerance (2 or more blood and urine determinations)
12.50
X -RAY EXAMINATIONS
Abdomen (intestines, colon, rectum, kidney, etc.)
$ 12.50
Chest (heart, lungs, ribs, etc.)
12.50
•
Colon, Barium enema
25.00
Extremities — Fingers, one or more of one hand
5.00
Arm, all or any portion between shoulder and fingers
10.00
— Shoulder, with or without humerus
12.50
•
— Toes, one or more of one foot
5.00
— Leg, all or any portion between hip and toes
10.00
Hip, with or without femur
12.50
Gallbladder, dye method
20.00
Gastro- intestinal series, complete: — Barium meal
30.00
•
— Barium meal with Gallbladder, dye method
40.00
— Barium meal and enema, with Gallbladder, dye method
50.00
Head (skull or sinuses excluding nasal bones)
15.00
Kidney, Intravenous Pyelogram
20.00
Myelogram 25.00
• Pelvis 15.00
The Insurance Company will determine an amount of payment, consistent with the
amounts listed, for an examination not listed in the foregoing Schedule — such deter-
mination, in each case, to take into account the nature and complexity of the examination
involved and the exclusions and other restrictions applicable.
0
0
• GR -23 x -2 -50 5 12
Ed. 4 -'59 Page 6 -A — LXEB 5625
n
L.
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0
m
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•
•
.Section 1.
Article II— BENEFITS
TITLE AEB— ACCIDENT EXPENSE BENEFITS
Schedule of Insurance
Maximum
Classification Benefit
All Employees
$30o
• If a covered family member sustains a non- occupational injury —and if, within ninety days
after the date of the accident which caused such injury, any hospital, surgical, or medical serv-
ices, or emergency professional ambulance service to transport the covered family member
from the place where he is injured to the first hospital where treatment is given, or the serv-
ices of a registered graduate nurse, are required by such family member for the treatment of
such injury —and if the amount of expenses incurred for such services is in excess of the aggre-
gate of the benefits provided under this policy (exclusive of this Title and Title MMEB, if in-
cluded in this policy) in connection with such expenses, the Insurance Company shall, subject
to the terms of this policy, pay a benefit in an amount equal to such excess expenses, but not
• exceeding the applicable Maximum Benefit in connection with all injuries sustained by such
family member through any one accident.
No benefit shall be payable under this Title
0
0
•
lJ
n
►J
(1) with respect to any expenses other than those for such services as, in the opinion of a
physician who is attending such family member, are required for the treatment of
such injury;
(2) for any services rendered more than ninety days after the date of the accident which
caused such injury; and
(3) under any of the circumstances for which no insurance is afforded by this Title as
stated in the provision of this Article entitled Exclusions, Limitations, And Provisions
Applicable To All Titles Under Article I1, or for surgical or medical services rendered
other than by a physician or a duly licensed dentist.
• GP. -23
Ed. 8 -'62 Page 6 — AEB
ALL 300
5756
0
•
0
•
0
0
•
•
Article II-- BENEFITS
TITLE MMEB- -MAJOR MEDICAL EXPENSE BENEFITS
Deductible
Family
Private
Per Family
Deductible
Maximum
Room
Classification Member
Limit
Benefit
Limit
All employees $100
$300
$10,000
The hospital's
average daily
rate for
board and room
in semi- private
accommodations
If an employee incurs, during a calendar year, "Covered Medical Expenses" for the treat-
ment of a covered family member in excess of the sum of
(a) the Deductible applicable to the member for that year and
(b) other benefits as described in the "Co- ordination With Other Benefits"
section appearing on Page 6.1 - -ELP of this Article,
the Insurance Company shall, subject to -the terms of this policy, pay a benefit in an
amount equal to 80% of such excess Covered Medical Expenses incurred as to the member
in that calendar year; but the aggregate of the benefits payable under this Title with
respect to a family member during his lifetime (whether or not there has been any
interruption in the continuity of his insurance) shall not exceed his "Maximum Bene-
fit".
•
•
• GR -23
N
r
• Article II— BENEFITS (Continued)
• TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued)
Covered Medical Expenses
Covered Medical Expenses are the reasonable charges which an employee is required to pay for
• the following services and supplies received by a covered family member for the necessary treat-
ment of any non - occupational injury or non - occupational disease:
HOSPITAL EXPENSES: These are the charges made by a hospital, in its own behalf, for
• (a) Board and room. However, if private accommodations are used, any excess of daily board
and room charges over the applicable Private Room Limit will be disregarded.
(b) Necessary hospital services, other than board and room, furnished by the hospital.
OTHER MEDICAL EXPENSES: The following charges are considered "Other Medical Expenses ",
provided that they have not been considered as "Hospital Expenses ":
(1) The fees of a physician or surgeon;
• (2) The charges of a registered graduate nurse other than a nurse who ordinarily resides
in the employee's home, or is a member of the family of either the employee or the em-
ployee's spouse;
• (3) The charges for the following medical services and supplies:
(i) Drugs and medicines obtainable only upon a physician's prescription;
(ii) Diagnostic x -ray and laboratory examinations;
• (iii) X -ray, radium, and radioactive isotopes therapy;
(iv) Anesthesia and oxygen;
• (v) Rental of iron lung and other durable medical and surgical equipment;
(vi) Artificial limbs and eyes —but not eye examinations, eye glasses, or hearing aids;
• (vii) Professional ambulance service when used to transport the individual from the
place where he is injured by an accident or stricken by a disease to the first hos-
pital where treatment is given —but no other charges for transportation or travel.
