HomeMy WebLinkAboutResolution - 2004-R0590 - Contract For Organ Transplant Insurance - AIG Insurance Company - 12_16_2004Resolution No. 2004-R 0590
December 16, 2004
Item No. 30C
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LU13BOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to enter into a contract by and between the City of Lubbock and AIG Insurance
Company for organ transplant insurance. Such agreement is attached hereto and
incorporated herein and into the minutes of the Council as though set forth fully therein.
Passed by the City Council this 16th
ATTEST:
Rebecca Garza, City Secretary
APPROVED AS TO CONTENT:
uincy Whi e
Assistant City Manager
APPROVED AS TO FORM:
Matthew L. Wade
Natural Resources Attorney
day of December , 2004.
AIG LIFE INSURANCE COMPANY Resolution No. 2004-RO590
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware December 16, 2004
[One Alico Plaza, Wilmington, DE 1980 i ] Item No. 30C
Administrative Office:
Medical Excess, LLC
8777 Purdue Road, #330
Indianapolis, Indiana 46268
Organ and Tissue Transplant Policy Application
Policy Applicant:
CITY OF LUBBOCK
Telephone:
(806) 775-2317
Tax ID:
75-6000590
Address:
1625 131h Street
City:
Lubbock
State:
TX
Zip Code:
79401
Names of Affiliates to be Included:
Location:
N/A
Is the Applicant:
❑ Single Employer
❑ HMO
❑ Trust
X Association or Other
Name of Agent/Broker
ICON Benefit Administrators II, LP
Contact Name:
Sue Garlin ton
Agent/Broker's Phone Number:
(806) 473-3000
Agent/Broker's License Number:
1 75-1857307
Covered Transplants: [x ] Heart [ x] Kidney [x ] Lung [x ] Heart/Lung [x ] Pancreas [x ] Kidney/Pancreas [ x] Liver
x Small Bowel x Bone Marrow/ Stem Cell Ventricular Assist Devices
Benefit Period: Start Date: [ x] Date of Evaluation [ ] 10 Days Before Transplant [ ] Other
(specify)
End Date: x 365 Days After Transplant ] Other (specify)
Lifetime Limit: [x] $1,000,000 [ ] Other (specify) Out of Network Reimbursement: [x ] 80% Other
Name of Medical Plan Administrator:
Requested Policy Effective Date Subject to Acceptance:
January 1,2005
Eligible Persons to be Covered Under the Policy: [x ] Employee [x ] Retiree [x ] COBRA Continuee [x ] Member
Subscriber x Spouse x I Dependents Other
To Be Completed by Medical Excess Only:
Single:
[ ]
x
Monthly Premium =
$
Family:
[ ]
x
Monthly Premium =
$
Composite:
[ ]
x
Monthly Premium =
$
Total Premium $
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Within the past 24 months, have any of the Eligible Persons (including but not limited to employees, members or their dependents) to
be covered under this Policy received any organ or tissue transplant, been recommended for a transplant evaluation, been evaluated (or
are currently waiting to be evaluated), or been accepted as a transplant candidate?
❑ YES ❑ NO
If YES, please provide a current list of all such persons who meet the above criteria, complete with diagnosis, transplant type, dates of
evaluation or acceptance by Transplant Facilitv and Transplant Facilitv where listed.
IMPORTANT NOTICE
ANY PERSON WHO WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN
INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT,
OR CONCEALS INFORMATION FOR THE PURPOSE OF MISLEADING, MAY BE FOUND GUILTY OF INSURANCE
FRAUD AND IS SUBJECT TO CRIMINAL AND/OR CIVIL PENALTIES.
The Applicant hereby applies for Organ and Tissue Transplant insurance coverage and:
1. Represents that the answers included in this application have been reviewed and are true and complete to the best of
the applicant's knowledge and belief;
2. Understands and agrees that insurance applied for shall not become effective until the application for insurance is approved by the
Company; and
3. Agrees that if the insurance applied for is approved by the Company, the Applicant will pay all premium due after the effective
date of insurance, including any premium which may accumulate between the effective date of the insurance and the date the
Policy is issued.
This Applicittion, as it may be amended, will become part of the Policy, if issued.
Signature of Owner, Partner, Member, Principal, or Officer Authorized to Sign as Applicant
Applicant's Printed Name:
Title:
Date:
Producer Name:
License #:
(For Office Use Only)
Accepted By: Declined By:
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CITY OF LUBBOCK:
ATTEST:
Re cca Garza
City Secretary
APPROVED AS TO CONTENT:
Quincy Whi e
Assistant City Manager
APPROVED AS TO FORM:
Matthew Wa e
Natural Resources Attorney
n
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Resolution No. 2004-RO590
December 16, 2004
AIGLIFE Item No. 30C
AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
Administrative Office:
Medical Excess, LLC
8777 Purdue Road, #330
Indianapolis, Indlana 46268
(888) "9-2377
POLICY
Organ & Tissue Transplant
AIG Life Insurance Company (herein called the Company) in consideration of the payment of premium, the statements made
in the Application, a copy of which is attached hereto and made a part of this Policy, and subject to the terms, conditions and
limitations of this Policy, does hereby issue this Policy to
INSURED: [ABC Company]
INSURED ADDRESS: [123 Anywhere
Any State, USA]
POLICY NUMBER [GX-==]
POLICY EFFECTIVE DATE: [January 1, 20021
PREMIUM DUE DATE: Premium i thIgMicy Effective Date and the first of each calendar month
there
This Policy, as issued to the Insured, is a I a ent between the Insured and the Company. The coverage described in
this Policy, along with the Certificate of In n nstitutes the entire agreement under which insurance is provided. The
first payment of premium is due and payable before the Policy Effective Date shown above and all other premiums are
due and payable on the Premium Due Date.
