Ordinance No. 1,286ORDINANCE NO. 1286
AN ORDINANCE OF THE CITY COUNCIL OF THE CITY OF BAYTOWN, TEXAS, ACCEPTING
THE BID OF REPUBLIC NATIONAL LIFE INSURANCE COMPANY FOR A GROUP INSURANCE
POLICY PROVIDING FOR LIFE INSURANCE, MAJOR MEDICAL BENEFITS, AND BASIC
MEDICAL BENEFITS FOR THE CITY OF BAYTOWN EMPLOYEES; AUTHORIZING AND DI-
RECTING THE MAYOR AND CITY CLERK TO EXECUTE AND ATTEST TO A CONTRACT WITH
REPUBLIC NATIONAL LIFE INSURANCE COMPANY, AND DIRECTING PAYMENTS OF PRE-
MIUMS PURSUANT TO THE TERMS OF SAID CONTRACT AND PROVIDING FOR THE EFFECTIVE
DATE HEREOF.
WHEREAS, the City Council of the City of Baytown, Texas, did authorize
the Administration to advertise for bids to supply the City of Baytown with
a group insurance policy providing for life insurance, major medical benefits,
and basic medical benefits for the City of Baytown employees, said bid to be
received September 14, 1972; and
WHEREAS, notice to bidders as to the time and place, when and where
the contract would be let was published pursuant to provisions of Section 74
of the Charter of the City of Baytown; and
WHEREAS, all bids were opened and publicly read at City Hall at 3:00
o'clock p.m., Thursday, September 14, 1972, as per the published notice to
bidders; NOW THEREFORE,
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF BAYTOWN:
Section 1: That the City Council of the City of Baytown, Texas, hereby
accepts the bid of Republic National Life Insurance Company providing for life
insurance, major medical benefits, and basic medical benefits to the City of
Baytown employees; and
Section 2: That the Mayor and City Clerk are hereby authorized and
directed to execute and attest to a contract with Republic National Life Insurance
Company, said contract marked Exhibit "A" attached hereto and made a part hereof,
and the Director of Finance is hereby authorized to make payments of premiums
pursuant to the terms of said contract.
Section 3: Effective Date: This ordinance shall take effect immediately
upon passage by the City Council of the City of Baytown.
INTRODUCED, READ and PASSED by the affirmative vote of the City Council
this 19th day of October , 1972.
ATTEST:
1 Y
EDNA OLIVER, City Clerk
APPROVED:
(r, L-, ti
C. GLEN WALKER, Mayor
Belinda Bingham, Deput ity Clerk
-2-
E X H I B I T "A"
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GROUP INSURANCE POLICY
T vf� 1, C 5011 T I o 11 ZIT -E �irc�rzcP. �` >j�rrl�
HOME OFFICE • 3988 N. CENTRAL EXPRESSWAY • DALLAS, TEXAS
(Herein called the Company)
In Consideration of the statements and agreements contained in the application for this policy, a copy of which is attached
and made a part hereof, and payment of the premium specified herein, hereby agrees with:
CITY OF BAYTOWN, TEXAS
(Herein called the Policyholder)
to insure certain individuals (herein called the Insured Individual or Insured Person) insured under the policy issued to the
Policyholder for the benefits provided herein subject to the exceptions, limitations and provisions hereinafter set forth and
made a part of this policy.
The initial premium is due on the date of issue hereof and subsequent premiums shall be due ....... - !H.LA ...... ...........
on ................. Oh- C- F-M.B.Ei A......-- ............. 19-7?---, and on the same day of each -------------- ON3tL ........... ................... thereafter.
Policy anniversaries shall be ------------- .... tov. EMeFR --- 1.,- ..1 ,973 ......................... and on the same day of each year thereafter.
Ali periods of insurance hereunder shall begin and end at 12:01 A.M., Standard Time, at the Policyholder's place of business
as stated herein.
IN WITNESS WHEREOF, the Republic National Life Insurance Company has by its President and Secretary signed, this
policy at its Home Office in Dallas, 'Texas, this ---------- 15.T----------------- day of ................ Nov EMB .E... -- . 19- .7. ?. -., which is
the date of issue hereof.
GP- 3000 -A -971
9secwary r
President
Countersigned ....... .......................... . . . .. ..............
Policy No............ ....................
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SECTION I -POLICY TERM
The policy continues in effect from its effective date as long as the prel:Zium is paid as herein agreed, subject to the
Grace Period as provided in the General Provisions hereof; provided ho%vever, that either the Policyholder or the Company
may terminate the policy by giving written notice to the other at least thirty -one days prior to any premium due date that
the premium rate for the insurance provided herein has been in effect for at least twelve months.
The Company reserves the right to discontinue the policy on any premium due date when there are less than
1clo individuals insured, or less than ... ... percent of the eligible individuals insured hereunder, provided the Company shall
give the Policyholder at least thirty -one days prior written notice of its intent to discontinue.
SECTION 2 -- ELIGIBILITY
Each Person becomes eligible for coverage applicable to his classification on:
Individual Insurance. As shown in the Schedule of Benefits.
Dependents Insurance. The latest of the following dates:
(A) The date of issue of the policy; or
(B) The date he is eligible for Individual Insurance; or
(C) The effective date of Dependents Insurance under the policy; or
(D) The date he first acquires a Dependent.
If dependents are to be insured, insurance for all dependents must be applied for.
SECTION 3 -PREMIUM CALCULATION AND PAYMENT
The initial and subsequent premiums shall be paid by the Policyholder to the Company or its authorized agent on or
before the dates specified on the face of the Policy. Premium will be adjusted in accordance with any change in the number
or classification of the Insured Persons, and are payable by the Policyholder directly to the Company at its Home Office in
Dallas, Texas.
The payment of any premium or installment thereof shall not maintain tfie policy in force beyond the due date of the
next premium or installment, except to the extent expressly provided in the Grace Period provision in the General Provi-
sions herein. If any premium is nor paid before the expiration of the grace period, the policy shall automatically terminate
at the expiration of the grace period, except that if the Policyholder shall have given the Company written notice in advance
of an earlier date of discontinuance during the grace period, the policy shall terminate as of such earlier date.
Premium for the policy shall be calculated on the basis shown in the Schedule of Benefits.
The Company reserves the right to change the premium rate for any insurance provided under the policy (a) on any
premium due date that the rate for such insurance has been in effect for at least twelve months by giving written notice to
the Policyholder at least 31 days prior to such premium due date; or (b) on any date the provisions of the policy are
changed as to the benefits provided or classes of Insured Persons.
The Company shall have the right to examine all of the books and records of the Policyholder relating to this insur-
ance at any reasonable time and within two years after the termination of the policy or until Final adjustment and settlement
of all claims hereunder, whichever is the later.
If the age of any Insured Person is incorrectly stated, the amount payable hereunder shall be the amount of insurance
determined by the Schedule of Benefits, and any necessary premium adjustment shall be made so that the Policyholder shall
pay the Company the actual premium called for at the true age of the Insured Person.
The Policyholder shall furnish such information as is necessary to administer the policy whenever required by the
Company.
GP- 3000.82 -971 WTIONS 1, 2, AND 3 — POLICY TERM, ELIGIBILITY, AND PREMIUM
SEC'niON 4 -- PERSON'S EFFECTIVE DATr_
If the individual makes no contribution toward the payment of the total premium for his and his dependents insurance,
the insurance of such persons shall take of cct (subject to "Deferred Dlectivc Date" below) on the date they become eli-
'gible and pay twin of prchnium shell commence from such date.
If the Individual contributes wholly or in part toward the payment of the premium for (1) his and his dependents'
insurance; (2) his insurance only; or ( 3 ) his dependents' insurance only, then written application for insurance for those
persons for whom the Individual contributes premium must be made within thirty days of the date such Individual and /or
dependent becomes eligible. If written application is made within thirty days, the insurance shall take effect (subject to
"Deferred Effective Date" below) on tine day such wiitten application is received by the Company at its home office or the date
they become eligible, whichever is later. If written application is received by the Company at its Home Office more than
thirty days after the date the Individual and /or dependent becomes eligible, the insurance shall take effect (subject to
"Deferred Effective Date" below) on the date of approval by the Company of such evidence of insurability as it may require.
To the group of individuals and dependents originally insured shall be added from time to time any new or other in-
dividuals and dependents.
DEFERRED EFFECTIVE DATE. If an individual is not actively at work or if an injury or sickness disables and prevents a
dependent (other than a child born while the individual's insurance is in force) from performing the duties of his regular
occupation or engaging in the normal activities of a person of like age and sex in good health when his insurance would
otherwise take effect, it shall take effect on the day next following the date the individual returns to work or the dependents'
disability ends, provided the person still meets the eligibility requirements. T s S PROV I S I ON DOES NOT A P P L Y TO
INDIVIDUALS OR THEIR DEPENDENTS WHOSE INSURANCE IS EFFECTIVE ON THE DATE OF ISSUE
OF THE POLICY. SECTION 5 PERSON'S TERMINATIONS
The insurance of the Insured Person shall terminate on the earliest of the following dates: ( 1 ) the date the policy is
terminated; (2) the premium due date when the Policyholder fails to pay the required premium for the Insured
Person; (3) the day next following the date the Insured Individual, (A) leaves or is dismissed from the employmenr
of the employer, or (B) ceases to be engaged regularly at least 30 hours weekly in the conduct of and on the premises
of the Policyholder's business, or (C) enters the armea forces of any country, or (D) ceases to be eligible according
to the eligibility- rules established by the Policyholder and agreed to by the Company; except that, if cessation of
active work is due to approved leave of absence or injury or sickness which disables and prevents the Employee from en-
gaging in any occupation for compensation, profit or gain, the Policyholder by paying the required premium may while the
Group Policy is in force, continue the Employee's Insurance (A) during the period of approved leave of absence bur not for
more than one month, or (B) during the period the Employee is disabled due to the injury or sickness which causes cessa-
tion of active work, until premium payments are discontinued by the Policyholder but not to exceed a period of six
months. However, such continuance in the event of temporary layoff or approved leave of absence shall not apply to weekly
indemnity; (4) as of the day next following the date the Insured Person, if a Dependent, ceases to be a Dependent as
defined herein.