•
•
•
t GR -23 PVT RM
Ed. 9257 Page 6- A —MMEB 7124
J • Article II— BENEFITS (Continued)
0
r
• TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued)
SPECIAL CONDITIONS:
Hospital Expenses and Other Medical Expenses incurred in connection with cosmetic surgery
• necessary for the prompt repair of a non - occupational injury which occurs while the indi-
vidual concerned is a covered family member are included as Covered Medical Expenses.
No other expenses for cosmetic surgery are included as Covered Medical Expenses.
Hospital Expenses and Other Medical Expenses, incurred in connection with dental work or
• oral surgery for the prompt repair of natural teeth or other body tissue, and required as
a result of a non - occupational injury which occurs while the individual concerned is a covered
family member, are included as Covered Medical Expenses. Also, Hospital Expenses and
Other Medical Expenses required in connection with the performance of the following oral sur-
gical procedures are included as Covered Medical Expenses: (i) the excision of partially or
completely unerupted impacted teeth; (ii) the excision of a tooth root without the extraction
. of the entire tooth; or (iii) other incision or excision procedures on the gums and tissues of
the mouth when not performed in connection with extraction or repair of teeth. For the pur-
poses of the dental work or oral surgery covered by the terms of this paragraph, Other Medi-
cal Expenses shall be deemed to include fees of a duly licensed dentist. No other expenses for
dental work or oral surgery are included as Covered Medical Expenses.
Hospital Expenses and Other Medical Expenses of a family member incurred in connection
with one of the following complications of a pregnancy are included as Covered Medical Ex-
penses: (i) surgical operations for extra - uterine pregnancy or for other complications requir-
ing intra- abdominal surgery after termination of pregnancy; (ii) pernicious vomiting of
• pregnancy (hyperemesis gravidarum) ; or (iii) toxemia with convulsions (eclampsia of preg-
nancy). No other expenses in connection with pregnancy or resulting childbirth or miscar-
riage are included as Covered Medical Expenses.
If a family member first becomes eligible for coverage under this Title after
• the effective date of this Title, hospital expenses and Other Medical Expenses
incurred during the first twelve months that insurance of a family member is
in force under this Title will not be included as Covered Medical Expenses if
they are in connection with a disease or injury for which he received treat-
ment, or services, or took prescribed drugs or medicines, during the three
. month period prior to the effective date of such insurance.
41
E
•
40
GR -23 NO 50% MENT
Ed. 9257 Page 6- B —MMEB 7405
Article. II— BENEFITS (Continued)
N
r
r
• TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued)
APPLICATION OF DEDUCTIBLE: Each calendar year a separate Deductible applies to each
family member regardless of the number of his disabilities, but, when any part of a calen-
dar year's Deductible is applied against expenses arising during the last three months of that
year, the following calendar year's Deductible will be reduced by the amount so applied.
FAMILY LIMIT ON DEDUCTIBLES: If, in a calendar year, the sum of the Covered Medical Ex-
penses incurred by covered family members and applied against their Deductibles exceeds the
• Family Deductible Limit, an additional benefit in an amount equal to gp% of such excess
shall be payable. Any additional benefit payable by reason of this paragraph does not count
against the "Maximum Benefit" of any family member.
0
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GR -23 FAMILY LMT
Ed. 9-'57 Page 6- C —MMEB 7472
a Article II— BENEFITS (Continued)
P
N
r
• TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued)
Maximum Benefit
• The Maximum Benefit of each family member applies to all Covered Medical Expenses com-
bined during his lifetime.
Reinstatement —When Major Medical Expense Benefits have been paid as to a covered family
member in an amount equal to his Maximum Benefit, in one year or over a period of years,
• no further benefits shall be payable as to him. The Insurance Company will, however, con-
sent to the ignoring of benefits paid for previous expenses in applying the Maximum Benefit
provisions to benefits payable for Covered Medical Expenses incurred with respect to a covered
family member after the effective date of such consent, but only if such family member after
• benefits of at least $1,000 have been paid with respect to him under this Title submits, at no
expense to the Insurance Company, evidence of his insurability satisfactory to the Insurance
Company.
•
•
0
0
•
•
40
0
• GR -23
Ed. 9-'57
Page 6 -D —MMES
7594
0
Article II— BENEFITS (Continued)
m
0
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EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO TITLE MMEB
No insurance is afforded under this Title MMEB
(1) as to charges in connection with a disease other than a non - occupational disease or an injury
• other than a non - occupational injury;
(2) as to charges incurred with respect to any individual while he is not a covered family mem-
ber;
• (3) under any of the circumstances for which no insurance is afforded as stated in the provision
of this Article entitled Exclusions, Limitations, And Provisions Applicable To All Titles Under
Article II.
0
C1
0
0
C,
0
0
0
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• GR -23
Ed. 9257 Page 6- E —MMEB 7603
Article II— BENEFITS (Continued)
N
N
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r
• TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued)
Extension of Benefits
If insurance with respect to a family member terminates while he is totally disabled and before
• benefits aggregating his Maximum Benefit become payable with respect to him, any benefits pro-
vided under this Title for that family member, but for no other family member, will continue to
be available as to expenses incurred during the uninterrupted continuance of such total disability
but not beyond the period of twelve months immediately following such termination of insurance
• and in no event beyond the date the family member becomes insured under any other group
policy, whether issued by the Insurance Company or any other insurer, for benefits of a type
similar to that provided for in this Title. The words "totally disabled" and "total disability"
mean that the family member, if an employee, is prevented, solely because of a non - occupational
• injury or non - occupational disease, from engaging in his regular or customary occupation and is
performing no work of any kind for compensation or profit, or if a dependent, is prevented, solely
because of a non - occupational injury or non - occupational disease, from engaging in substantially
all of the normal activities of a person of like age and sex in good health.