IMPORTANT NOTICE:
THIS POLICY PROVIDES LIMITED BENEFITS AND IS NOT INTENDED TO BE A MAJOR MEDICAL
BENEFIT BEALTH PLAN.
PLEASE READ THIS POLICY AND CERTIFICATE CAREFULLY. They contain a complete description of the benefits
provided as well as EXCLUSIONS and/or LIMITATIONS which apply.
The Policy Period shall begin and end at 12:01 a.m. Standard Time at the address of the Insured shown in this Policy.
IN MT174M WHEREOF, the Company has caused this Policy to be signed by a duly authorized representative of the
Company
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Secretary
President
• Table of Contents
SECTION L• SCHEDULE OF BENEFITS FOR ORGAN AND TISSUE TRANSPLANT .......................... 4
SECTION II: DEFINITIONS........................................................................................................... 6
SECTION III: EXCLUSIONS........................................................................................................... 10
SECTION IV: TERMINATION........................................................................................................... 11
SECTION V. GENERAL INFORMATION................................................................................................... I 1
SECTION VI: COORDINATION OF BENEFITS.......................................................................................... 12
SECTION VII: APPEAL AND GRIEVANCE PROCEDURES...................................................................... 15
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ORGAN AND TISSUE TRANSPLANT POLICY
Declarations Page
[INSURED:
ADDRESS:
POLICY EFFECTIVE DATE:
INITIAL ENROLLMENT:
PREMIUMS PER MONTH: $ Single
$ Family
$ Composite
POLICY NUMBER: -
EXPIRATION DATE:
MINIMUM ENROLLMENT:
PREMIUM DUE DATE:
Resolution No. 2004-RO590
December 16, 2004
Item No. 30C
ELIGIBLE PERSONS:
COVERED TRANSPLANTS: j ]Heart [ ]Kidney/ Pancreas N�te specify):
[ ] Kidney [ ] Liver
[ ] Lung [ ] Small Bowel
[ ] Heart/ Lung [ ] Bone Marr
[ ] Pancreas [ ] Ven a ce
BENEFIT PERIOD: Start Date: [ ] Date of Evaluatio d ate: [ ] 365 Days After Transplant
[ ] 10 Days Before n [ ] Other (specify):
[] Other (spec' 62
LIFIrTIME LIMIT:
OUT OF NETWORK
ENDORSEMENTS
If yes, please specify
YES NO
ADMINISTRATOR OF HEALTH PLAN:
ADDITIONAL EXCLUSIONS & LIMITATIONS:
ADDITIONAL INFORMATION:
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. Organ & Tissue Transplant Policy
THIS POLICY PROVIDES COVERAGE FOR CLAIMS THAT ARE INCURRED WITHIN THE POLICY PERIOD AND
REPORTED WITHIN TWELVE MONTHS OF THE LATER OF THE END OF THE POLICY PERIOD AND THE END
OF THE TRANSPLANT BENEFIT PERIOD, UNLESS OTHERWISE ENDORSED. THIS POLICY HAS CERTAIN
PROVISIONS AND REQUIREMENTS UNIQUE TO IT, AND MAY BE DIFFERENT FROM OTHER POLICIES YOU
MAYHAVE PURCHASED.
PLEASE READ THE ENTIRE POLICY CAREFULLY TO DETERMINE THE PARTICIPANTS' RIGHTS AND DUTIES,
AND WHAT IS AND IS NOT COVERED. VARIOUS PROVISIONS THROUGHOUT THIS POLICY RESTRICT OR
EXCLUDE COVERAGE.
DEFINED TERMS ARE CAPITALIZED. PLEASE REFER TO SECTION H TO EXAMINE THE APPLICABLE
DEFINITIONS
SECTION I: SCHEDULE OF BENEFITS FOR ORGAN AND TISSUE TRANSPLANT
A. INSURING AGREEMENT:
Subject to the Declarations Page, the Schedule of Insurance, and all to c n ' n, efinitions, provisions, limitations
and exclusions of this Policy, this Policy provides benefits for Cov es overed Transplant Services that are
directly related to Covered Transplant Procedures performed on P a n a Transplant Facility.
B. NOTIFICATION:
The Company or its designee must be notified in a r ted by the Company when a Participant's Physician
• advises a Participant that a Covered TransplanOF60 ure ing considered, and before referral is made. Failure to
notify the Company in the designated manne s e decrease or denial of benefits. The Company's designee
shall be Medical Excess, LLC, 8777 Purdue O,&dianapolis, Indiana 46268, (888) 449-2377.
•
C. TRANSPLANT BENEFIT
The Transplant Benefit Period for a ipant is shown on the Declarations Page. For a Bone Marrow/Peripheral Stem
Cell Tissue Transplant, the date the tissue is re -infused is deemed to be the date of the Transplant. No Transplant Benefit
Period can begin prior to the Policy Effective Date or prior to the Participant's first day of coverage under this Policy if the
Participant first becomes covered after the Policy Effective Date.
Benefits for a Participant continue beyond the Policy Expiration Date only if the Participant:
a. has established a Transplant Benefit Period prior to the Policy Expiration Date, and
b. has undergone transplantation prior to the Policy Expiration Date, and
c. the established Transplant Benefit Period has not been exhausted, and
d. the Participant's Lifetime Limit has not been reached.
All coverage and benefit payments will be based on the Policy terms in effect at the start of the Transplant Benefit Period.
D. SCHEDULE OF INSURANCE: Benefits will be payable for Covered Charges as follows:
1. Participating Transplant Facility. 100% of Covered Charges for Covered Transplant Services provided through a
Participating Transplant Facility with respect to the type of Covered Transplant Procedure performed.
2. Nonparticipating_ Transplant Facility. [80%] of Covered Charges for the Covered Transplant Services provided
through a Nonparticipating Transplant Facility with respect to the type of Covered Transplant Procedure performed.