If more than one employer unit or association unit is included for coverage under the policy and coverage is terminated
for any such unit, the policy shall be deemed to be terminated with respect to all persons covered under the terminated unit
in the same manner as if the policy had been terminated for all persons under the policy.
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SECTION 6 --- CHANGE IN AMOUNT OF INSURANCE
jA change it tLe ,amount of an Insured Person's insurance by reason of change of classification or change in the amount
of Risurance payA vnder the Policy shall become effective on the first day of the policy month coinciding with or next fol-
lowing the effective date Of such change; however, if an individual is not actively at work or if an injury or sickness
prevents a depeno*U from performing the duties of his regular occupation or cngae.itg_.1n the normal activities of a
person of like.aq aaf 4 e in good,healrh when an increase in the amount of his insurance would otherwise take etiect,
it shall =take effect t% ttic day next following the dare the individual is actively at work or the dependents' disability ends„
provided the person still meets the eligibility requirements. '
If written notice of such change is not received by the Company at its Home Office within thirty days after the dare of
a change in classification or amount, the Company may require satisfactory evidence of insurability before acceptance of
such change.
(Over)
UP- 3000- 0.971 SECTIONS 4, S, 6, AND 7 - PARSON'S EFFECTIVE DATE, TERMINATIONS, CHANGE, AND RFINSTATEMENTS
SECTION 7 --- REINSTATEMENTS
Insurance terminated with respect to an Insured]. Person formerly insured, may be reinstated if mutually agreed upon in
writing between the Policyholder and the Company. Insurance reinstated in accordance with such written agreement shall be
treated as if the insurance first became effective on the date of reinstatement, unless the agreement explicity provides otht-r-
wise.
Of-MO- 07.971 (CONT.)
SECTION 8 —DEFINITIONS AND EXCEPTIONS
(Not Applicable to life IIISUrMWC licnclits or Accidcntal Death and
Dismemberment Iicnclits, if any such licnclits are provided herein)
DEFINITIONS. w1wrevcr used in the policy, the term:
INSURED INDIVIDUAL, means tile person insured under the policy who is eligible for individual insurance.
INSURED PERSON means either the Insured Individual or the Insured DL,pendcnt.
DEPENDENT means any of the following persons not otherwise eligible as Insured Individuals under the policy.
1. The Insured Individual's spouse
2. The Insured Individual's unmarried child or children for whom the individual claims an exemption on his federal
income tax return FROM BIRTH and under 19 years of age, but extending to under 24 years of age while
attending an accredited educational institution on a full -time basis. Ilowever, if an unmarried child is, on the dare
such child's coverage would other -,vise terminate, incapable of self- sustaining employment by reason of mental
retardation or physical handicap and such incapacity commenced prior to the date such child's coverage would
otherwise terminate and such child is chiefly dependent upon the Person for support and maintenance, the Company
will upon payment of the applicable premium, continue coverage for such child so long as such Person's coverage
remains in force and such incapacity continues; provided proof of such incapacity is submitted to the Company
within thirty -one days of the dare such dependent's coverage would have otherwise terminated.
HOSPITAL means only an institution constituted and operated pursuant to law, engaged in providing on an in- patient
basis at the patient's expense, diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment and
care of injured and sick individuals by or under the supervision of a licensed physician and surgeon and continuously
provides 24 -hour a day services by registered nurses. The term "hospital" shall not include an institution or part thereof,
which is 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 or convalescent hospital. However, an institution specializing in the care and treatment of mentally ill or
tubercular patients, which would qualify under this definition as a hospital except solely for the fact that it Packs organized
facilities on its premises for major surgery, shall nevertheless be deemed a hospital under the policy with respect to Room
and Board charges only.
CONVALESCENT HOSPITAL means a duly licensed institution meeting the conditions of participation for an extended
care facility under Medicare, Title XVIII, of the Social Security Act, as enacted and amended.
RESIDENT PATIENT means an Insured Person who is confined in a hospital and for whom a room and board charge
is made.
PHYSICIAN AND SURGEON means a doctor operating within the scope of his license as: (a) Medical Doctor, M.D.;
(b) Osteopath, D.O.; (c) Podiatrist, D.P.M.; (d) Doctor of Dental Surgery, D.D.S.; (e) Chiropractor, D.C.; (f) Optome-
trist, O.D.
NECESSARY means medically necessary as recommended by a physician and surgeon.
REASONABLE CHARGES OR EXPENSES means the usual, customary, and regular charges for the area wherein such
expenses are incurred.
EXCEPTIONS. the policy does not cover any expense incurred for which the Insured Person is not legally liable, or is not
medically necessary, or which are in excess of the usual and customary charges or in excess of such charges as would have
been made in the absence of this insurance, or by reason of:
1. Intentionally self - inflicted injury, whether sane or insane;
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3. Services, supplies or trcarments provided by or covered under any governmental plan or law, or provided by any
hospital or institution which does not require the Insured Person to pay for such expenses In the absence of insurance;
(Over)
GP- 3000-D -172 SECTION 8 —DEFINITIONS AND FXCfPT1ONS (PERSONS)
SECTION 3 —DEFINITIONS AND EXCEPTIONS (CONT.)
4. War or any act of war (dcelarcd or tmdcclarcd) or service in the Armed Forces of any country;
5. Any drub, except those drugs prescribed by a physician, including narcotics and hallucinogens, or any gas or fumes,
taken or inhaled voluntarily; or by voluntary poisoning;
G. Loss, unless specifically provided for herein, in connection with: (a) optometrical services, including refractions,
visual aids or orthoptics and examinations related thereto; (b) pregnancy (including resulting; childbirth or
complications therefrom); (c) routine neonatal or nursery care for a newborn child; (d) services performed on
or to the teeth, gingivae, or alveolar processes, except for tumors; (e) foot appliances and castings therefor;
(f) professional psychological services excep! for testing, evaluation and treatment of mental illness;
7. Manipulation of anatomical displacements including the articulations of the spinal column, except for the reduction
Of fractures and dislocations.
GT•3000•a2•17z.- (CENT.)
SECTION 9 — GENERAL PROVISIONS
ENTIRE CONTRACT: CHANGES. This Policy, the application of the Group Policyholder (a cop)' of which is
attached hereto) and the individual applications, if any, of persons insured shall constitute the entire contract between the
parties. All statements made by the Group Policyholder or by the persons insured shall be deemed representations and not
warranties. No statement made by any person insured shall be used in any contest unless a copy of the instrument containing
the statement is or has been furnished to such person or to his beneficiary.
No agent or other individual except in Officer of the Company has authority to make or modify this Policy or extend
the time for payment of any premium.
No change in this Policy shall be valid unless made by endorsement hereon, or by amendment signed by the Group
Policyholder and an Officer of the Company. Any change so made shall be binding on each Person insured and on any
other individual or individuals referred to in this Policy.
Masculine pronouns used in this Policy shall include both masculine and feminine gender unless the context
indicates otherwise.
INCONTESTABILITY. No statement made by any person insured under this Policy relating to this or his dependents
insurability shall be used in contesting the validity of the insurance with respect to which statement was made after
such insurance has been in force prior to the contest for a period of one year during such person's lifetime nor unless it is
contained in a written instrument signed by the person.
GRACE PERIOD. A grace period of 31 days will be granted for the payment of premiums accruing after the first pre-
mium during which grace period the policy shall continue in force, but the Policyholder shall be liable to the Company for
the payment of the premium accruing for the period the policy continues in force, provided the Policyholder has not pre-
viously given written notice to the Company of termination.
LEGAL ACTIONS. No action at law or in equity. shall be brought to recover on the policy prior to the expiration of 60
days after written proof of loss has been furnished in accordance with the requirements of the policy. No such action shall
be brought after the expiration of three years after tine time written proof of loss is required to be furnished.
CHANGE OF BENEFICIARY. The right to change of beneficiary is reserved to the Insured Individual, and the consent
of the beneficiary or beneficiaries shall not be requisite to any change in beneficiary. The Insured Individual may designate
a new beneficiary at any time by filing written request of such change, but such change shall become binding upon the
Company only upon receipt and acceptance of such request at the office where the beneficiary records are kept as designated
by the Company.
CONFORMITY WITH STATE STATUTES. Any provision of the policy which, on its effective date, is in conflict
with the stathites of tike state in which the policy was delivered or issued for delivery, is hereby amended to conform to the
minimum requirements of such starute.
POLICY NON - PARTICIPATING. The policy is not entitled to share in the surplus earnings of the Company.
WORKMEN'S COMPENSATION. The policy is not in Iieu of and does not affect any requirements for coverage by
workmen's compensation insurance.
CERTIFICATES. The Company will issue to the Policyholder, for delivery to the Insured Individual, an individual certifi-
cate describing the benefits to which the Insured Individual is entitled under the policy and to whom payable.
CLERICAL ERROR. It is expressly understood and agreed that if non - payment of premiums within the time specified or
failure to comply with any terms of this Policy is shown to be unintentional and the result of misunderstanding or oversight
on the part of either the Company or the Policyholder, both the Company and the Policyholder shall be restored to the
positions they would have occupied had no such error or oversight occurred.
If the classification of an Insured Individual is misstated, the amount of insurance due in the event of the death of the
Insured shall be the amount, if any, to which he would have been entitled tinder his correct classification, and an adjustment
of premiums paid shall be made on the basis of his correct classification.
The Policyholder shall be deemed to be acting; as an agent of the Indivldual insured under the provisions of the Policy
with respect to certifying; eligibility in the class or classes eligible for insurance and with respect to paying any contributions
by the Individual toward the premium.