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• GR -23
Ed. 9257 Page 6- F —MMEB 7652
Article II-- BENEFITS
• EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO
ALL TITLES UNDER ARTICLE II
Extension of Benefits: If insurance with respect to a family member under one or more of
the Titles under Article II (except Titles ADDC, WBC, MMES, FEB, and AEB, if included in
• this policy) terminates while he is totally disabled, any benefit provided under such
Titles for that family member, but for no other family member, will continue to be avail-
able as to expenses incurred during the uninterrupted continuance of such total disability
but not beyond a period of three months following the date such termination of insurance
• occurs. Expenses in respect of which benefits are payable under Title HEB, if included
in this policy, will be deemed to be incurred within such three months period if the hos-
pital confinement commenced within such period. The words "totally disabled" and "total
disability" mean, for the purposes of this paragraph, that the family member, if an em-
ployee, is prevented, solely because of injury or disease, from engaging in his regular
or customary occupation and is performing no work of any kind for compensation, or if a
dependent, is prevented, solely because of injury or disease, from engaging in substan-
tially all of the normal activities of a person of like age and sex in good health.
• No insurance is afforded under any Title of Article II as to charges
(1) that would not have been made if no insurance existed or that no individual with
respect to whom insurance under such Title relates is legally obliged to pay; or
• (2) for services or supplies which are furnished or paid for, or with respect to which
benefits are provided, under any law of a government (national or otherwise) by
reason of the past or present service of any person in the armed forces of a govern-
ment; or
•
•
•
•
•
•
(3) for services or supplies, other than those referred to in item (2) above, which
are paid for, or with respect to which benefits are provided, under any law of a
government (national or otherwise) except where such payments are made or such
benefits are provided under a plan specifically established by a government for
its own civilian employees and their dependents; or
(4) in connection with any hospital confinement or any surgical, medical, or other
treatment, services, or supplies which are not recommended and approved by a
physician who is attending the covered family member; or
(5) for care, treatment, services or supplies which are not necessary for the treatment
of the injury or disease concerned nor to the extent that any charges for care,
treatment, services or supplies are unreasonable; or
(6) caused or contributed to by, or as a consequence of pregnancy or resulting child-
birth, miscarriage or abortion; except to the extent, if any, that benefits are
specifically provided therefor under the provisions of any title of Article II of
this policy; or
(7) resulting from mental or nervous conditions incurred while the covered family
member is not confined in a hospital or similar institution on an in- patient
basis;
GE-23
Page 6 - -ELP
Article II-- BENEFITS (Continued)
EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO
• ALL TITLES UNDER ARTICLE II (Continued)
and before determining benefits under any Title, the amount of any such charges shall
be deducted from the family member's expenses which are covered under such Title and
from his Allowable Expenses (as hereinafter defined).
• No benefits are payable under this policy to the extent that the provision of such
benefits is prohibited by any applicable law of the jurisdiction in which the indi-
vidual resides at the time the claim is incurred.
•
•
•
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• GR -23 Page 6 - -ELP (Continued)
N
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Article II— BENEFITS
EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO
ALL TITLES UNDER ARTICLE II (Continued)
CO- ORDINATION WITH OTHER BENEFITS:
• Note: This provision applies to all of the benefits provided under this Article II (except those
provided under Titles ADDC and WBC, if included) ; provided, however, that this pro-
vision applies with respect to a family member only during periods in respect of which
insurance is in force, or benefits are available, under Title MMEB as to such member.
• Any benefits actually payable as to a family member under any plan or plans by reason of
expenses which are covered under this policy will be deducted from such expenses before any
benefits are determined under this policy. If a plan provides for the furnishing of services
or supplies rather than for payments in cash, then the total cash value, computed on an equi-
table basis, of all services and supplies furnished to the family member shall be taken into
• account in such determination.
"Plan ", as used in the preceding paragraph, means any plan providing benefits or services for
or by reason of medical or dental care or treatment, which benefits or services are provided by
(i) group insurance or any other arrangement of coverage for individuals in a group whether
• on an insured or uninsured basis, or (ii) Blue Cross, Blue Shield or any other prepayment cov-
erage, or (iii) any coverage for students which is sponsored by, or provided through, a school
or other educational institution.
0
0
0
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9
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0
• GR -23 CAL. —BASIC G MMEB
Ed. 9 -'57 Page G- 1 —ELP 5827
0
Article II-- BENEFITS
EXCLUSIONS, LIMITATIONS AND PROVISIONS APPLICABLE TO
0 ALL TITLES UNDER ARTICLE II (Continued)
Effect of Coverage under the Prior Blue Cross Plan carried or sponsored by the Employer
which terminated on July 31, 1964.
• As to Title M1,EB:
(a) if any part (or all) of a covered family member's Deductible under the prior
• plan providing Major Medical Expense Benefits is applied under said plan
against covered expenses incurred thereunder by the employee with respect to
such member
(i) during the calendar year in which Title RSIEB of this policy becomes
• effective, or
(ii) during the last three months of the calendar year preceding the
calendar year in which said Title becomes effective,
• the member's Deductible under said Title for the calendar year in which said
Title becomes effective shall be reduced by the amount so applied to the same
extent as though such Deductible under the prior plan had been applied under
said Title,
• (b) if any benefits have been paid or accrued as to a covered family member under
any section of the prior plan providing Major Medical Expense Benefits, the
"Maximum Benefit" of such member shall be the applicable `Maximum Benefit"
• shown on Page 6 of Title MMEB of this policy, reduced by the aggregate amount
of benefits remaining charged against such member's "Maximum Benefit" as of
the day before said Title becomes effective.