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Benefits paid are [80%] of Covered Charges and cannot exceed the Maximum Amount stated below for the type of
Covered Transplant Procedure performed:
Covered Transplant Procedure
Maximum Amount
[Heart
$243,000
Kidney
$ 89,000
Lung
$206,000
Heart/Lung
$241,000
Pancreas
$ 91,000
Kidney/Pancreas
$111,000
Liver
$196,000
Small Bowel
$379,000
Autologous Bone Marrow/Peripheral Stem Cell-
$116,000
Including High Dose Chemotherapy
Allogeneic Bone Marrow/Peripheral Stem Cell-
$186,000
Including High Dose Chemotherapy - related
Allogeneic Bone Marrow/Peripheral Stem Cell-
$235,000
Including High dose chemotherapy- unrelated
Lk
E LIFETIMELIWT:
The maximum dollar amount the Company will pay for any Participant r i li and any preceding or succeeding
Organ and Tissue Transplant Policy between the Insured and th ) 's a Lifetime Limit as shown on the
Declarations Page. The limit shown for transportation costs u er i e. is included in and accrues toward this
Lifetime Limit. ,.
F. NON-PERFORMANCE OF COVERED TRANSPVOCWMES:
If a Covered Transplant Procedure is not perfo a due to the Intended Recipient's medical condition or the
Intended Recipient's death, benefits will be pa' oansplant Services up to and until the earlier of:
1. the Intended Recipient's death;
2. the date the decision is ed Recipient's Physician not to perform the Covered Transplant
Procedure.
G. MULTIPLE TRANSPLANTS:
If a Participant requires more than one Covered Transplant Procedure, the Company will determine benefits for Covered
Transplant Services during each Transplant Benefit Period as follows:
1. If each Covered Transplant Procedure is due to unrelated causes, each Covered Transplant Procedure will begin a
separate Transplant Benefit Period.
2. If each Covered Transplant Procedure is due to related causes, each Covered Transplant Procedure will begin a
separate Transplant Benefit Period if:
a. in the case of a Participant, the transplants procedures are separated by the Participant's return to being
actively employed by the Insured for a period of 90 days; and
b. in the case of a Dependent, the transplants are separated by at least 90 days.
3. If the Covered Transplant Procedures are due to related causes, they are considered as one Transplant Benefit
Period when not separated as required in Section I.G.2 above and the Transplant Benefit Period is determined in
accordance with the earlier Covered Transplant Procedure.
4. All Covered Transplant Procedures are subject to the Lifetime Limit per Participant, regardless of the number of
Covered Transplant Procedures performed.
H. TRANSPLANT CARE COORDINATION
The Company or its designee may assign a nurse case manager to assist and coordinate the Participant's continuing
transplant related needs.
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• SECTION U: DEFINITIONS
A. Additional Organ Transplant Coverage — means any policy covering the Insured or any Participant for Covered
Transplant Procedures or Covered Transplant Services including, but not limited to, a group or individual major medical
policy and a limited benefit medical policy.
B. Adverse Determination — means a determination by the Company that a Transplant Related Service has been reviewed
and, based upon the information provided, is not Medically Necessary, and is therefore denied, reduced or terminated.
C. Company— means AIG Life Insurance Company.
D. Covered Charges — means charges that are not excessive, in the Company's judgment, for Covered Transplant Services.
The determination as to whether a charge is excessive shall be based on whether the charge is in conformity with one or a
combination of the following: (1) a negotiated rate based on services provided; (2) a fixed rate per day; or (3) the
Reasonable and Customary allowance for similar Providers who perform similar Covered Transplant Services.
E. Covered Services — means services or supplies for which benefits will be paid when provided by a Provider acting within
the scope of such Provider's license. In order to be considered a Covered Service, charges must be incurred during the
Policy Period (prior to any earlier termination), or during the Transplant Benefit Perio .
F. Covered Transplant Procedures — means the following Medically Necess ediatric human organ and tissue
transplants: [(a) Bone marrow/peripheral stem cell, including High D c e y; (b) Heart; (c) Heart/Lung; (d)
Lung; (e) Liver; (0 Pancreas; (g) Kidney/Pancreas; (h) Small Bowel; ajW� eyr]
G. Covered Transplant Services — means the following se Avided to a Participant, performed within a
transplant facility, and which are directly related to a C ocedure:
• a.
Inpatient and outpatient hospi&see tb. Servicesof a Physician for diaand surgery.
c.
Diagnostic Services.
d.
Procurement of an or tng services provided to a living donor of an organ or tissue for
procurement of an o ue, compatibility testing, procurement expenses, donor's surgical procedure to
remove the organ or npatient and outpatient services.
e.
Reasonable and nece ransportation costs, as detennined by the Company, for travel related to a
Covered Transplant Procedure for the Transplant Recipient and one companion during a Transplant Benefit
Period, subject to a limit of $200.00 per day for lodging and meals per Covered Transplant Procedure and
$10,000.00 for all transportation, lodging, and meals, per Covered Transplant Procedure. The Participant
shall submit itemized receipts in a form satisfactory to the Company when claims are filed. If the Participant
is a minor, transportation costs for two companions will be covered.
f.
Rental of durable medical equipment for use outside the Hospital, subject to a limit of the purchase price of
such equipment.
g.
Prescription drugs, including immunosuppressive drugs.
h.
Oxygen.
i.
Speech Therapy, Occupational Therapy, Physical Therapy, and Chemotherapy.
j.
Services and supplies for and related to High Dose Chemotherapy and bone marrow tissue transplantation
when provided as part of a treatment plan which includes bone marrow transplantation and High Dose
Chemotherapy.
k.
Surgical dressings and supplies.
1.
Home health care.
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H. Custodial Care — Care that is not Skilled Care.