OP- 3000-E-971 SECTION9— GENERAt PROVISIONS
SECTION 10 ---- UNIFORM PROVISIONS
(Applicable to all 15enefits, except Life Insurance)
NOTICE OF CLAIM. Written notice of claim must be given to the Company within 20 days after the occurrence or
commencement of any loss Covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on
behalf of the claimant to Republic National Life Insurance Company, Dallas, Texas, with information sufficient to identify
the insured Individual, shall be deemed notice to the Company.
CLAIMS FORMS. The 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 requirements of the policy as to proof of loss upon sub-
mitting, 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.
PROOF OF LOSS. Written proof of loss must be furnished to the Company, in case of claim for any loss of time on
account of disability or hospital confinement, within 90 days after the termination of the period for which the Company is
liable, and in case of claim for any ocher 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 claimant, later than one year from the time proof is otherwise required.
PAYMENT OF CLAIMS. Benefits for loss of life, if any, will be payable in accordance with the beneficiary designation
and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such
designation or provision is then effective, such benefits shall be payable to the estate of the Insured Individual. Any ocher
accrued benefits unpaid at the Insured Individual's death may, at the option of the Company, be paid either to such beneficiary
or to such estate. All other benefits will be payable to the Insured Individual.
If any benefits of the policy shall be payable to the estate of the Insured Individual, or to an Insured Individual or
beneficiary who is a minor or otherwise not competent to give a valid release, the Company may pay Such benefits tip to an
amount not exceeding $1,000 to any relative by blood or connection by marriage of the Insured Individual or beneficiary who
is deemed by the Company to be equitably entitled thereto. Any payment made by the Company in good faith pursuant to
this provision shall fully discharge the Company to the extent of such payment.
Subject to any written direction of the Insured Individual in any application or otherwise, all or a portion of any benefits
provided by the policy on account of hospital, nursing, medical or surgical service may, at the Company's option, and unless
the Insured Individual requests otherwise in writing not later than the time for filing proof of such loss, be paid directly to
the hospital or person rendering such services, but it is not required that the services be rendered by a particular hospital
or person.
TIME OF PAYMENT OF CLAIM. Benefits payable to the Insured Individual under the policy for any loss other than
loss of time on account of disability or hospital confinement will be paid as they accrue immediately upon receipt of due
written proof of such loss. Subject to due written proof of loss, all accrued benefits for loss of time on account disability will
be paid each two weeks and any balance remaining unpaid upon the termination of the period of liability will be paid
immediately upon receipt of due written proof.
PHYSICAL EXAMINATION AND AUTOPSY. The Company at its own expense shall have the right and oppor-
tunity to examine the person of any individual whose injury or sickness is the basis of claim when and as often as it may
reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden
by law.
CHOICE OF SERVICE. The Insured Persons shall have the sole right to select their own physician and surgeon, and
hospital; and a physician- patient relationship shall be maintained.
OP•3000 -F -971 SECTION 10- UNIFORM PROVISIONS
1iG11T 'T0 T«;CEIVF . ANL ELEASE NECESSARY INFORMATIO.
for the purlxrsc; of determining the applicability of and implcmenting the terms of this provision of this Plan
or any Provision of similar purpose of any other I'lan, the Insurance Company may, without the consent of or notice
to any Ix-rstm, release to or obtain from any whcr insurance co.npany err other organization or person any informa-
tion, wi €h fu-;p x to any person, which the Insurance Company dcerns to be necessary for such purposes. Any person
claiming bcuc•frts under this Plan shall furnish to the Insurance Company such information as may be necessary to
implement this provision.
FACILITY OF PAYMENT
Whenever payments which should have been made under this Plan in accordance with this provision have been
made under any other flans, the Insurance Company shall have the right, exercisable alone and iu its sole discretion,
to pay over to any organizations making such other payments any amounts it shall determine to be warranted in
order to satisfy the intent of this provision, ^nd amounts so paid shall be deemed to be benefits paid under this plan
and, to the extent of such payments, the Insurance Company shall be fully discharged from liability under this Plan.
RIGHT OF RECOVERY
Whenever payments have been made by the Insurance Company with respect to AIlowable Expenses in a total
amount, at any time, in excess of the maximum amount of payment necessary ar that time to satisfy the intent of this
provision, the Insurance Company shall have the right to recover such payments, to the extent of such excess, from
among one or more of the following, as the Insurance Company shall determine. Any persons to or for or with respect
to whom such payments were made, any other insurance companies, any other organizations.
GP- 7000 -H -971 (CONT.)
SECT: `4 12 —CO— ORDINATION O: 3ENEFITS
This provision does not apply to Life Insurance Bencfits, Accidental Death and Dismemberment Benefits, or benefits
payable for any loss of time on account of disability, if any such benefits arc provided in the Policy.
BENEFITS SUBJECT TO THIS PROVISION
All of the benefits provided under this policy are subjecl to this provision, except those specifically excluded above.
DEFINITIONS
"Plan" means any plan providing benefits or services for or by reason of medical or dental care or treatment,
which benefits or services :ire provided by (1) group, blanket or franchise insurance coverage, (x0xWicvdd;iW>wW
7famid�C �tp�eltv5 st ele�oNaesa tz�C(iii) Blue Cross, Blue Shield, group practice, individual practice and other prepay-
ment coverage, (iv) any coverage under labor- in a nagement trusteed plans, union welfare plans, employer organization
plans, or employee benefit organization plans, and (v) any coverage under governmental programs, and any coverage
required or provided by any statute, except Title XV11I and X1X of the Social Security Act, as enacted or amended.
The term "Plan" shall be construed separately with respect to each policy, contract, or other arrangement for
benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement,
which reserves the right to take the benefits or services of other Plans into consideration in determining its benefits
and that portion which does not.
"This Plan" means that portion of this policy which provides the benefits that are subject to this provision.
"Allowable Expense" means any necessary, reasonable, and customary item of expense at least a portion of which
is covered under at least one of the Plans covering the person for whom claim is made,
When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of
each service rendered shall be deemed to be both an Allowable Expense and a benefit paid,
"Claim Determination Period" means calendar year.
EFFECT ON BENEFITS
(1) This provision shall apply in determining the benefits as to a person covered under this Plan for any Claim
Determination Period if, for the Allowable Expenses incurred as to such person during such period, the sum of
(a) the benefits that would be payable under this Plan in the absence of this provision, and
(b) the benefits that would be payable under all other Plans in the absence therein of provisions of similar pur-
pose to this provision
would exceed such Allowable Expenses.
(2) As to any Claim Determination Period with respect to which this provision is applicable, the benefits that would
be payable under this Plan in the absence of this provision for the Allowable Expenses incurred as to such
person during such Claim Determination Period shall be reduced to the extent necessary so that the sum of such
reduced benefits and all the benefits payable for such Allowable Expenses under all other Plans, except as pro-
vided in item (3), shall not exceed the total of such Allowable Expenses. Benefits payable under another Plan
include the benefits that would have been payable had claim been duly made therefor.
(3) If
(a) another plan which is involved in item (2) and which contains a provision co- ordinating its benefits with
those of this Plan would, according to its rules, determine its benefits after the benefits of this Plan have
been determined, and
(b) the rules set forth in item (4) would require this Plan to determine its benefits before such other Plan.
Then the benefits of such ocher Plan will be ignored for the purposes of determining the benefits under this plan.
(4) For the purposes of item (3), the rules establishing the order of benefit determination are:
(a) The benefits of a Plan which covers the person on whose expenses claim is based other than as a dependent
shall be determined before the benefits of a Plan .which covers Sikh person as a dependent.
(b) The benefits of a Plan which covers the person on whose expenses claim is based as a dependent of a mate
person shall be determined before the benefits of a Plan which covers such person as a dependent of a
female person.
(c) When rules (a) and (b) clo not establish an order of benefit determination, the benefits of a Plan which
has covered the person on whose expenses claim is based for the longer period of time shall be determined
before the benefits of a Plan which has covered such person the shorter period of time.
OP-9000 -H -471 SECTION 12 -- CO- ORDINATION OF BENEFITS
SECTION 13 SCI- 11:DULE OF BENEFITS
Iri.lr1111LITY
EACH INDIVIDUAL DECOMES ELIGIBLE FOR THE INSURANCE APPLICABLE TO HIS CLASSIFICATION
ON:
(A) THE DATE OF ISSUE HEREOF, PROVIDED THE PERSON IS A FULL—TIME EMPLOYEE
WITH THE GROUP POLICYHOLDER ON THAT DATE; OR
(0) THE DATE OF FULL —TIME EMPLOYMENT WITH THE GROUP POLICYHOLDER, IF
SUCH DATE IS SUBSEQUENT TO THE DATE OF ISSUE OF THIS POLICY.
CLASSIFICATION
INDIVIDUALS LIFE
A — POLICE, FIRE, AND CIVIL
PERSONNEL $5,000.00*
$ ALL OTHERS 4,000.001-
C — CLASS A WITH OPTIONAL LIFE 7,000.00*
D — CLASS B WITH OPTIONAL LIFE 8,000.00 **
AMOUNT OF INSURANCE
ACCIDENTAL DEATH AND DISMEMBERMENT
24 HOUR COVERAGE
$5,000.00*
4,000.00*
NONE
NONE
*REDUCES TO $3,000.00 AT RETIREMENT
"TERMINATES AT ATTAINMENT OF AGE 65
The initial premium rate for individual life insurance is $ .56 PER T HOU SA N D .
The initial premium rate for individual accidental death and dismemberment insurance is $.08 P E R THOUSAND.