Cl
•
•
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• GR -23 Page 6- 2 - -ELP
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0
0
0
0
9
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Article III— TERMINATION OF INSURANCE
Section 1. Employee and Dependent Coverage
All insurance of any employee under this policy shall terminate at the earliest time specified below:
(1) Upon discontinuance of the policy.
(2) Immediately when the employee's employment with a Participant Employer in the classes
of employees eligible for insurance terminates. Cessation of active work by an employee
shall be deemed to be termination of his employment, except that
(a) in the case of an absence from active work because of sickness or injury, his employ-
ment may, for the purposes of insurance under this policy, be deemed to continue until
terminated by his Participant Employer but in no case beyond twelve months from the
date such absence from active work started, or
(b) in the case of absence of an employee from active work because of temporary lay-off
or leave of absence, his employment may, for the purposes of insurance under this policy,
be deemed to continue until terminated by his Participant Employer but in no case be-
yond the end of the policy month following the policy month in which such lay -off or
leave of absence commenced.
In the case of any of the exceptions in the foregoing paragraph, the insurance under this
policy for such employee shall automatically cease on the date of such termination of his em-
ployment by his Participant Employer, as evidenced to the Insurance Company by the Policy-
holder, whether by notification or by cessation of premium payment on account of such em-
ployee's insurance hereunder. Any maximum period of continuation permitted by the
foregoing paragraph may be extended by written mutual agreement between the Policy-
holder and the Insurance Company in each individual case.
In no event may any insurance provided on a contributory basis be continued beyond the end of the
period for which the employee has made to his Participant Employer the contributions required.
GR -23
Ed. 9-'57
Page 7
8713
• Article III— TERMINATION OF INSURANCE (Continued)
N
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m
• As to any insurance under Title CMEB or Title MMEB, the Employee Coverage shall terminate
prior to any time specified above when such employee shall have become entitled to the Maximum
Benefit thereunder, in which event all other insurance, if any, under the policy may be continued,
subject to payment of premium by the Policyholder, until the earliest time otherwise specified in
this Article.
Section 2. Dependent Coverage Only
• I. All Dependent Coverage of an employee shall terminate, notwithstanding any continuation of
his Employee Coverage, at the earlier of the times specified below:
(a) Upon the discontinuance of all Dependent Coverage under this policy.
• (b) Immediately when the employee shall cease to be included in the classes of employees
eligible for Dependent Coverage.
II. When Individual Dependents Cease To Be Covered:
• Any dependent of an employee insured for Dependent Coverage shall cease to be covered
under this policy prior to the termination of all of the employee's Dependent Coverage at
the earliest time specified below:
• (a) When such dependent becomes insured for Employee Coverage under this policy.
(b) When such person ceases to be a dependent of the insured employee.
(c) As to any insurance under Title CMEB or Title MMEB, when such employee shall have
• become entitled to the Maximum Benefit thereunder with respect to such dependent, in
which event the employee's Dependent Coverage under other Titles with respect to that
dependent, if any, may be continued, subject to the payment of premium by the Policy-
holder until the earliest time otherwise specified in this Article.
•
•
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• GR -23
Ed. 9-'57
Page 7 -A
8762
' Article IV— PREMIUMS
0
m
Section 1. Premium Rates
• The initial premium rates are as follows:
The premium rates shown are for a period of one month.
• Premium Per Employee
Employee Coverage Dependent Coverage
Plan A Plan B
•
Title
HEB
$3.67*
$4.29**
$8.34 * **
Title
SEB
1.09*
1.41*-**
2.93 * * **
Title
ANEB
.15 * **
.21 ***
.44***
Title
IIRYMB
.31 * **
.31 ***
.63 * * **
•
Title
LXEB
.39 * **
.34 * **
.62** **
Title
AEB
.22 * **
.18 * **
.56 ***
Title
141EB
1.91 * **
2.48 * **
3.50* **
*(currently
subject
to a 90% reduction)
•
* *(currently
subject
to a 10o reduction)
** *(currently
subject
to an 8% reduction)
* ** *(currently
subject
to a 70 /o reduction)
•
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Section 2. Premium Calculations and Experience Rating
• The premium due under this policy on any premium -due date shall be the sum of the premium
charges for the insurance provided under the Titles then forming a part of this policy. The
premium charges for the insurance under any such Title shall be calculated at the Initial
Premium Rates specified above, subject to such reductions or increases as the Insurance Com-
pany shall determine to be warranted by experience or by reason of any change in factors
• bearing on the risk assumed. Each reduction or increase in any premium rate shall be made
by written notification to the Policyholder by the Insurance Company.
No premium rate may be increased except either by written notification from the Insurance
Company to the Policyholder at least thirty -one days before the effective date of such increase
or by mutual agreement between the Policyholder and the Insurance Company.
No experience reduction or increase in premium rates shall become effective less than twelve
months after the effective date of this policy.
As of the end of any policy year the Insurance Company may declare an experience credit in
such amount as the Insurance Company shall determine. The amount of each experience
credit declared by the Insurance Company shall be refunded to the Policyholder, or upon re-
quest by the Policyholder, a part or all of the experience credit shall be applied against the
0 payment of any premium or premiums
• GR -23 CAL
Ed. 9257 Page 8 8808
• Article IV— PREMIUMS (Continued)
• Section 2. Premium Calculations and Experience Rating (Continued)
If at any time the aggregate of employee contributions theretofore made for group insurance
shall exceed the aggregate of premiums theretofore paid for group insurance (after giving
• effect to any experience credits allowed the Policyholder), such excess shall be applied by
the Policyholder for the sole benefit of employees, but the Insurance Company shall not be
obliged to see to the application of any such excess.