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1. Dependent — means the following persons covered under the In sured's Health Plan: (1) a Member's spouse, (2) any of the
following who qualify as the Member's Dependent(s) for federal income tax purposes, until they reach the Limiting Age:
(i) unmarried children; (ii) unmarried stepchildren; (iii) unmarried children for whom the Member or the Member's spouse
has legal guardianship; or (iv) unmarried adopted children of the Member or the Member's spouse, from the earlier of
either the date of placement for the purpose of adoption, or the date of entry of a court order granting the adoptive parent
custody of the child for adoption. However, such children identified in item (2) of this definition may be continued as
Dependents past the Limiting Age, if they, because of a handicapped condition that occurred before reaching the Limiting
Age, are incapable of self-sustaining employment and are dependent on Member or are Dependent On Other Care
Providers for lifetime care and supervision. The Company may require proof of disability and dependency two months
before such children reach the Limiting Age, or at any reasonable time thereafter. If proof is not submitted within 31 days
of such inquiry, coverage for such children will terminate when they reach the Limiting Age. If the Company does not
make such an inquiry, coverage for such children shall continue while this Policy is in effect.
J. Dependent On Other Care Providers — means requiring a community integrated living arrangement, group home,
supervised apartment, or other residential services licensed or certified by the Department of Mental Health and
Developmental Disabilities, the Department of Public Health, the Department of Public Aid or their equivalent.
K. Diagnostic Services — means the following procedures that are directly related to a Covered Transplant Procedure and are
ordered by a Provider Individual because of specific symptoms in order to dete . e a definite condition or disease: (i)
radiology, ultrasound, and nuclear medicine; (ii) laboratory and pathology; d (i EKGs, EEGs, and other electronic
diagnostic medical procedures.
L. Effective Date — means the date coverage begins under this Policy. �, 1
M. Experimental Treatment — means any drug, device, proced �u pment, treatment, supply or service (i) that is
deemed to be experimental or investigational in nature }e technological assessment body established by
any state or federal government, or (ii) where the C a y, s le discretion, determines that, at the time it is used,
• one or more of the following conditions is prese
1. Its use requires approval by the a e or other governmental agency which has not been granted,
such as, but not limited to the ministration (FDA).
2. Its use is not yet recogni p medical practice throughout the United States to treat that illness or
injury; or is subject to
a) a written al or research protocol; or
b) a written in consent or protocol used by the Treating Facility in which reference is made to
the drug, device, procedure or treatment as being experimental, investigative, educational, for a
research study, or posing an uncertain outcome, or having an unusual risk; or
c) a written protocol, protocols or informed consent used by any other facility studying substantially
the same drug, device, procedure or treatment which states it is experimental, investigative,
educational, for a research study, or posing an uncertain outcome, or having an unusual risk; or
d) an ongoing review by an Institutional Review Board.
3. It does not have either:
a) the positive endorsement of national medical bodies or panels, including but not limited to, as the
American Cancer Society, or the Agency for Health Care Policy and Research, or the National
Cancer Institute; or
b) multiple published peer review articles, in a recognized professional medical journal, concerning
such drug, device, procedure or treatment and reflecting its reproducibility by non-affiliated
sources which Company determines to be authoritative; or
c) trial results, which indicate the drug, device, procedure or treatment, is at least as effective as
current standard therapy.
4. For adult bone marrow/stem cell transplant, the patient is participating in a Phase I or II trial; or in a Phase III
trial that is using protocols that have not been reviewed and approved by the National Cancer Institute (NCI)
or similar national cooperative body and does not conform to the rigorous independent oversight criteria as
defined by the NCI for the performance of clinical trials.
•
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• S. For pediatric bone marrow/stem cell transplant, the patient is participating in any Phase trial using protocols
that have not been reviewed and approved by the National Cancer Institute (NCI) or similar national
cooperative body (e.g. Pediatric Oncology Group) and does not conform to the rigorous independent
oversight criteria as defined by the NCI for the performance of clinical trials.
6. For both adult and pediatric, the clinical trial is not a single institution or investigator study (NCI designated
Comprehensive Cancer Center trials are exempt from this requirement).
7. Patient is treated "off protocol" and is not actually enrolled in the trial.
8. It does not meet all specific state -mandated criteria required to not be considered experimental or
investigational.
N. Grievance means a written complaint submitted by or on behalf of the Insured regarding: (1) the Company's decisions,
policies or actions related to availability, delivery or quality of Covered Transplant Services; (2) claims payment, handling
or reimbursement for Covered Charges; (3) the contractual relationship between the Insured and the Company; or (4) the
outcome of an Adverse Determination.
O. health Plan — means a group health plan maintained by the Insured, including group insurance coverage, health
maintenance organizations, self-insurance plans, and preferred provider organizations, prepayment coverage, any other
coverage which, as defined by the Employee Retirement Income Security Act of 1974, is a labor-management trustee plan,
a union welfare plan, an employee organization plan, or an employee benefit org ization, any other coverage provided
because of sponsorship by or membership in any other association, union, or ilar organization, any government
program except Medicare or Medicaid, the medical payments and/or no -fa of automobile insurance, and any
other group type coverage as permitted by law.
P. High Dose Chemotherapy — means the use of a
recurrence of, cancer or cancer -like illness, with or
commonly recognized dosage range for the drug or (
bone marrow which would likely be lethal if untreated.,
0
Q. Insured— means the named Insured listed on
R. Intended Recipient — means a
but who has not yet received s
agents for treating, or for preventing
t doses which exceed the FDA approved or
which is expected to result in effects upon the
of this Policy.
Physician has properly authorized a Covered Transplant Procedure
Procedure.
S. Limiting Age — means the end of twndar year of a child's 19th birthday; or, if the child is a full-time student at an
accredited educational institution, the end of the calendar year of the child's 23rd birthday.
T. Medically Necessary or Medical Necessity — means those drugs, devices, procedures, treatments, services or supplies,
provided by a Provider Facility or a Provider Individual, which are required for treatment of illness, injury, diseased
condition, or impairment, and are:
1. consistent with Participant's diagnosis or symptoms and Participant is an appropriate candidate for the proposed
treatment;
2. appropriate treatment, according to generally accepted standards of medical practice;
3. not provided only as a convenience to Participant or to the Provider.