DEPENDENTS AMOUNT OF LIFE INSURANCE
NONE
Th- initial premium rate for dependents life insurance is t4oNE
OP•5000- IA-971 SECTION 13 — SCHU)ULE OF BENEFITS (FtIGIBILITY, LIFE, AND ADaD)
NONE
SCHEDULE --SCI It DUI.I: OI" I,I-NE FIT (CONTINUED)
CLASSIFICATIONS AND INITIAL PREMIUM RATES YOR INDIVIDUALS
INSURED FOR INDIVIDUAL. INSURANCE
CLASStFICATinN
POLICE, FIRE, AND CIVIL SERVICE
RATES 1'11[ INDIVII)I]AL
A
PERSONNEL
$12.28
$
ALL OTHERS
12.28
C
CLASS A WITH OPTIONAL LIFE
NONE
D
CLASS B WITH OPTIONAL LIFE
NONE
INDIVIDUAL INSURANCE PROVISIONS
BENEFITS ACCORDING TO CLASSIFICATION
"None" means no mcb iluurance is proridcd for that classi(rarion
SECTION 16— WI :J:KLY INUI:1+1NI1Y BENEFITS.
A & B
WeeklyIndemnity ....................................... ...............................
NONE
Maximum Bencfit Period ........ ................weeks ........................
Day Benefits Begin ........................................ Accident..................
(Days Disabled) ..................................... Sickness ...................
SECTION 17— HOSPITAL BENEFITS. * *X*
Daily Room and Board Limit .................................................... .
35.
Aggregate Limit ........................................... ...............................
31 DA Y
Miscellaneous Limit ............. .. ........ - ... ...--•.................................
700.
HOSPITAL DEDUCTIBLE AMOUNT . . . .
25.
INTENSIVE CARE DAILY ROOM LIMIT
70.
SECTION IS —SURGICAL BENEFITS, Aggregate Limit --------
3 .
OOLLAP, FACTOR
SECTION 19 — MEDICAL BENEFITS.
Benefits begin on the ........... I.S- T.......... day for Accident and
the .----- IST------- - - - -- -- day for sickness.
Hospital Daily Limit ............... – .................. - --- ...............
5.
HomeDaily Limit ................................... ...............................
NONE
Office Daily Limit - -- ---- -• ......................... •- °................._..........
NONE
AggregateLimit ___ -------------------------------------------------------------
31 D Y
SECTION 2D— LABORATORY AND X -RAY BENEFITS.
Accident Limit .....................-----................ .................................
NONE
SicknessLimit -------------------------------- - -------------- ------- ----- ---- ----- --- -------
NONE
SECTION 21 — SUPPI.EhIF.NTARY ACCII)FNT BENEFITS, * **
Maximum Payment ... . .................. ..............................................
300.
SECTION 22— MATERNITY BEN @FITS. ****
Hospital Confinement Limit ....................... ...............................
SEE SE
T I ON 22
– MATf
N I TY BE
EF I TS
Obstetrical Limit
NormalDelivery ..................................... ............•..................
NONE
Caesarean Section . ... . .. ............................. .. .... ..
................. .. .. ..
Abdominal Operation for Extrauterint: Pregnancy ..................
NONE
Miscarriaf;e or Lepil Ahnrtion _ ............ ..... ... ...... .................
NONE
NONE
SECTION 23 —MAJOR 11ILDICAL Br:NI_F1'rS. * * **
Maximum Payment
25 J� OQQ
Room Limic ................................................. ...............................
AVERAGE
SEMI –P
IVATE
OT TO £
CEED $45.00
Coinsurance
HospitalCharges ..................................... ...............................
Followedby ....................................... e .... ...............................
80��JJO
m
Mental and Eotional Condiduns ........... .............................._
f
50,
AllOther Char) cs ...................................... ...............................
/0
0�
Deductible PC[ Calendar Year ....................................................
} 00.
I'ref;nancy Dcductilde .............................. ...............................
Arculnul�tion I'crin l
NON[:
jr I VF
MONTII^
SECTION 1`IJ1lRiFtln Payment ............
tlrlrlF
OP-1000 18-971 SICTIOH 13 – SCMIJUtE OF 6INNITS (1140IVIDUAIS)
" " "'Ti.NMI NA IE::; A I R L T 11,1 1. 11'14'1
SCHEDULE 13 — SCIIE -DULr Or 3)LNI;I ITS (CONTINUED)
CLASS IF1CA'1'r 1NS AND INITIAL PRE'N1111M It A'1 ES ],OR INDIVIDUALS
INSURED FOR D)✓PENDE'NT'S INSURANCL
GLASSIPIC'.A11ON AWAIAnNA1 RATR Pblr NVII-111 'i-r,.
_ ... _. ..••�,• �+ - .�.nw�.� .,r ornrnu tULYLNllLNtSI
* It TI_RMINAII-, AT RETIItCMI NT
PO 1
A
$16.28 $11.49 $27.77
13
16.28 11.49 27.77
C
NONE NONE NONE
D
NONE NONE NONE
DEPENDENTS INSURANCE PROVISIONS BE-NEFITS ACCORDING TO CLASSIFICATION
"None" means no arch insurance is provided /or that classifcariorr
SECTION 17 — IJOSIIITAL 131;:HI:FITS. * ** * A L L
Daily Room and Board Limit ..................... ............................... 5.
AggregateLimit
........................................... – .................. ........... 1 DAYS
Miscellaneous Limit
.......--• ................._...------------ ..............--- - -.... 00.
HOSPITAL DEDUCTIBLE AMOUNT . . . . . 5.
INTENSIVE CARE DAILY ROOM LIMIT. 70,
SECTION 18-- SURGICAL BENEF 7a. **
DOLLAR FACTOR
SECTION 19 — MrDICAL BENEFITS. * *
Benefits begin on the --------- LaT............ day for Accident and
the ---------- 1.51 -- .-- - -_ - -- day for sickness.
Hospital Daily Limit ....-----•---------• ........... ............................... 5.
HomeDaily Limit .................................... ..___...- ------------ .... ONE
Office Daily Limit ...........................................
.... .............. .... NONE
AggregateLimit . ...... ... . . . . .. ............................ - ..... .... -...........
1 DAYS
SECTION 20 —LABORATORY AND X -RAY BENEFITS.
AccidentLimit
.................................................... - ...................... NONE
SicknessLimit .....---•-•-• ....................°.--------
--- -........................... ONE
SECTION 21--- SUPPLEMENTARY ACCIDENT BENEFITS* *)F*
MaximumPayment ....--'-• ........................... ......... .. ... .. .......... . . . .. 00.
SECTION 22 — 1MATERNITY BENEFITS. � * *�
Hospital Confinement Limit
....................... .............................. SEE SEC
Obstetrical Limit
ION 22 MATER
I T Y BENEFITS
Normal Delivery .------------------------°..-----
......---- -•-- ---._....-- - - - -.. ONE
CaesareanSection .......--°--° .....................
............................... NONE
Abdominal Operation for Extrauterine Pregnancy .... ........ . . ....
Miscarriage or Legal Abortion .............. ........ ONE
ONE
SLC'1'ION 23- 1tfAjOx 1AL•DICA1. BENEFITS.""
MaximumPayment ..................................... ............................... 5,000.
.
Room Limit ................................................. ..............:................ AVERAGE
Coinsurance
SEMI–PRIVATE N
T TO EXCEED
$4.
.00
Hospital Clrargcs . ....................................... I........................... 0%
Followedby ............................................. ............................... 0%
Mental and Iirnotiunal Conditions ........... ............................... -C)%
All Oilier (:harf;rs ...............................................................
. 30%
Deductible Per Calendar Year _............ .................................
. .... 100 .
Pregnancy I)Cduc(I'He ..........
Accumulation Pulled ...... 1014E
rWCLVE
IONTHS
SECIIUN Marimunt 1'apurrnt .........._.�ONr
�e
_ ... _. ..••�,• �+ - .�.nw�.� .,r ornrnu tULYLNllLNtSI
* It TI_RMINAII-, AT RETIItCMI NT
SECTION 14 — LIFE INSURANCE BENEFITS
(for individuals)
Immediately upon receipt of due proof of the de•tth of any Insured Individual while insured under the policy, the
Company will pay, subject to the provisions contained in the policy, the amount of life insurance specified in the Schedule
of Benefits.
The phrase "Insured Individual" as used in this Benefit, means the person insured under the Policy who is eligible for
individual insurance.
FACILITY OF PAYMENT
If any Person or if any beneficiary is, in the opinion of the Company, legally incapable of giving a valid receipt for
any payment due him and no guardian has been appointed, the Company may, at its option, make such payment to the
individual or individuals as have, in the Company's opinion, assumed the care and principal support of such Person or of
such beneficiary, except that any payment due a minor shall be paid at a rate not exceeding $100.00 per month.
If, after the death of any Insured Individual, there is no beneficiary surviving to receive payment of tiie insurance, or
if no beneficiary shall have been clearly designated, the amount of insurance shall be payable in one sum, at the option of
the Company, either: ( I ) to any one or more of the following surviving relatives of the Insured Individual, the (a) spouse
(b) child or children (c) parent or parents (d) brothers and sisters, or (2) to the estate of the Insured Individual.
In determining any such person or persons indicated above, the Company may rely upon an affidavit by a member of
any of the classes of beneficiaries. Payment based upon such affidavit shall be full acquittance hereunder unless, before such
payment is made, the Company has received at its Home Office written notice of a valid claim by some other person.
The Company may, at its option, pay an amount not to exceed $250.00 to any person appearing to it to be equitably
entitled to the payment because of expense incurred in connection with the last illness or burial of the Insured Individual.
The liability of the Company shell thereby be discharged to the extent of the amount so paid.