Any insurance becoming effective shall be charged for from the first day of the policy month
• coinciding with or next following the date the insurance takes effect. Premium charges for
any insurance terminated shall cease as of the first day of the policy month coinciding with
or next following the date the insurance terminates. If premiums are payable quarterly, semi-
annually, or annually, premium charges or credits for a fraction of a premium- paying period
shall be made on a pro -rata basis for the number of policy months between the date premium
• charges commence or cease and the end of the premium - paying period.
Instead of the method of calculation of premiums above provided, premiums may be calcu-
lated by any method which produces approximately the same total amount of premiums and
• is mutually agreeable to the Insurance Company and the Policyholder.
Section 3. Premiums, How Payable
• Premiums shall be payable by the Policyholder in advance at the Home Office of the Insur-
ance Company or to its authorized agent.
The first premium under this policy shall be due and payable as of the date of issue to cover
the period beginning on that date and ending on the last day of the first policy month and
• thereafter premiums shall be due and payable on the first day of each policy month.
Section 4. Grace Period
A grace period of thirty -one days following the due -date shall be allowed the Policyholder for
the payment of each premium.
If any premium is not paid before the expiration of the grace period, this policy shall auto-
matically discontinue at the expiration of the grace period, except that if the Policyholder
shall have given the Insurance Company written notice in advance of an earlier date of dis-
continuance, this policy shall discontinue as of such earlier date. The Policyholder, and each
Participant Employer with respect to employees of such Employer, shall be jointly and sever-
ally liable to the Insurance Company for all unpaid premiums for the period during which this
policy was in force.
0
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• GR -23 MO CAL
Ed. 9 -'57 Page 8 -A 8846F
Article V— DISCONTINUANCE OF POLICY
The Policyholder may discontinue this policy with respect to all employees of any one or more
Participant Employers, and any Participant Employer may discontinue this policy with respect
to all employees of such Employer, by giving to the Insurance Company written notice stat-
ing when, after the date of such notice, such discontinuance shall become effective; but no
such discontinuance shall become effective with respect to employees of any Participant Em-
ployer during any period for which a premium has been paid to the Insurance Company with
respect to employees of such Employer.
The Insurance Company reserves the right to discontinue this policy,
(a) with respect to all employees of any Participant Employer, at any time when such Em-
ployer and the Policyholder are no longer associated in business to an extent which, in
the opinion of either the Policyholder or the Insurance Company, is sufficient to warrant
the continued inclusion of such Employer as a Participant Employer in this policy;
(b) in its entirety, when either (i) fewer than ten employees are insured; or (ii) less
than 75% of the employees eligible for any contributory insurance are insured there-
for; or (iii) less than 100% of the employees eligible for any non - contributory insurance
are insured therefor; or (iv) the Policyholder is no longer included as a Participant
Employer in this policy;
(c) either in its entirety or with respect to all employees of any Participant Employer, if
such Employer or the Policyholder shall fail to furnish promptly any information which
the Insurance Company may reasonably require or if the Employer or the Policyholder
shall fail, without good and sufficient cause, to duly perform in good faith any one or
more of its or their other obligations pertaining to this policy.
Any discontinuance made in accordance with item (a), item (b), or item (c) above shall be
subject to the condition that the Insurance Company shall give to the Policyholder written
notice stating the premium -due date as of which such discontinuance shall become effective,
but such premium -due date shall not be one that occurs earlier than thirty -one days after
the date of such notice unless mutually satisfactory to the Policyholder and the Insurance
Company.
If this policy discontinues with respect to any of the employees of a Participant Employer,
the Policyholder and the Employer shall be jointly and severally liable to the Insurance Com-
pany for all unpaid premiums for the period during which this policy was in force with re-
spect to any of the employees of such Employer.
GR -23
Ed. 9 -'57 Page 9 8846R
Article VI-- MISCELLANEOUS PROVISIONS
m
0
• Section 1. Assignment
No assignment of any present or future right, interest, or benefit under this policy shall bind the
Insurance Company without its written consent.
• Section 2. Employees' Certificates
The Insurance Company will issue to the Policyholder, for delivery to each insured employee,
an individual certificate setting forth a summary of the essential features of the insurance cov-
erage to which the employee is entitled and stating to whom the benefits are payable.
Section 3. Data Required— Clerical Error — Misstatements— Non - Discrimination
The Policyholder and each of the Participant Employers shall furnish to the Insurance Com-
pany all information which the Insurance Company may reasonably require with regard to
any matters pertaining to this policy. All documents, books, and records which may have a
• bearing on the insurance or premiums shall be open for inspection by the Insurance Company
at all reasonable times during the continuance of this policy and until the final determination
of all rights and obligations under this policy.
Neither clerical error (whether by the Policyholder, by any of the Participant Employers, or by
the Insurance Company) in keeping any records pertaining to the insurance, nor delays in
• making entries thereon, shall invalidate insurance otherwise validly in force or continue insur-
ance otherwise validly terminated, but upon discovery of such error or delay an equitable ad-
justment of premiums shall be made.
If any relevant facts pertaining to any individual to whom the insurance relates shall be found
• to have been misstated, an equitable adjustment of premiums shall be made, and if such mis-
statement affects the existence or the amount of insurance, the true facts shall be used in .de-
termining whether insurance is in force under the terms of this policy and in what amount.
No refund of any premium or portion thereof, whether paid in error or otherwise, shall be
made for any period commencing earlier than twelve months prior to the date on which evi-
dence that the particular refund should be made is received by the Insurance Company.
In connection with the administration of this policy, the Policyholder and the Participant Em-
ployers shall act so as not to discriminate unfairly between individuals in similar situations at
the time of such action, but the Insurance Company shall be entitled to rely upon any action of
the Policyholder or of any of the Participant Employers without being obliged to inquire into
• the circumstances thereof.