4, not an Experimental Treatment; and
S, not excessive in scope, duration, or intensity to provide safe, adequate, and appropriate treatment. Any service or
supply provided at a Provider Facility will not be considered medically necessary if Participant's symptoms or
condition indicate that it would be safe to provide the service or supply in a less comprehensive setting.
The fact that a Provider individual may prescribe, order, recommend, or approve a service, supply, or level of care does
not, of itself, make such treatment Medically Necessary or make the charge a Covered Charge.
U. Medicare — means the programs of health care for the aged and disabled established by Title XVIII of the Social Security
Act of 1965, as amended.
V. Member — means an individual covered by the Insured's Health plan, either as an employee, a retiree, a COBRA
continuee, a member, or as a subscriber.
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• W. Participant — means an individual covered by the Insured's Health Plan, either as an employee, a retiree, a COBRA
continuee, a member, a subscriber, or as a Dependent who is also covered under this Policy as an Eligible Person as
indicated on the Declarations Page.
X. Premium Due Date —means the date the Insured's premium is due, as stated on the Declarations Page.
Y. Policy Period — means the period from the Effective Date of this Policy to the Expiration Date or earlier termination date,
if any, of this Policy.
Z. Provider— means'any of the facilities and individuals listed below:
(1). Provider Facilities — means any of the following facilities:
(a)
Clinical Laboratory — means a laboratory that performs clinical procedures and is not affiliated or associated
with a Hospital, Physician, or other Provider.
(b)
Hospital — means a facility which is a short-term general hospital and which: (1) is primarily engaged in
providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick
persons by or under the supervision of physicians, for compensation from its patients; (2) has organized
departments of medicine and major surgery; and (3) provides 24-h r nursing service by or under the
supervision of registered nurses. Surgical facilities may be either o p ises or in facilities available to the
Hospital on a prearranged basis.
(c)
Nonparticipating Transplant Facility — means a Hospital t co acted with the Company or its
designee(s) through an applicable transplant network, to o ov r Transplant Procedures. A Hospital
may be a Nonparticipating Transplant Facility with re e ( in Covered Transplant Procedures; or (2)
all Covered Transplant Procedures.
'
(d)
Participating Transplant Facility — Any Ho a with the Company or its designee(s) through an
applicable transplant network, to provide a ed ant Procedures. A Hospital may be a Participating
Transplant Facility with respect to: e n e d Transplant Procedures; or (2) all Covered Transplant
•
Procedures.
(e)
Pharmacy— means a facility li Ift lunacy by the state in which it operates.
(2) Provider Individuals— means, iWollowing individuals:
(a) Occupational Therapis AM person who is licensed as an Occupational Therapist by the state in which
he or she practices. If th does not issue such licenses, an Occupational Therapist is a person certified as
an Occupational Therapist by an appropriate professional body.
(b) Physical Therapist — means a person who is licensed as a Physical Therapist by the state in which he or she
practices. If that state does not issue such licenses, a Physical Therapist is a person certified as a Physical
Therapist by an appropriate professional body.
(c) Physician — means a person performing services within the scope of his or her license, who is a duly licensed:
(1) doctor of medicine (MD); (2) doctor of osteopathy (DO); (3) dentist; (4) podiatrist; (5) optometrist; (6)
chiropractor; or (7) psychologist.
(d) Respiratory/Inhalation Therapist — means a person who is licensed as a Respiratory/Inhalation Therapist by
the state in which he or she practices. If that state does not issue such licenses, a Respiratory/Inhalation
Therapist is a person certified as a Respiratory/Inhalation Therapist by an appropriate professional body.
(e) Speech Pathologist and Speech Therapist — means a person licensed as a Speech Pathologist or Speech
Therapist by the state in which he or she practices. If that state does not issue such licenses, a Speech
Pathologist or Speech Therapist is a person certified as such by an appropriate professional body.
AA. Reasonable and Customary means: (i) Customary — the amount charged by a majority of Providers in the same
geographic areas for similar services or supplies and/or is relative to the value and worth of similar services; and (ii)
Reasonable — a charge that meets the above criteria and, that in the judgment of the Company, is not an excessive amount
for similar services or supplies; or, a charge that merits special consideration due to complexity of treatment in the opinion
of a peer review committee or consultant. If a Provider accepts as full payment, in the absence of insurance, an amount
less than Reasonable and Customary, the lesser amount will be the maximum Reasonable and Customary. The Company
will pay the lesser of the actual billed charge or the Reasonable and Customary, subject to SECTION I: SCHEDULE OF
a
BENEFITS.
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BB. Skilled Care — The recognition and utilization of professional methods and procedures in the assessment, observation, or
treatment of an illness or injury. Skilled care must be performed by or under the supervision of Provider Individuals.
CC. Spouse — The person recognized as the Member's spouse or dependent under the group health plan, as defined above,
maintained by the Insured.
SEMON III: EXCLUSIONS
This Policy provides no coverage for any of the following:
A.
Any service or supply not directly related to Covered Transplant Procedures (including any service or supply rendered to
treat the underlying disease that is not part of the actual Covered Transplant Procedure).
B.
Services and supplies for treatment of complications related to a Covered Transplant Procedure, unless such
complications are determined by the Company to be the immediate and direct result of a Covered Transplant Procedure.
C.
Charges for any transplant related services or supplies incurred before the Effective Date of this Policy.
D.
Services, and supplies for immunizations.
E.
Animal organ or artificial organ transplants.
F.
Stand-by charges of a Physician.
G.
Services of a Provider who is a member of Participant's immediate family.
's
A.
Services, supplies, or Hospital care which, in the judgment of the Compan ical consultants, are not medically
necessary for the treatment of illness, injury, diseased condition, or impai specifically, stated as covered.