MODES OF SETTLEMENT
Any Life Insurance Benefit becoming due hereunder shall be payable in a lump sum to the beneficiary of record on file
at the office where the beneficiary records are kept as designated by the Company. If the Insured Individual has made prior
written election, the amount due, or such portion thereof as may have been requested by the Insured Individual in lieu of a
lump sum payment, will be paid in a fixed number of monthly installments for each $1,000.00 of insurance as selected by
the Insured Individual according to the table set forth below. If the Insured Individual has not elected any such mode of
settlement, the beneficiary, if other than the estate and after the death of the Insured Individual may elect in writing that
all or any part of the amount payable be paid in a fixed number of monthly installments as selected by the beneficiary
according to said table, with the remainder, if any, paid in a lump sum. Any ltzmp sum payment will be made immediately
upon receipt of the required proofs of claim. Where installment payments are elected, the first installment will be paid
immediately upon receipt of such proofs.
Number of Years During
Which Monthly Installments
Will be Paid
3
4
5
10
15
20
Amount of Each Monthly
Installment Payment Per
$1,000.00 of Insurance
$28.79
21.86
17.70
9.39
6.64
5.27
The amount of insurance elected to be paid in monthly installments shall not be less than $1,000.00 and no monthly
installment shall be less than $10.00.
The Company reserves the right to change the above table on any policy anniversary or on any date the provisions of
the Policy are changed as to the amount of insurance or classes of Persons insured, but such new table shall apply only to
instructions for settlement thereafter elected.
(Over)
OP- 3000.1A- 47) -TEX. SECTION 14 -- LIFE INSURANCE BENEFITS (INDIVIDUALS)
SECTION 14 — LIFE INSURANCE BENEFITS (CONT.)
If any beneficiary dies while receiving monthly payments in accordance with these provisions the remaining payments,
unless ntlienvise sl ecified in the instructions for settlements, shall be commuted oti the basis of compound interest at the
rate of two and one -half percent per annum and paid in one sum to the executor or administrator of the estate of the
beneficiary.
Instructions for settlement other than the one set out above may be arranged if mutually agreed upon between the
Company and the individual entitled it) elect the option,
If any beneficiary dies either simultaneously with the Insured Individual or within fifteen days after the insured but
before written proof of the death of the insured Individual has been received by the Company at its Home Office, payment
shall be made as if the Insured Individual had survived such beneficiary, unless otherwise provided.
CONVERSION PRIVILEGE
(1) If the insurance, or any portion of it, on an Insured Individual ceases because of termination of employment or
of membership in the class or classes eligible for insurance under the Policy, such Insured Individual shall be entitled to
have issued to him by rite Company, without evidence of insurability, an individual policy of life insurance without disability
or other supplementary benefits, provided written application for the individual policy shall be made by the Insured
Individual and the first premium paid to the Company, within thirty -one days after such termination, and provided further
that:
(a) the individual policy shall, at the option of such Insured Individual, be on any one of the forms, except term
insurance, then customarily issued by the Company, at the age and for the amount applied for;
(b) the individual policy shall be in an amount not in excess of the amount of life insurance which ceases because of
such termination, less the amount of any in force individual policy of life insurance which was obtained by the
prior exercise of this Conversion Privilege;
(c) the premium on the individual policy shall be at the Company's then customary rate applicable to the form and
amount of the individual policy, to the class of risks to which such Insured Individual then belongs, and to his
age attained on the effective date of the individual policy.
(2) If the Policy terminates or is amended so as to terminate the insurance of any class of Insured Individuals, every
individual insured thereunder at the date of such termination whose insurance terminates and who has been so insured for
at least five years prior to such termination date shall be entitled to have issued to him by the Company as individual policy
of life insurance, subject to the same conditions and limitations as are provided by (a) above, except that the amount of
such individual policy shall not exceed the smaller of:
(a) the amount of the Insured's life insurance protection ceasing because of the termination or amendment of the
Policy, less the amount of life insurance for which he is or becomes eligible under any Group Policy issued or
reinstated by the Company or any other insurer within thirty -one days after such termination; and
(b) two thousand dollars.
(3) If an Insured Individual dies during the period within which he is entitled to have an individual policy issued to
him in accordance with (a) or (b) above and before such an individual policy shall have become effective, the amount of
life insurance which lie %could have been entitled to have issued to him under such individual policy shall be payable as a
claim under the Group Policy, whether or not application for the individual policy or the payment of the first premium
therefor has been made.
GP•7000 -JA -971 •TEX. (CONT.)
SECTION 14 —LIFE INSURANCE BENEFITS
(For Individuals)
INSURANCE DURING DISABILITY
If an Insured Individual becomes totally disabled prior to the date he is sixty years of age and while he is insured under
the policy, then upon termination of his insurance tinder the policy, if such total disability continues uninterruptedly from
the dare of such termination to the date of his death, which death occurs while the policy is in force, the Company, upon
receipt of written proof as set forth in this section and subject to all provisions of the policy, will pay to his beneficiary as
a benefit the amount of life insurance in force on his life as of the date total disability commenced, subject to the
Amount Of Insurance To Be Continued provision below.
Total disability, for the purposes of this section, is defined as disability resulting from accidental bodily injury or sickness
occurring while the Insured Person is insured hereunder which completely prevents the Insured Individual from performing
any work or engaging in any occupation for wage or profit.
Initial written proof that total disability exists and has continued uninterruptedly must be furnished to the Company
within one year after the date of termination of the Insured Individual's insurance but not before such disability has con-
tinued uninterruptedly for at least nine months. Further written proof that total disability exists and has continued uninter-
ruptedly must be furnished to the Company when and so often as it may reasonably require, but not more often than once
each year after total disability has continued uninterruptedly for at least two years beyond the date the initial written proof
is received by the Company.
If the Insured Individual dies at any time after initial written proof of total disability has been received by the Company,
further written proof that total disability continued uninterruptedly until the date of death must be furnished to the Company.
If the Insured Individual dies within one year after the date of termination of his insurance under the policy but before
written proof that total disability has been received by the Company, then written proof that total disability continued
uninterruptedly until the date of death must be furnished to the Company within one year after the death occurs.
The Company, upon receipt of any notice or proof of an Insured Individual's total disability, shall have the right and
opportunity to have a physician it designates examine such Insured Individual when and so often as it may reasonably require,
but not more often than once each year after total disability has continued uninterruptedly for at least two years beyond
the date the initial written proof is received and approved by the Company. Any such examinations made are to be at the
Company's expense.
If an individual policy of life insurance has become effective for a totally disabled Insured Individual in accordance
with the provisions of the Conversion Privilege, these Total Disability Benefit Provisions shall be applicable to that Insured
Individual only if such individual policy is surrendered to the Company without claim thereunder other than for return of
the premiums paid thereon less any dividends and indebtedness.
All rights under these Total Disability Benefit provisions shall automatically and immediately cease on the earliest of
the following dates:
(a) the date the Insured Individual's total disability no longer exists; or
(b) the date the Insured Individual fails to submit to any required medical examination; or
(c) the date the Insured Individual fails to submit any required proof of the uninterrupted existence of such total dis-
ability; or
(d) the date of termination of the policy.
AMOUNT OF INSURANCE TO BE CONTINUED.
The amount for which the insurance of any Insured Individual will be continued under this provision shall be the
amount of insurance in effect on the date his insurance would otherwise have terminated in accordance with the Individual
Termination provision, except that if the Schedule of Benefits provides for a reduction in the amount of insurance upon
retirement or attainment of a specified age by the Insured Individual, the amount of insurance being continued under this
provision shall be so reduced when such Insured Individual retires or attains such specified age.
(Over)
GP- 3000451.971 SECTION 14 — LIFE INSURANCE BENEFITS (INDIVIDUALS)
.SEC'I'I€)N 14 ---- LIFE INSURANCE BENEFITS (CONT.)
RIGHTS ATTER - MRMiNATION OF DISABILITY.
If any Insured Individual ceases to be disabled and returns to the class or classes of individuals eligible for insurance
hereunder by resuming gainful employment, his insurance will be continued in force only upon the payment of premiums
by the Policyholder for such Insured individual. If any Insured Individual ceases to be disabled and does not return to the
class or classes eligible for insurance hereunder by resuming gainful employment, or if the Insured Individual fails to submit
proof of continuation of Permanent Total Disability or refuses to submit to medical examination as provided above, the
insurance of such Insured Individual shall terminate immediately. During the thirty-one day period following the termination
of his insurance he shall be entitled to those benefits specified in paragraphs (1) and (3) of the Conversion Privilege
provision.
OP-3000-M-971 (C ONT. )
SECTION 15 --- ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
(For Individuals)
The phrase "Insured Individual" as used in this benefit, means the person insured under the Policy who is eligible for
individual insurance.
When accidental bodily injury which was causes directly and independently of all other causes by external, violent, and
accidental means occurs while the insurance is in force as to the Insured lndivid::.il and results in any of the following losses to
the Insured Individual within ninety days after the date of the accident, the Company will pay in addition to any other benefit
provided by the Policy:
(a) the Principal Sum for loss of life; or
(b) one -half of the principal Sum for loss of one hand by severance at or above the wrist, or loss of one foot by severance
at or above the ankle, or irrecoverable loss of the sight of one eye; or
(c) the Principal Sum for loss of more than one of the members enumerated in paragraph (b) above;
But the total payment for all such losses resulting from injuries due to the same accident shall not exceed the Principal
Sum. If benefits are payable for loss of life, the Company shall have the right and opportunity to have an autopsy made when
it is not forbidden by law.
The Principal Sum, as referred to herein, shall be the amount of AD&D Principal Sum stated in the Schedule of Benefits
hereof.