Section 4. Entire Contract: Changes
This policy constitutes the entire contract between the parties, and any statement made by the
Policyholder or by any employee shall, in the absence of fraud, be deemed a representation and
• not a warranty. No such statement shall avoid the insurance or reduce the benefits under this
policy or be used in defense to a claim unless it is in writing, nor shall any such statement of the
Policyholder, except a fraudulent misstatement, be used to void this policy after it has been in
force for two years from the date of its issue, nor shall any such statement of any employee eligi-
ble for coverage under the policy, except a fraudulent misstatement, be used in defense to a claim
• for loss incurred or commencing after the insurance coverage with respect to which claim is
made has been in effect for two years.
This policy is issued in the non - participating department of the Insurance Company. This policy
may be changed at any time or times by written agreement between the Insurance Company and
the Policyholder, without the consent of any employee or other person. No change in this policy
• shall be valid unless approved by an executive officer of the Insurance Company and unless such
approval be endorsed hereon or attached hereto. No agent has authority to change this policy
or to waive any of its provisions.
Failure to insist upon compliance with any provision of this policy at any given time or times
• or under any given set or sets of circumstances shall not operate to waive or modify such pro-
vision, or in any manner whatsoever to render it unenforceable, as to any other time or times
or as to any other occurrence or occurrences, whether the circumstances are, or are not, the
same.
• GR -23 CAL
ED. 9-'57 Page 10 9036F
Article VI— MISCELLANEOUS PROVISIONS (Continued)
Section 5. Time Limit oil Certain Defenses— Notice of Claim— Claims Forms
No claim for loss incurred or commencing after two years from the effective date of the insurance cov-
erage with respect to which claim is made shall be reduced or denied on the ground that a disease or
physical condition, not excluded from coverage by name or specific description effective on the date of
loss, had existed prior to the effective date of the coverage with respect to which claim is made.
Written notice of claim must be furnished to the Insurance Company within 20 days after the occurrence
or commencement of any loss or period of disability covered by the policy, or as soon thereafter as is
reasonably possible. Notice given by or on behalf of the claimant to the Insurance Company at its
Home Office in Hartford, Connecticut, or to any authorized agent of the Insurance Company, with in-
formation sufficient to identify the insured employee, shall be deemed notice to the Insurance Com-
pany.
The Insurance Company, upon receipt of a written notice of claim, will furnish to the claimant such
forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15
days after the giving of such notice, the claimant shall be deemed to have complied with the require-
ments of this policy as to proof of loss upon submitting within the time fixed in the policy for filing
proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which
claim is made.
Section 6. Proofs of Loss
Written proof covering the occurrence, the character, and the exent of loss must be furnished to the In-
surance Company, in case of claim for loss under Title WBC, if included in this policy, within 90 days
after the termination of the period for which the Insurance Company is liable, and in case of claim for
any other loss, within 90 days after the date of such loss. Failure to furnish such proof within the time
required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within
such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the
absence of legal capacity of the employee, later than one year from the time proof is otherwise required.
No action at law or in equity shall be brought to recover on this policy after the expiration of three years
after the time written proof of loss is required to be furnished.
Section 7. Payment of Claims
Benefits payable under this policy for any loss will be paid immediately upon receipt of due written
proof of loss.
The benefit, if any, for loss of life will be payable in accordance with the beneficiary designation and
the provisions respecting such payment. All other benefits are payable to the insured employee.
If any benefit under any Title of this policy shall be payable to the estate of the insured employee, or
to an insured employee who is a minor or otherwise not competent to give a valid release, the Insurance
Company may pay such benefit up to an amount not exceeding $1,000 to any relative by blood or con-
nection by marriage of the insured employee who is deemed by the Insurance Company to be equitably
entitled thereto. Any payment made by the Insurance Company in good faith pursuant to this provi-
sion shall fully discharge the Insurance Company to the extent of such payment.
Subject to any written direction of the insured employee in a request for insurance or otherwise, all or
a portion of the benefits, if any, provided by this policy on account of hospital, nursing, medical, or sur-
gical service may, at the Insurance Company's option, and unless the insured employee requests other-
wise in writing not later than the time proof of loss is filed, be paid directly to the hospital or person
rendering such services, but it is not required that the service be rendered by a particular hospital or
person.
The Insurance Company at its own expense shall have the right
of any individual whose injury or sickness is the basis of claim
require during the pendency of a claim hereunder.
and opportunity to examine the person
when and as often as it may reasonably
GR -23 Page 11 9036R
Ed. -9-'57
•I
•
•
•
•
• Article VI— MISCELLANEOUS PROVISIONS (Continued)
Section 8. Conversion Privilege
Note: This section does not continue group insurance, but provides for the
Q obtaining of an individual policy under certain conditions.
• As used in this section, the expression "said Titles" shall mean all Titles included in this policy
with the exception of Titles ADDC and WBC, if included in this policy.