I.
Custodial care.
J.
Charges for any Experimental Treatment, except as specifically state 'n i
K.
Charges paid or payable under Workers' Compensation.
L.
Preventive or routine care, including physicals, premarital a d any other routine or periodic examinations,
except as specifically stated as covered.
M.
Research studies or screening examinations.
N.
Treatment of any illness or injury sustained as a 1 an o war or terrorism.
•
O.
Services or supplies to the extent Participant ' o igated to pay for them.
P.
Expenses incurred before the Policy Pe ' or er it ends, except as stated as covered.
Q.
Rest cures or sanitarium care.
IL
Services or supplies furnished b der acting beyond the scope of such Provider's license.
S. ,
Any service or supply that is a M A or Part B liability.
T.
Services or supplies received from 1 or medical department maintained by or on behalf of a group, mutual benefit
association, labor union, trust, or similar person or group.
U.
Services provided by any governmental agency to the extent that Participant is not charged for them, except when this
exclusion conflicts with state or federal law.
Y.
Services or supplies not specifically stated as covered.
W.
Telephone consultations, charges for failure to keep a scheduled visit, or charges for completing a claim form.
X.
Recreational or diversional therapy.
Y.
Materials used in occupational therapy.
Z.
Personal hygiene and convenience items, such as air conditioners, humidifiers, hot tubs, whirlpools, or physical exercise
equipment, even if a Provider prescribes such items.
AA. Hospitalization for environmental change and all related charges.
BB.
Services and supplies, which are eligible to be repaid under any private or public research fund whether or not such
funding was applied for or received.
CC.
Services and supplies for treatment of complications arising from a live donor procedure.
DD.
Immunosuppressive drugs for the treatment or prevention of a rejected organ or tissue following the end of the Transplant
Benefit Period. This Policy will no longer pay benefits following the end of the Transplant Benefit Period,
EE
Services and supplies of any Provider located outside the United States of America, except for procurement services.
FF.
Biological and/or Mechanical devices used as a bridge to transplant unless specifically included on the Declarations Page.
GC.
Charges for any transplant -related services or supplies incurred during the Policy Period when the transplant procedure
occurred prior to the Effective Date of this Policy, except for Covered Charges pursuant to a Covered Transplant
Procedure the Participant received under a previous Organ and Tissue Transplant Policy issued by the Company to the
Insured and where such Covered Charges were for services or supplies that were incurred within the Transplant Benefit
.
Period for the Covered Transplant Procedure.
M20001 10
C�
SECTION IV: TERMINATION
A. This Policy may be canceled by the Insured by returning this Policy to the Company or its designee. The Insured can also
cancel this Policy by written notice to the Company stating at what future date cancellation is to be effective. The
Company may cancel this Policy by giving written notice to the Insured, at the address last known to the Company. The
Company will provide written notice at least thirty (30) days before cancellation is to be effective. The mailing of any
notice of cancellation shall be sufficient proof of notice.
B. There are exceptions to the length of the notice that must be provided to the Insured. The Insured will only be entitled to
at least ten (10) days notice if the Company cancels because the actual enrollment drops below the Minimum Enrollment
as shown on the Declarations Page. The Company may cancel this Policy without any notice if the Insured has failed to
pay any premium due by the end of the Grace Period.
SECTION V: GENERAL INFORMATION
A. Grace Period. Unless either the Company or the Insured gives written notice of cancellation, there is a grace period of 31
days for the payment of any premiums due, except the first. At the end of the ay grace period, the Company may
cancel the Insured's Policy without further notice. During the grace period, th will remain in force; however, the
Company is not obligated to pay any claims incurred by a Participant t eriod, until the premium due is
received. It is possible that the Company inadvertently may accept a o e Insured after the grace period has
expired. This acceptance does not obligate the Company to rein t P Unless this Policy is reinstated, the
payment will be refunded within a reasonable time after the mis v d.
B. Incontestability. The Company may declare this P u r ncel it, if the Policy application contains a material
• misrepresentation. However, this provision will n In t two years after this Policy becomes effective.
C. Representations Not Warranties. A co n and Tissue Transplant Application is attached to the Insured's
Policy. All statements made by the e r dividual Participants in applying for coverage will be considered
representations rather than warran ' teme t appearing on an application will be used to contest the validity of the
Insured's right to the benefits of less the Insured has been furnished a copy of the application.
D. Evidence of Insurability. The Company may ask the Insured for verification that a Participant is covered by the
Insured's Health Plan.
E. Preexisting Conditions Waiting Period. If an individual is nQt listed on the application, and is found to have received an
organ or tissue transplant, or has been recommended for a transplant evaluation, or has been evaluated, or is currently
waiting or has been accepted as a transplant candidate within the past 24 months, limited benefits or no benefits may be
paid during the first 365 days after that individual becomes a covered Participant.
F. Filing Claims. Claims must be filed in a manner approved by the Company, and must include the following information:
1. Participant's name.
2. ID number.
3. Provider's name.
4. Date, place and description of service.
5. Diagnosis.
Claims must be filed within twelve months of the later of the end of the Policy Period or the Transplant Benefit Period.
G. Claim Payment. Company will pay benefits for all Covered Charges in accordance with the terms of this Policy within 60
days after receiving all necessary information. Benefits are paid to the Participant or to the Participant's assignee or
designee. The Company may pay benefits directly to the Provider or to a blood relative of the Participant when a benefit is
payable to a Participant who dies, or to a Participant who is a minor or who is legally incapable of giving valid receipt and
• discharge of payment.
M20001 11
•
•
E
H. Legal Action. Legal action against Company to receive benefits may not be taken: (i) earlier than 60 days after Company
receives the claim; or (ii) later than three years after the date the claim is required to be furnished to Company.