The Company shall not be liable hereunder for any loss caused by or contributed to by: (a) attempted suicide or
intentional self destruction, while sane or insane or the intentional act of another during an altercation in which the Insured
Individual participated, otherwise than as a spectator; (b) travel or flight in or descent from any kind of aircraft, except as
a fare - paying passenger on a regularly scheduled commercial route or chartered flight; (c) war or any act of war, whether
declared or undeclared, or while in the Armed Forces of any country; (d) bodily or mental infirmity, ptomaines,
bacterial infections (except pyogenic infections which shall occur with and through accidental cut or wound), or by any
other kind of disease; (e) any drug, except those drugs prescribed by a physician, including narcotics and hallucinogens, or
any gas or fumes, taken or inhaled voluntarily; or by voluntary poisoning; (f) injuries or death arising out of or occurring
in the course of any occupation or employment for wage or profit, unless specifically provided for in the Schedule of Benefits
hereof by inclusion of the words "24 hour coverage" with the amount of benefit.
The amount payable upon the death of the Insured Individual shall be paid: (a) if Life Insurance Benefits are provided
in the policy, in accordance with the "Modes of Settlement" provision therein; (b) if Life Insurance Benefits are not provided
in the policy, in accordance with the beneficiary designation of record effective at the time of payment. If no such designation
is then effective, such benefits shall be payable to the estate of the Insured Individual. Any other accrued benefits unpaid at
the Insured Individual's death may, at the option of the Company, be paid either to such beneficiary or to such estate.
All other benefits will be payable to the Insured Individual.
GP•3000-K•172 SECTION 15— ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
SECTION if 7 -- HOSPITAL BENEFITS
When accidental bodily injury or sickness requires the Insured Person to be confined within a hospital as a resident
patient, such confinement commencing while this insurance is in force as to such person, the Company will pay the expense
actually incurred for:
1. Room and board not to exceed the Hospital Daily Rate applicable to such Insured Person and for the applicable
period of such confinement as stated in the Schedule of Benefits hereof;
2. Miscellaneous necessary services and supplies in excess of the Hospital Deductible Amount, furnished by the hospi-
tal which are not included in the room charge during the period for which the Hospital Daily Rate is payable, not
to exceed in the aggregate the applicable Miscellaneous Hospital Benefits stated in the Schedule of Benefits hereof.
Miscellaneous Hospital Benefits include: (1) the Anesthetist's fee when charged by the hospital; (2) the fee of
an Anesthetist, if no fee is charged by the hospital, not to exceed 25% of the maximum amount applicable to the
operation performed as provided in the Schedule of Operations in the policy, but not less than $10.00; (3) licensed
ambulance service to the hospital for confinement therein and from the hospital immediately following such con-
finement, not to exceed for each confinement $25.00. If the surgical benefit provides for the payment of an Anesrheisr
Benefit, then payment under (1) and (2) shall not be made.
Two or more periods of hospital confinement. shall be considered one period of hospital confinement with respect to
the Insured Individual, unless separated by the Insured Individual's return to full -time duties of his regular occupation fox v
�i#d �Rt<Ye�stxotixtaehk or unless the subsequent confinement is due to causes entirely unrelated to the causes of the
previous confinement, or with respect to the Dependent, unless separated by three months return to normal activity of a per-
son of like age and sex in good health or unless the subsequent confinement is due to causes entirely unrelated to the causes
of the previous confinement.
Hospital Benefits otherwise payable under the policy will also be paid as specified above while the Policy is in force
when the Insured Person shall commence hospital confinement and suffer loss occurring within three months after the
termination of the person's insurance if from the dare of such termination of insurance to the date of the loss the Insured
Person has been wholly and continuously disabled due to the same injury or sickness causing the loss.
When accidental bodily injury or sickness does not require the Insured Person to be confined within a hospital as a
resident patient, the Company will pay, charges in excess of the Hospital Deductible Amount, not to exceed the applicable
Miscellaneous Hospital Benefits stated in the Schedule of Benefits hereof, the expense actually incurred in connection with:
1. Hospital charges by reason of a surgical procedure resulting from accidental bodily injury or sickness;
2. Hospital charges by reason of emergency first aid treatment resulting from accidental bodily injury ( including
licensed ambulance service to and from such hospital not to exceed $25.00) provided such treatment is rendered
to the Insured Person within twenty -four hours after such injury is sustained.
3. Expenses incurred up to $15.00 for drugs, dressings, operating room fee and administration of anesthesia, if an
Insured Person undergoes a tonsillectomy and /or adenoidectomy performed in a place other than a hospital.
Any charges for a physician and surgeon or any charges for the services of a special nurse shall not be payable under
this section.
OP•3000•MA7.971 SE.CTION 17— HOSPITAL BENEFITS (DEDUCTIBLE)
SECTION 17 -HOSPITAL BENEFITS
INTENSIVE CARL, CONFINEMENT. If an insured person, while confined in a hospital and entitled to benefits
under the Hospital Bcnefics, is confined to the intensive care unit of the hospital, the Company, subject to all provisions of
the policy and in liCll of room and board benefits which otherwise would be payable, will pay for each day of such confine-
ment the actual cost charged to the Insured Person by the hospital for intensive care up to the Intensive Care Daily Limit,
but for no more than ten days of such confinement during one period of hospital confinement.
The total payment for all intensive care charges together with other charges which are subject to the Aggregate Limit
(room and board) shall not exceed such Aggregate Limit (room and board) for one period of hospital confinement.
Charges made by the hospital for intensive care, for any day of confinement for which payment is made under these
intensive care provisions, shall not be paid under any other provision of the Hospital Benefit Section.
The Intensive Care Daily Limit and the Aggregate Limit (room and board) shall be determined for an Insured Individ-
ual by the Schedule of Benefits.
INTENSIVE CARE UNIT. The term "Intensive Care Unit ", as used herein, means a section, ward or wing within
the hospital which is separated from other hospital facilities and
(A) Is operated exclusively for the purpose of providing professional care and treatment for critically ill patients; and
(B) Has special supplies and equipment, necessary for such care and treatment, available on a standby basis for imme-
diate use; and
(C) Provides room and board and constant observation and care by registered professional nurses or other highly
trained hospital personnel;
Excluding any hospital facility maintained for the purpose of providing normal post - operative recovery treatment or
service.
OP- 3000 -MB -971 SECTION 17 — HOSPITAt BENEFITS (INTENSIVE CARE BENEFITS)
SECTION 18 -SURGICAL BENEFITS
When accidental bodily injury or sickness causes the Insured Person to undergo any operation listed in the accompanying
Schedule of Operations, such operation being performed by a legally qualified physician and surgeon while this insurance is
in force as to such person, the Company «•ill pay the actual expense incurred for Surgery and Anesthesia service, such
amounts payable to include [he usual Follow-up days for post- operative care, not to exceed:
(1) for Surgery — the "Surgery Value" shown in the Schedule of Operations times the applicable Dollar Factor shown
in the Schedule of Benefits hereof;
(2) for Anesthesia --- (a) If administered by an anesthesiologist (M.D.) whose practice is limited to anesthesiology,
the "Anesthesia Value" shown in the Schedule of Operations times the applicable Dollar Factor shown in the
Schedule of Benefits hereof, plus one additional Value unit for each 15 minutes of time or major part thereof;
however,
(b) if administered by the attending physician or his assistant, or if the charge is made by the hospital for a nurse
anesthetist or an anesthesiologist, the fee shall be one -half the amount calculated in accordance with (a) above.
(3) for all operations as the result of any one accident or sickness, the Surgical Benefits Maximum as shown in the
Schedule of Benefits hereof with respect to surgery, and in addition: (a) the Benefits Maximum with respect to
anesthesia, and (b) [Ile Maximum with respect to Surgical Assistants.
When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed
at the same operative session, the total value shall be the value of the major procedure plus 50c,o of the value of the lesser
procedure(s). When an incidental procedure, (i.e., incidental appendectomy, lysis of adhesions, excision of previous scar,
puncture of ovarian cyst) is performed through the same incision, the value will be that of the major procedure only,
unless otherwise specified in the Schedule.
Payment for a vasectomy shall be limited to 5% of the Surgical Benefits maximum.
Surgical Benefits otherwise payable under the.policy, will also be paid as specified above while the policy is in force
when the Insured Person shall suffer loss occurring within three months after the termination of the person's insurance
if from the date of such termination of insurance to the date of the loss the Insured Person has been wholly and continuously
disabled due to the same injury or sickness causing the loss.
For surgical procedures not shown on the surgical schedule, and which are not expressly excluded by the terms of the
Policy, the Company will determine the amount payable for the procedure. An operation of equal gravity and severity
will be used as a basis for the Company's determination.
GP•9000•N2.971 SECTION 10 —SURGICAL BENEFITS (RVS)
SECTION 18 —SURGICAL Bl"NEFITS
SCHEDULE OF OPERATIONS
Surgery Follow -Up Anesthesia
Value Dana Value
Surgery
Value
Follow -Up
Dart
Anesihede
Value
SURGICAL ASSISTANTS
Hernioplasry: Herniorrltapy: Her -
Assist at surgery, minioium ..........
7
niotomy, ISTguinal, unilateral _.. ... 35
45
3
or 20% of listed value for
Ventral, incisional .__.._----- ____- ........ 45
45
3
surgery, whichever is greater
URINARY SYSTEM
INTEGUMENTARY SYSTEM
Nephrectomy ... ............................... 80
90
5
Burns — Dressings, tinder anesthesia,
Urcterolithotomy, upper 3/4 ............ 70
90
5
large or with major debridement,
lower t/4 ________ _____ __ _______________________ 80
90
5
per hour ....... ...............................
10 0 3
Cystoscopy, diagnostic, office,
Breast — Excision of cyst, fibro-
initial _____________ ____________________ _________ __ 5
7
adenoma or other benign tumor,
Litholapaxy: crushing of calculus in
aberrant breast tissue, duct lesion
bladder and removal of fragments 50
90
3
or nipple - ------------------- - - - - --
Complecte (simple) mastectomy .__ .