In the event that
is (a) all of an employee's insurance under said Titles of this policy (including insurance, if
any, with respect to dependents) terminates because of termination for any reason what-
soever of the employment of the employee or because of termination of membership in
the class of employees then still eligible for such insurance, or
• (b) the employee's Employee Coverage under said Titles continues but the employee's De-
pendent Coverage under said Titles for an individual terminates because such individual
ceases to be eligible for inclusion under Dependent Coverage,
then the employee in case (a), or the dependent in case (b) or in the event the employee's
• employment terminates by reason of his death, shall have the privilege of obtaining from the
Insurance Company, without any requirement of evidence of insurability, an individual policy
of insurance of a kind then being issued by the Insurance Company for group conversion pur-
poses (such policy being hereinafter referred to as the "converted policy ") which includes
therein a right of refusal by the Insurance Company to renew the converted policy, provided
• written application for the converted policy shall be made, and the initial quarterly (or at
option of the applicant, semi - annual or annual) premium therefor paid, to the Insurance
Company within thirty -one days after the date of such termination of insurance; provided,
further, that
• (1) except as otherwise specifically stated, the form of the converted policy, the insurance
provided thereunder, and all of the other terms of the converted policy, shall be such as
are then customarily being offered by the Insurance Company for conversions of group
insurance of the kind or kinds provided by said Titles of this policy at the time the ap-
plication for the converted policy is made to the Insurance Company, but in no case
shall the converted policy at date of issue provide benefits less than those specified in
• any applicable law or regulation or be contrary in any other respect to the terms of any
applicable law or regulation —the Insurance Company or the Policyholder, upon request,
will furnish the details of the converted policy then available; and
(2) the converted policy may provide that any benefits payable under the converted policy
• with respect to any individual covered thereunder will be reduced by the amount of any
like benefits payable under said Titles of this policy with respect to such individual after
the termination of his insurance hereunder; and
(3) the Insurance Company shall not be required to issue a converted policy covering any
• individual if it is indicated that such individual shall at the date of conversion be cov-
ered by another policy of hospital or surgical expense insurance or hospital service or
medical expense indemnity corporation subscriber contract providing similar benefits or
is covered by or eligible to be covered by a group contract or policy providing similar
benefits or is provided with similar benefits required by any statute or provided by any
welfare plan or program, which together with the converted policy would result in over-
insurance or duplication of benefits according to the Insurance Company's applicable
standards relating to converted policies last made effective by the Insurance Company
with respect to the jurisdiction in which the converted policy would otherwise be de-
livered; and
•
• GR -23 CAL
Ed. 7259 Page 12 9186
i
o Article VI— MISCELLANEOUS PROVISIONS (Continued)
0
N
O
• Section 8. Conversion Privilege (Continued)
< (4) the Insurance Company may decline to issue the converted policy
V
(i) if application therefor is not made in the jurisdiction in which this group policy is
• delivered or in some other jurisdiction in which the Insurance Company is author-
ized to issue or deliver the converted policy; or
(ii) if termination of insurance under said Titles of this policy takes place prior to the
date the employee concerned has been insured thereunder for at least three months;
• and
(5) the Insurance Company may decline
M to cover an individual who it is desired be included in the converted policy, if the
• insurance under said Titles of this policy terminated because such individual had ex-
hausted the maximum benefit available to him under said Titles; and
(ii) to cover an individual who it is desired be included in the converted policy for any
one or more of the benefits included in the converted policy, if the provision of such
• benefit or benefits, as the case may be, is prohibited by any applicable law of the
jurisdiction in which the individual resides at the time application for such policy
is made: and
(6) the premium payable under the converted policy on its effective date shall be at the In-
surance Company's then customary rate applicable to the class of risk to which the in-
sured individual under the converted policy belongs, to the age of such insured individual
and to the form and amount of insurance under the converted policy; and
(7) any converted policy issued under the terms of this section shall take effect as of the
• date of termination of insurance under said Titles of this policy.
Any converted policy issued pursuant to this section shall be in exchange for all privileges and
benefits under said Titles with respect to a person named in the converted policy, without pre-
judice, however, to an event insured against by this policy which occurred while insurance was
in force for such person.
•
• GR -23 CAL
Ed. 7-'59 Page 12 -A 9200
r
A
Gr. Pol. No.
APPLICATION FOR GROUP INSURANCE 13�
Application is hereby made to 2ETNA LIFE INSURANCE COMPANY
providing the kinds of insurance specified below. I
Applicant. CitZ- Ol.-Ll lt------------ -- ----------- ----
Address .---...----- --------37- - --- - . l�ii_.MMWJL _ .
The purpose of the application is to request
2 a..w. issuance of new coverage. jr
b. (]`change in existing coverages.
c. extension of existing coverages to additional groups of employees.
3
This application includes the following associated employers (Any e
af;Bartford, Connecticut for group insurance 1.
in conflict with applicable law cannot be included):
located at
- - - - -- - -
- - - -- -- - -- ------- - - - - -- ------------------------------------------------------------ - - - - --
----------------------------------------------- > ----- - - -- - --- --------- located at ------------ .. ------------------------------------------
- ----- --- --- ----- ----- --_ - - -- located at
All of the regular, full -time, active employees of -all inployer mentioned above shall be eligible to participate as to
4 theiusurance hereby applied for, except the following (State here the class or classes excluded).
-- ---------------------------------- -------- --- -- --- -- ----- - -- -- -- -- ---- --- ----- - ----- ------ ----------------------------------------------------------------
Ret red employees are ❑ are not (X to be eligible.
F
5
For
Employees
For
Dependents
Kind of Insurance
Maximum Scheduled Amount
*Dependents:toverage available only
❑
❑*
Term Life where not c6iktpxy to law.
$
Not
❑
Available
Paid -up & Term Life
$
❑
❑
Accidental Death & Dismemberment
$
Not
❑
Available
Disability Income""
$
-
❑
❑
Comprehensive Medical Expense
$
Major Medical Expense
$
Other Medical Expense (Specify)
X X X X X X
❑
❑
I Other (Specify)
X X X X X X
Agent(s) of Record ......... . VUJLa Mt. V._ WAftw ............. ........................... ........................... -...... ......... ............................... I....
6 ........................ .................................. ........ ...................... ... ....... ................................................. ............................. ............................
Note: If countersignature laws require commission sharing with a duly Licensed Resident Agent in another jurisdiction
G
the above designation will be modified to the extent required by the law.
j
L�
It is requested that the policy or policies be issued on the it contributory, It non - contributory basis.