SECTION VI: COORDINATION OF BENEFITS
A. Applicability. This Section applies when the Insured makes a claim for reimbursement of Covered Charges for a
Participant who is covered by Additional Organ Transplant Coverage. If this provision applies, review the Order -of
Benefit -Determination Rules, under the heading of the same name, to determine whether this Policy's coverage is payable
before or after Additional Organ Transplant Coverage. This Policy's coverage will not be reduced when its coverage is
payable first, as determined under the Order -of -Benefit -Determination Rules; but may be reduced when another Plan's
benefits are payable first, as determined under the Order -of -Benefit -Determination Rules as set forth below.
B. Order -of -Benefit -Determination Rules. When there is a basis for a claim under this Policy and Additional Organ
Transplant Coverage, this Policy is secondary if: (1) the Additional Organ Transplant Coverage does not have rules
coordinating its benefits with this Policy; or (2) the Additional Organ Transplant Coverage's rules, this Policy's rules, or
both, require this Policy's coverage be determined after those of the Additional Organ Transplant Coverage, except as may
occur under the gender rule exception in Section VI.C.2 below.
C. Filing Guidelines. The general guidelines which follow discuss the
the Participant is covered under Additional Organ Transplant Coverag
Insured should file claims when
he rules which applies:
i. The Additional Organ Transplant Coverage coveri#afalls
subscriber is obligated to pay before the
Policy covering the Participant as a Dependent.
2. When the parents of a Dependent child are neit ivorced:
a. The Insured must file first under th o iditional Organ Transplant Coverage covering the
Dependent child of the Participan bi earNlier in the year; then file under the Policy or
Additional Organ Transplant Co ent whose birthday falls later in the year; but
b. if both Participants have t h , the Insured must file first under the Policy or Additional Organ
Transplant Coverage, o the Participant for the longer period of time, and then under Policy,
or Additional Organ Coverage of the other parent.
EXCEPTION: If the Additi410FOrgan Transplant Coverage does not have the "birthday rule," but instead has a
rule based upon the parent's gender, and as a result this Policy and the Additional Organ Transplant Coverage do
not agree on the order of benefit determination, the rule of the Additional Organ Transplant Coverage will
determine the order.
3. When the parents of a Dependent are separated or divorced:
a. The Insured must file first under the Policy or Additional Organ Transplant Coverage which covers the child
as a Dependent or the parent with custody; then
b. The Insured must file under the Policy or Additional Organ Transplant Coverage which covers the child as a
Dependent of the spouse of the parent with custody; then
c. The Insured must file under the Policy or Additional Organ Transplant Coverage, which covers the child as a
Dependent of the parent without custody.
EXCEPTION: If there is a court decree which establishes financial responsibility for medical, dental, or other
health care expenses regarding the Dependent child of parents who have separated or divorced:
a. the Insured must file first under the Plan which covers the child as a Dependent of the parent with such
financial responsibility; then
b. file under the Plan, which covers the child as a Dependent of the other parent.
If the specific terms of the court decree state that the parents have joint custody without stating that one parent is
responsible for the child's medical, dental, or other health care expenses, file as described in "2" above.
M20001 12
4. The Insured must file first under the Health Plan which covers the Participant as a subscriber who is neither laid -
off nor retired, or as that subscriber's Dependent; then file under the Health Plan which covers that Participant as
a laid -off or retired subscriber or as that subscriber's Dependent. Ignore this paragraph if the Health Plan does
not contain this paragraph and, as a result, this Policy and the Health Plan do not agree on the order of benefit
determination.
5. When the order of payment cannot be determined in accordance with these general guidelines, file first under the
Policy or Additional Organ Transplant Coverage which has covered the Participant for the longer period of time,
then under the Policy or Additional Organ Transplant Coverage which has covered the Participant for the shorter
period of time.
D. Effect on this Policy's Coverage. When a Participant or a Dependent is covered under two or more policies, which
together pay more than the Covered Charges for Covered Transplant Services, the Company will pay this Policy's benefits
according to the Order -of -Benefit -Determination Rules. This Policy's benefit payments will not be affected when it is
primary. However, when this Policy is secondary under the Order -of -Benefit -Determination Rules, benefits payable will
be reduced, if necessary, so that combined benefits of all policies covering the Participants or their Dependents do not
exceed the Covered Charges.
E. Right to Receive and to Release Information. To coordinate benefits, the Comp ny will release or obtain information
regarding a claim from any insurance company, organization, or person. Par!&pAk claiming benefits must furnish the
Company with any information necessary to coordinate benefits.
F. Right to Obtain Recovery. The Company is not liable for any fai eIWT& M benefits. If the Company pays full
benefits on a claim for which it has only secondary liability, the o y ecover the difference from the Participant
or from any other appropriate party.
G. Information Release and Data Confidentiality. Woi !&I nt makes a claim for benefits, the Company or its
• designated contractors may need more informa ' e I r7 must notify all Participants that by claiming benefits
under this Policy, the Participant allows the C t n information for a claim for the Participant and Dependents.
Also, the Company may furnish such i t her entities providing similar benefits. In the normal course of
business, the Company may furnish re to the designated contractors of both the Insured and the Company,
historical data setting forth the vo re, and cost of health care services paid by the Company. The Insured agrees
that all information will be treated 'al.
0
H. Not Liable for Provider Acts or Omissions. The Company is not responsible for the quality of care any Participant or
Dependent receives from any Provider. This Policy does not give anyone any claim, right, or cause of action against the
Company based on what a Provider of health care or supplies does or does not do.
I. Entire Contract; Amendments. This Policy is the entire contract between the Insured and the Company. No amendment
to this Policy shall be effective unless confirmed by an endorsement issued to form a part of this Policy. No agent or
representative of the Company, other than an executive officer, may change this Policy or waive any of its provisions. No
verbal statement by any executive officer or other employee of the Company is binding on the Company
J. Audit: The Company shall have the right to inspect and audit all records and procedures of the (1) Insured, (2) its Health
Plan administrator, or (3) any other organization involved in the administration or adjudication of claims, and to require,
upon request, proof of records satisfactory to the Company that payment has been made to the Provider of such services or
benefits which are the basis for any claim hereunder.