15 30 3
30 45 3
MALE GI ?VITAL SYSTEM
Radical mastectomy, including
Circumcision, newborn .................... 3
Excision of varicocele ( independent
15
es and
breast, pectoral muscles
l___________________
GO 3
procedure) unilateral - ____ -____ ------ 30
90
3
ary lymph nodes
7Q
Prostatectomy, per ineal, subtotal .__. 80
90
G
MUSCULOSKELETAL SYSTEM
perineal, radical ___________________ _ __ _ ___ __100
90
6
Fractures, Humerus, shaft, simple
suprapubic, one or two stages _... 80
90
5
closed reduction ____________________ _ __ ___
25 120 3
Simple or compound,
FEMALE GENITAL SYSTEM
open reduction ____________________________
45 120 3
Combined anterior - posterior
Fractures — Radius, head, simple
Colporrhaphy- ------------ ---------_----- 50
60
3
closed reduction .
15 60 3
Salpingo- oophorectomy, complete of
head, compound ---- _---------------------
20 60 3
partial, unilateral or bilateral (in-
Femur, neck, simple, with fixation
dependent procedure) ______ __________ 45
45
4
or traction _____ _______________________________
50 180 3
Oophorectomy, unilateral or bilateral 45
60
4
multiple pinning, with or with-
Total hysterectomy (corpus and
out external fixation ______________ __
80 180 5
cervix) with or without tubes
Tibia and fibula, shafts, simple,
and /or ovaries, one or both ........ 60
45
4
closed reduction --------------------------
30 180 3
Vaginal hysterectomy, with or
without pelvic floor repair ........ 70
45
4
RESPIRATORY SYSTEM
Dilation and curettment of
Bronchoscopy, with removal of
cervical stump ............................ 15
15
3
foreign body -- -------- ---------------- - - - - --
25 30 4
ENDOCRINE SYSTEM
THORACOPLASTY
Thyroidectomy, total or complete ____ 70
45
5
Extrapleural resection of ribs, any
subtotal or partial _____________ ___ ---- 60
45
5
type, fast stage _______________ ____ ____ _____
60 90 6
total or subtotal, for malignancy
second stage _ _________________________ _ _ _ ___
30 90 5
with neck, radical, dissection ---------- 100
45
6
CARDIOVASCULAR SYSTEM
NERVOUS SYSTEM
Ligation and division and com-
Craniotomy — Sub - occipital crani-
plete stripping of long or short
ectomy for brain tumor ................150
90
11
saphenous veins, unilateral ------
30 30 3
bilateral ------------ ------ ------------ - - - - --
50 30 3
EYE
Repair myocardial aneurysm ---------- 200 90 15
Extraction of lens, intracapsular or
extracapsular, unilateral .............. 80
90
8
DIGESTIVE SYSTEM
Any type of muscle operation in-
Tonsillectomy, with or without
volving one or more muscles in
adenoidectomy, under age 18________
15 30 3
one or both eyes done in one stage 60
30
4
age 18 years or over --------- ----------
20 30 3
Local excision of stomach ulcer or
EAR
tumor ........... ...............................
60 45 5
Mastoidectomy, radical .................... 80
180
4
Total gastrectomy ..................... .... .._100
90 6
SURGERY VALUE shows the maximum payable for the
Suture of intestine (entcrorrhaphy),
listed operation.
large or small, for perforated
ulcer, wound, injury or rupture ..
60 45 5
FOLLOW -UI' DAYS shows period post- operative care is
Appendectomy ................................
40 45 4
included in Surgery Value.
Cholceystectomy ..............................
60 45 5
with open exph. -ation of
ANESTHESIA VALUE shows minimum allowance. Also
common duct .............................. .
70 45 5
see Surgical Benefits, Part 2.
GP,30W,NR2.9?I SECTION 1B— SURGICAL BENEFITS (64 RVS)
SECTION 19 ---- MEDICAL BENEFITS
(Dwing Hospital ContinenZent)
When accidental bodily injury or sickness causes the Insured Person to be confined as a resident patient in a hospital
while this insurance is in force as to such person, the Company will pay the expense acnlally incurred for treatment by a legal-
ly qualified physician and surgeon during the period for which hospital room and board benefits are payable under the policy,
not in excess of:
(1) one treatment per day;
(2) the Medical Benefits Rate applicable to such person per day;
(3) the applicable maximum Ntedical Benefits stated in the Schedule of Benefits hereof.
In the event expenses are incurred for treatment under the Medical Benefits and the Surgieal Benefits provisions in the
Policy, for services rendered by any physician and surgeon as the result of the same injury or sickness, the Company will pay
under Medical Benefits up to but not including the date of surgery.
OP- $000.01.971 SECTION 19- MEDICAL BENEFITS (IN- HOSPITAL)
SECTION 21 -SUPPLEMENTARY ACCIDENT BENEFITS
When accidcntal bodily injury occurs while the Insured Person's insurance is in force, the Company will pay the actual
expense incurred, spcc'€fied bclow, provided that treatment commences within thirty days of the occurrence of the accident,
as the result of such accident which is in excess of the amounts orhervvise payable under the policy except under any major
medical benefits provided. The expense payable under this benefit must be incurred within ninety days from the date of the
accident and while the policy is in force and shall not exceed in the aggregate as the result of any one accident the Supple -
mentary Accident Benefit stated in the Schedule of Benefits hereof as follows:
1. Necessary hospital services and supplies, room and board;
2. Services of a licensed registered nurse, other than a person who normally resides in the Insured Person's home;
3. Services of licensed physicians and surgeons;
4. Laboratory and x -ray examinations;
5. Repair of sound natural teeth, including replacement of such teeth;
G. Braces, crutches, artificial eyes or for rental of a wheelchair, hospital -type bed, or an artificial respirator;
7. Drugs and dressings
OP- 3000.0 -971 SECTION 21 — SUPPLEMENTARY ACCIDENT BENEFITS
SECTION 22 ---- MATERNITY BENEFITS (HOSPITAL AND SURGICAL)
When pregnancy (including resulting childbirth or complications therefrom) causes the female Insured Individual
or male Insured Individual's wife, if this coverige applies to such person, to incur expense for operation or treatment by a
legally qualified physician and surgeon or for necessary hospital service, the Company will pay the expense actually incurred
for such operation, treatment or service on account of any one pregnancy not to exceed in the aggregate $150.00.
GA- 3000 -RA3 -971 SECTION 22- MATERNITY BENEFITS MOSPITAL AND SURGICAL)
SECTION 22 -MATERNITY BENEFITS (CONT.)
Maternity Benefits under this section will be paid only if the policy is in force on the date of termination of the
pregnancy.
DEFERRED BENEFITS. Maternity Benefits will be paid:
1, if the Person was insured on the effective date of the Policy and was pregnant while covered under the policy.
2. If the Person was not insured on the effective date of the policy, Maternity Benefits will be paid only if the
pregnancy commenced while the insurance of the Insured Person for whom claim is made was in force.
EXTENDED BENEFITS. Maternity Benefits will be paid if termination of pregnancy is within nine months of the date
of termination of insurance or the date of confinement if such Insured Person is a male Insured Individual's wife, and ter-
mination of pregnancy is within nine months of the date of termination of insurance hereunder as to such Insured Person,
provided the policy is in force at the termination of such pregnancy.
OP- 7060 -M-971 SECTION 22 - MATERNITY 9ENEFITS (CONT. -IMM. 3 NO EXT.)
SECTION 22 -- MATEIZNITY BENEFITS (CONT.)
An Insured Person is eligible For thew benefits only if she is insured hereunder with respect to her husband.
GP,2000 RC•97! SECTION 22 - MATERNITY BENEFITS (CONT.-SWITCH)
SECTION 23 ---- MAJOR MEDICAL BENEFITS
When as the result of Accidental bexiily injury or sickness, an 111SUrcd Person incurs Covered Expenses shown herein
while this insurance is in force as to such person, the Company will pay applicable Percentage, shown in the SChCdUle of
Benefits hereof, of such expenses incurred in excess of the Deductible Amount, not to exceed the Maximum Amount,
DEDUCTIBLE AMOUNT
The Deductible Amount is the amount shown in the Schedule of benefits in addition to the amounts payable under the
other benefit provisions of the policy, if any, subject to the Deductible Accumulation Period provisions below.
DEDUCTIBLE ACCUMULATION PERIOD
Covered Expenses in an amount at least equal to the Deductible Amount must be incurred during a continuous period
as indicated in the Schedule of Benefits, beginning the day that the first Covered Expense is incurred which is credited
toward the accumulation of the Deductible Amount. This continuous period is herein referred to as the Deductible Ac-
cumulation Period. Expenses incurred prior to the beginning of the Deductible Accumulation Period cannot be considered
for payment. Covered Expenses which are incurred during the last three months of one Calendar Year and which are used
toward satisfying the Deductible Amount may be used toward satisfying the Deductible Amount in the next succeeding
Calendar Year, subject to the condition chat the Deductible ArnOUnt must be satisfied within an interval of time not
exceeding the applicable Deductible Accumulation Period. Except as stated in the preceding sentence, all expenses credited
toward the accumulation of the Deductible Amount must be incurred in ont Calendar Year. Calendar Year means the
period from January 1st to the December 31st next thereafter, inclusive.
COMMON ACCIDENT PROVISION
If two or more family members insured under the Policy sustain bodily injuries in the same accident, and if the Deduc-
tible Amount of one such family member incurring Covered Expenses in such accident has been applied, then the Covered
Expenses incurred as a result of such accident by other such family members shall be reimbursed as if their Deductible
Amounts had already been applied. This provision shall not affect administration of benefit payments with respect to Covered
Expenses not incurred as a result of such accident.
MAXIMUM AMOUNT
The maximum payable for all Covered Expenses for each Insured Person shall not exceed in the aggregate the Maximum
Amount shown in the Schedule of Benefits hereof.