The Applicant agrees that at no time shall any employee be permitted or required to contribute for non - contributory
7 insurance; or, unless the change is approved in writing by the Insurance Company at its Home Office, to make con-
tributions for contributory insurance at a rate higher than the initial contribution rate applicable for the employee's
then current insurance. It is agreed that no insurance shall become effective as to any person if he is not then a bona
fide, full time employee, regularly performing the duties of his occupation, unless otherwise specifically provided in
the Group Policy.
Signed at..)tyrr........
IL al rq¢ ................. ..
Date
......... ............ .... .. ..r
Witness
GR -23 -3
Official Title
9953
F
March 12, 1965
TO: CITY CLERK
FROM: C. E. Monson, Administrative Assistant
Attached is the City's official copy of the executed rider to the Aetna contract
on Group Health Insurance as approved by the City Council on March 8, 1965.
CEM /bl
Calvin E. Monson
jay _prr"'I) -\
Group Control No.. 46443
• RIDER
a , ATTACHED To AND MADE A PART OF GROUP POLICY NO. GC- 46443
A CONTRACT BETWEEN IETNA LIFE INSURANCE COMPANY AND TIIE POLICYIloLDER,
CITY OF xWORT BF,ACH
It is understood and agreed that the policy is changed by the addition or deletion of the pages
listed below.
• Page Numbers Of Pages Added Page Numbers Of Pages Deleted
6 -2 -ELP (Rev.) 6 -2 -&LP
0
0
0
L
Nothing contained in this rider shall be held to alter or affect any of the terms of the policy
other than as herein specifically stated.
•
IN WITNESS WHEREOF the =NA LIFE INSURANCE COMPANY has signed this rider at
HARTFORD, CONNECTICUT, to become effective August 1, 1964•
• Signed by the Insurance Company January 20, 1965•
• � "t�� �hJ�2o��it�lk�.�s�eti
egxstrar Assistant Secretary
• Signed by the Policyholderr ................ _ ........ ..... ............... ........
..
ACTT G CI MANAGER
....._ ....... ..............-- _.............. _...................... .I..........- .............._... _. .............. ........ I .... ..... - .... W1................._............. _...._.........................
Signature ial Title
AS AUTHORIZED BY THE CITY COUNCIL
• GR -23 -RI ON MARCH 8, 1965
Ed. 9 -'57 9981
• ' iN ARTICLE II— BENEFITS
EXCLUSIONS, LIMITATIONS AND PROVISIONS APPLICABLE TO ALL TITLES
UNDER ARTICLE II (Continued)
Effect of Coverage under the Prior Blue Cross Plan carried or sponsored by the Esployer
which terminated on July 31, 1964.
As to Title MM, if any part (or all) of a covered family member Is Deductible under
• the prior plan providing Major Medical Expense Benefits is applied under said plan
against covered expenses incurred thereunder by the employee with respect to such
member
• (i) during the calendar year in which Title MM of this policy becomes effec-
tive, or
(ii) during the last three months of the calendar year preceding the calendar
year in which said Title becomes effective,
• the member's Deductible under said Title for the calendar year in which said Title
becomes effective shall be reduced by the amount so applied to the same extent as
though such Deductible under the prior plan had been applied under said Title.
0
9
0
r-1
Li
0
0
0
0 GR -23 Page 6 -2 -ELp (Rev.)
46443
11��wee
l54 �12)
I
6
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2 I A tE lit3h OW to CITY COMIL (W M CM
KDava AI3Ti Au:'ZJI@
3 l[J tilt PCiA t,ti�!►
am
INSURAM
4'
5 it8s tbs caty COMS x Ot do city of Mwport istah
,11 less ltsratotoms ONAL and app**Ved tbs PCOV044.1 that dw City
7 POY 00 astire CONt of bmalth 180099aao tote City asipUVOW affaatLY40
8 Augst is 1464= asd
9 wow"* the boalth iarmance propas e! as Gity b"
10; best Voviawdt psrepoaals for ;seep health 3aso a mos and nom -
11 ' U RS tbare= have beet raeeeivad and *MWI409*4, sad *A
12 J► 1 Of the AStea Life is ea CaaMsy Pg*$ ttd 09090 it.
13 s B+tltax & Sullivan, b" bom appwo"4 by do City CaA41;
14 tad
15 WHROA", a policy contract for Stow Leap=t Isomat►ce has
16 beMOt paosSated is the City by the A*=* Life Uwamume CwVMy Sd
17I the City Cwj=Ll hss reviewed the tes'#w and caaditiaas *evot MW
18 fomd tbom to be fair and wpi"blo;
19 XWO =MEMRO MIT RSSMVIM that swirl dtaup bsalth
20 I*wx aaee pokey is appr*md sad she City Swasom is bwoby aathes-
21 ix" tad directed to obtala the saw for the City of Newt >iascb.
22 ADM= this 27th day of .July, 1964.
23
24
25 Amt
26
27
28
29
30
31
32
iIi
s
CITY OF' NEWPORT BEACH
OFFICE OF THE CITY MANAGER
12/24/64
TO: CITY CLERK
FROM: Administrative Assistant
SUBJECT: CONTRACT FOR GROUP HEALTH INSURANCE WITH AETNA
I am transmitting the official copy of the City's
group health insurance contract with the Aetna Life Insurance
Company. The City Council authorized the City Manager to
enter into this agreement effective August 1, 1964.
I have reviewed the contract in detail with the
Aetna representative Don Landwehr, and our broker, William
Kelter and it conforms to the understanding that was reached
earlier and that we have been operating under since August 1.
I have retained a work copy for the Personnel Office files.
Because the contract is already in effect and
payments have been made, it will not be necessary to send
it to the Finance Director. I have discussed this with the
Finance Director and he has all the information he needs.