K. Right of Recovery. If the Company makes any payment that according to the terms of this Policy should not have been
made, including payment made in error, the Company may recover that incorrect payment, whether or not it was due to
our error, from any appropriate party. If the incorrect payment is made directly to Participant, the Company may deduct it
when making future payments directly to Participant.
M20001 13
•
•
L. Subrogation and Right of Reimbursement. Another party may be liable or legally responsible to pay expenses,
compensation and/or damages in relation to Covered Transplant Services. Such party may include, but is not limited to,
any of the following: (a) the party or parties who caused the need for the Covered Transplant Procedure; (b) the insurer or
other indemnifier of the party or parties who caused the Covered Transplant Procedure; (c) a guarantor of the party or
parties who caused the Covered Transplant Procedure; (d) a worker's compensation insurer; (e) any other person, entity,
policy or plan that is liable or legally responsible in relation to the Covered Transplant Procedure. When this happens, the
Company may, at its option, (a) subrogate, that is, take over the Participant's right to receive payments from such party
(the Participant or his or her legal representative must transfer to the Company any rights be or she may have to take legal
action arising from the Covered Transplant Procedure to recover any sums paid under this Policy on behalf of the
Participant), or (b) recover from the Participant or his or her legal representative any benefits paid under this Policy from
any payment the Participant is entitled to receive from the Other Party. The Participant or his or her legal representative
must cooperate fully with the Company in asserting its subrogation and recovery rights. The Participant or his or her legal
representative will, within 5 days of receiving a request from the Company, provide all information and sign and return all
documents necessary to exercise the Company's rights under this provision.
The Company will have a first lien upon any recovery, whether by settlement, judgment, mediation or arbitration that the
Participant receives or is entitled to receive from any of the sources listed above. This lien will not exceed the greater of
(a) the amount recovered from any other party, or (b) the amount of benefits paid by this Policy for Covered Charges plus
the amount of all future benefits which may become payable under this Policy wh' h result from the Covered Transplant
Services. The Company will have the right to offset or recover such benefits o e amount received from any other
party. 16
If the Participant, or his or her legal representative, makes any rec eother party and fails to reimburse the
Company for any Covered Charges then the Participant, or his h sentative, will be personally liable to the
Company for the Covered Charges paid under this Policy. ay reduce future benefits payable under this
Policy for any Covered Charges by the payment that the or her legal representative has received from any
other party.
The Company's first lien rights will not be
being made whole; or due to attorney'
including, but not limited to, school
[1/2%] per month commencing o
,Other Party. The Company is
doctrine, which would purport to re l
fees and costs.
e Participant's own negligence; or due to the Participant not
c . The Company is secondary to any excess insurance policy,
IlelWicies. The Company has the right to recover interest at the rate of
ie Participant or his or her legal representative recovers any funds from an
o any state law doctrines, including, but not limited to, the common fund
Company to reduce its recovery by any portion of a Participant's attorney's
The Company will not pay for future Covered Charges until such Covered Charges have exceeded all amounts that were
recovered or are to be recovered by or on behalf of a Participant. If the Participant resides in a state where automobile
personal injury protection or medical payment coverage is mandatory, that coverage is primary and this Policy takes
secondary status. This Policy will reduce benefits for an amount equal to, but not less than, that state's mandatory
minimum personal injury protection or medical payment requirement.
This provision also applies to any funds recovered from any other party by or on behalf of any Dependent, the estate of
any Participant; or on behalf of any incapacitated person.
M. Conformity with State and Federal Laws. This Policy is construed and enforced in accordance with applicable state and
applicable federal law, including but not limited to, the Health Insurance Portability and Accountability Act of 1996 or the
Employee Retirement Income Security Act of 1974. In the event new state or federal laws are enacted which conflict with
current provisions of this Pblicy, the affected provisions of this Policy will be administered in accordance with the new
laws despite anything in this Policy to the contrary.
M200o 1
14
SSECTION VII: APPEAL AND GRIEVANCE PROCEDURES
A. Appeal and Grievance Program. The following levels of review are available to the Insured upon filing a Grievance:
1) Informal Review. The Insured or its designee may submit an oral complaint to the Company for Informal Review within
60 days after an event that gives rise to the Grievance. The Company must respond to the Insured or its designee in
writing within 30 days after receiving the Grievance and any additional information requested for the Informal Review. At
any time during the Informal Review, the Insured may submit a written request for the Grievance to be reviewed through
the Formal Review Process.
2) Formal Review. The Formal Review process includes a First Level, Second Level and Expedited Review Process.
a) First Level Review. The Insured or its designee, or a Provider in the event of an Adverse Determination, may submit
a written Grievance to the Company for review. The Insured will not be allowed to attend, or have a representative
attend, a First Level Review. However, the Insured may submit written material for the review. The Company must
issue a written decision to the Insured and, if applicable, to the Insured within 30 days after receiving the Grievance
and any information necessary to complete the review.
b) Second Level Review. The Second Level Review process is available when the Insured is not satisfied with the
outcome of the First Level Review. The Insured, or its designee, may attend the Second Level Review. Persons
reviewing a Second Level Grievance that involves a Utilization Review ap al or a clinical issue will include a
Provider who has appropriate expertise. The Second Level Review will be on ted within 45 days after the request
for such review is received. The Company will issue a written decision
c) Expedited Review. An Expedited Review of a Grievance may be e d lly or in writing by the Insured or its
designee. This level of review is available only in situations a t' ames for the Informal Review, First
Level Review or Second Level Review would serious] 'co z ife or health of a Participant or would
jeopardize a Participant's ability to regain maxim a Company must conduct the review and
communicate its decision within four days after rece' information to complete the review.
M20001 15