REINSTATEMENT OF MAXIMUM AMOUNT
On January Ist of each year there shall be an automatic reinstatement for each Insured Person whosz Major Medical
Maximum Amount has been reduced below the original Major Medical Maximum due to the payment of benefits. The
amount of such reinstatement shall be equal to the lesser of the amounr of benefits paid or $1,000.00 but in no event shall
the Major Medical Maximum Amount for the Insured Person exceed the original Major Medical Maximum Amount speci-
fied by the plan.
(Over)
GP•3000•SA -971 SECTION 23 —MAJOR MEDICAL RENEFIIS
SECTION 2 3 —MAJOR MEDICAL BENEFITS (CONT. )
COVERED EXPENSES
Covered Expenses shalt be the reasonable usual and cusromary charges in the area where incurred for the following
services, supplies and trearmenr when medically necessary and when ordered by a licensed physician and surgeon.
1. Daily Room Charge in a hospital, but not to exceed a daily rate equal to the lesser of the hospital's usual semi-
private room charge or the 1t(xun Allowance as shown in the Schedule of Benefits hereof, or double such daily
rate if confined in an Intensive Care Unit;
2. Services and supplies furnished by a hospital;
3. Treatment by a physician and surgeon;
Q. Services of a registered nurse, and treatment by a licensed physiorherapist, other than a person related by blood
or marriage or who ordinarily resides in the Insured Person's home;
5. Anesthetic and its administration;
6. Dental treatment for a fractured jaw or for injury to sound natural teeth including replacement of such teeth
within six months after the date of the accident, provided that such accident occurs while the insurance is in
force as to the Insured Person;
7. Diagnostic radiology, radiation therapy and laboratory examinations;
$. Licensed ambulance service to and from the hospital;
9. Medical supplies as follows: (A) drugs and medicines which can Ee obtained only by numbered prescription,
and when for the specific accident or sickness for which rile patient is being treated, (B) blood and blood plasma,
(C) for initial but not subsequent artificial limbs and eyes, (D) casts, splints and braces, (E) crutches, (F) rental
of wheelchairs and hospital bed, (G) oxygen and rental of equipment for its administration including IPPB
(Intermittent positive pressure breathing) equipment.
EXTENSION OF MAJOR MEDICAL BENEFITS PROVISIONS
If accidental bodily injury is sustained or sickness commences while these Major Medical Benefits are in force as to dze
Insured Person, Covered Expenses otherwise payable under the policy will be paid for any such expenses incurred as the
result of such injury or sickness after the termination '.if insurance of an Insured Person if from the date of such termination
of insurance to the date such Expenses are incurred the Insured Person is wholly and continuously disabled by reason of
such accidental bodily injury or sickness. Such benefits shall be payable only during the continuance of such disability but
not beyond the earliest of the following dates: (A) three months from the date the insurance of the Insured Person ter-
minated, (B) on the dare the policy is terminated, (C) for persons whose insurance became effective after the effective date
of the Master Policy, on the last day of a period equal to the time the Insured Person was insured under these Major Medical
Benefits, (D) on the date the Insured Person bcomes covered or insured under any other group policy (whether issued by-
the Company or any other Insurer) or any group basis service or prepayment plan, (E) the reinstatement of Maximum
Amount shall not be applicable in the case of any Insured Persons entitled to benefits in accordance with this provision.
LIMITATIONS
In addition to the Exceptions contained in the policy, benefits shall not be payable under this section for:
A. Any charge for cosmetic surgery: (1) except for medical services or treatment for injuries sustained in an ac-
cident while insured under the Major Medical Benefits provision of this policy but only for that such medical
care and treatment is rendered within six months after the dare of such accident, or (2) unless the medical
care or treatment is for the correction of an abnormal congenital condition in a child born while the mother
of such child is insured under the Policy as an Insured Person.
B. Any charge for treatment or services for the prevention or cure of alcoholism or narcotism.
GP•30WSA -471 SECTION 23 —MAJOR MEDICAL BENEFITS {CONT.)
SECTION 23 -MAJOR MEDICAL BENEFITS
PRE - EXISTING CONDITION'S. No benefits shall be paid to an Insiireci Person after an amount equal to 101-;
SECTION 23 -- MAJOR MEDICAL BENEFITS
MENTAL AND EMOTIONAL CONDITIONS LIMITATION. Subject to the applicable Percentage Payable stated
in the Schedule of Benefits hereof and to all of the Major Medical l3enelits provisions, Covered Expenses incurred by an
Insured Person by reason of mental and emotional conditions due to necuosis, psychoneurosis, psychopathy, psychosis and
other mental and emotional sicknesses or disorders of any type are payable only as follows:
1. When hospital confined, the Company's liability shall not exceed 1510 of the Major Medical Maximum in the
aggregate for all such conditions during each Insured Person's lifetime;
2. When not hospital confined, the fees charged by a physician and surgeon for phychiatric treatment with re-
spect to each insured Person shall not exceed:
(A) $20.00 covered expenses per treatment
(B) one visit per day,
(C) $500.00 in the aggregate during each calendar year.
(D) 15, /o of the Major Medical Maximum in the aggregate for all such conditions during each Insured
Person's lifetime, such aggregate to include any payment made under item (1) above.
The Reinstatement of Maximum Amount does not apply to the above conditions.
GP-3000-SC-971 SECTION 23 - MAJOR MEDICAL BENEFITS (MENTAL AND EMOTIONAL CONDITIONS}
SECTION 3 0 -MEDICARE PROVISION
This Provision dxs not apply to Life Insurance licnefits, Accidental Dc:tih and Dismemberment Benefits, or benefits
payable for any loss of time on account of disability, if any such benefits are provided in the Policy.
Wherever used in this Provision, the term "Medicare" refers to Health Insurance for the Aged as provided under
both Parts A and B, Title XVIII of the Social Security Act, as amended from time to time.
INTEGRATION OF BENEFITS WITH THE MEDICARE PROGRAM
With respect to each Insured Person who is eligible for coverage under Medicare, a benefit otherwise payable under
the Group Policy shall be reduced by the amount of any similar Medicare benefit. It will be presumed that each Insured
Person eligible for coverage under Medicare becaric covered for all parts of Medicare on the earliest possible date and
has maintained such coverage in force.
If the Policy contains a "Coordination of Benefits" provision, the definition of "Platt" contained therein shall not be
construed to include coverage under Medicare.
GP•3000- 22.971 SECTION SO- MEDICARE PROVISION {INTEGRAT]ON)
SECTION 31 - CONVUSION PRIVILEGE
ANY INDIVIDUAL, WITHIN THIRTY -ONE DAYS AFTER THE DATE HIS HOSPITAL, SURGICAL
AND PREGNANCY INSURANCE UNDER THE POLICY IS TERMINATED BECAUSE OF TERMINATION OF
EMPLOYMENT, SHALL BE ENTITLED TO HAVE ISSUED TO HIM, WITHOUT EVIDENCE OF INSURABILITY,
AN INDIVIDUAL POLICY OF HOSPITAL -- SURGICAL- PREGNANCY INSURANCE PROVIDED WRITTEN APPLI-
CATION THEREFOR AND PAYMENT OF THE FIRST PREMIUM THEREON IS MADE TO THE COMPANY WITHIN
SAID THIRTY -ONE DAYS. ANY SUCH INDIVIDUAL POLICY ISSUED SHALL COVER:
(A) THE INDIVIDUAL, IF THE HOSPITAL, SURGICAL AND PREGNANCY INSURANCE UNDER
THE POLICY COVERED THE INDIVIDUAL ONLY; OR
(B) THE INDIVIDUAL AND HIS DEPENDENTS, IF THE HOSPITAL, SURGICAL AND PREGNANCY
INSURANCE UNDER THE POLICY COVERED THE INDIVIDUAL AND HIS DEPENDENTS,
AND SHALL BECOME EFFECTIVE ON THE DAY IMMEDIATELY FOLLOWING THE DATE OF TERMINATION
OF SUCH INSURANCE UNDER THE POLICY, THE FORM OF THE INDIVIDUAL POLICY, THE COVERAGE
THEREUNDER, THE PREMIUM RATES AND ALL OTHER TERMS AND CONDITIONS THEREOF SHALL BE
SUCH AS IS THEN PROVIDED BY THE COMPANY WITH RESPECT TO INSURANCE ISSUED PURSUANT TO
AN APPLICATION MADE IN ACCORDANCE WITH THESE PROVISIONS,
IF THE INDIVIDUALS HOSPITAL AND SURGICAL INSURANCE UNDER THE POLICY WITH RESPECT
TO A DEPENDENT IS TERMINATED 8ECAUSE OF THE DEATH OF THE INDIVIDUAL, SUCH DEPENDENT
SHALL BE ENTITLED TO HAVE ISSUED TO HIM AN INDIVIDUAL POLICY OF HOSPITAL- SURGICAL
INSURANCE IN THE SAME MANNER AND SUBJECT TO THE SAME CONDITIONS AS PROVIDED FOR THE
INDIVIDUAL INSURED.
SUPERIMPOSED MAJOR MEDICAL INSURANCE (CONTINUED)
FAMILY DEDUCTIBLE. IF THREE FAMILY MEMBERS SATISFY THEIR DEDUCTIBLES, THEN BENEFITS
WILL BE PAYABLE TO THE OTHER FAMILY MEMBERS AS IF THEIR DEDUCTIBLES HAD BEEN SATISFIED
WITH THE EXCEPTION THAT BENEFITS PAYABLE UNDER THE OTHER BENEFIT PROVISIONS, IF ANY,
WILL STILL BE DEDUCTIBLE. BENEFITS WILL BE PAYABLE UNDER THIS PROVISION ONLY FOR
EXPENSES FOR TREATMENT OR SERVICES INCURRED AFTER THE REQUIRED NUMBER OF DEDUCTIBLES
HAS BEEN SATISFIED. FOR THE PURPOSES OF THOS PROVISION A FAMILY SHALL CONSIST OF AN
INDIVIDUAL AND HIS DEPENDENTS COVERED UNDER THE POLICY.