HomeMy WebLinkAboutResolution - 2007-R0538 - Purchase Transplant Insurance Coverage - AIG Insurance Company - 11_20_2007Resolution No. 2007-RO538
November 20, 2007
Item No. 5.3
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to purchase for and on behalf of the City of Lubbock, transplant insurance
coverage, by and between the City of Lubbock and AIG Insurance Company, with first
dollar coverage pursuant to the terms and conditions attached hereto as Exhibit "A,"
within the amount budgeted for said coverage, offering the same benefits as set forth in
Exhibit "A" hereto, and in a final form and substance acceptable to the City Manager and
City Attorney; and
THAT the City Manager or designee may execute any routine documents and
forms associated with said insurance coverage.
Passed by the City Council this 20th day of November , 2007.
DAVID A. MILLER, MAYOR
ATTEST:
r
i �' becca arza, City Secretary
APPROV AS TO CONTENT:
Leisa Hutcheson, Director of Risk Manager
Transplant Proposal
Resolution No. 2007—R0538
Medical Excess
8777 Purdue Road, Suite 330
Indianapolis. IN 46268
Phone 317-876-1250
Tall Free 888-449-2377
Fax 317-472-0298
EXHIBIT "A"
Group: City of Lubbock
Producer: Wachovia Insurance Services, Inc.
Option: 1
Effective Date: January 1, 2008
Summary of Coverage
Lifetime Maximum : $1,000,000
Policy Deductible; $0
Notification / Coordination: See requirements in attached policy specimen
Transplant Benefit Period : Evaluation through 365 days post transplant
Reimbursement
* 100% of ALL covered transplant -related costs,
including organ procurement, when performed in -network
* 80% of ALL covered transplant -related costs up to
scheduled maximum amount per transplant when
performed out -of -network (see policy)
Transportation : $200 per day, $10,000 maximum for patient and
companion
Experimental : Coverage of NCI Clinical Trials Phase III and IV for
adults, all phases for pediatric
Pre -Existing Requirements : Any employee or dependent that has been
recommended, evaluated or placed in waiting for a
transplant within the past 24 months before the effective
date of this policy issue will be excluded from coverage
for a period of twelve months from time of effective date.
Other Coverage/Services : Please refer to policy specimen
Carrier: AIG Life (AM Best A++)
Rates : $ 4.68 Single
$ 10.76 Family
Premium : $216,544.8
Commission: Rates include 0% commission
Russ Jehs, VP Organ Transplant Program Management
(888) 449-2377
Russ.Jehs@aig.com
All Transplant Value Propositions, Proposals, Rates and other Indications are not final until applicatiorNdisclosures are received,
reviewed and approved.
Medical Excess
AIG LIFE
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, Indiana 46268
(888) 449-2377
CERTIFICATE
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 to and made a part of the Policy, and subject to the terms, conditions and
limitations of this Policy and Certificate, does hereby issue this Certificate to
POLICYHOLDER: City of Lubbock
POLICY/CERTIFICATE NUMBER: 280-5338
POLICY/CERTIFICATE EFFECTIVE DATE: January 1, 2006
This Certificate, as issued to the Participant, is a legal document between the Participant and the Company. The coverage
described in the Policy, along with this Certificate of Insurance, constitutes the entire agreement under which insurance is
provided. Premium is paid by the Insured. No premiums are due from the Participant.
IMPORTANT NOTICE:
THIS CERTIFICATE PROVIDES LIMITED BENEFITS AND IS NOT INTENDED TO BE A MAJOR MEDICAL
BENEFIT HEALTH PLAN.
PLEASE READ THIS CERTIFICATE CAREFULLY. It contains 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 Certificate.
IN WITNESS WHEREOF, the Company has caused the Policy and this Certificate to be signed by a duly authorized
representative of the Company
0
Secretary
President
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TABLE OF CONTENTS
SECTION 1: SCHEDULE OF BENEFITS FOR ORGAN AND TISSUE TRANSPLANT .................................................4
SECTION 11: DEFINITIONS. .......................................... ............................................................................. .......................... 6
SECTION Ill: EXCLUSIONS ................................................................................................................................................. 10
SECTION IV: TERMINATION ......................................................................................................................................... .... I I
SECTION V: GENERAL INFORMATION .................................................. . ........................................................................ I I
SECTION VI: COORDINATION OF BENEFITS ................................................................................................................. 12
SECTION Vil: APPEAL AND GRIEVANCE PROCEDURES ........................................................................................... 15
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ORGAN AND TISSUE TRANSPLANT CERTIFICATE
Declarations Page
POLICYHOLDER: City of Lubbock
POLICYHOLDER ADDRESS: 1625 131h Street Lubbock, TX 79401
POLICY/CERTIFICATE EFFECTIVE PERIOD: From January 1, 2006 Through December 31, 2006
COVERED TRANSPLANTS:
Heart
Lung
Heart/ Lung
Liver
Ventricular Assist Device
BENEFIT PERIOD:
Start Date:
Date of Evaluation
10 Days Before Transplant
Other (specify):
Kidney
Pancreas
Kidney/ Pancreas
Small Bowel
Bone Marrow/ Stem Cell
❑ Other (specify):
End Date
®365 Days After Transplant
Other (specify):
LIFETIME LIMIT: S1,000,000.00
OUT OF NETWORK REIMBURSEMENT: 80%
ENDORSEMENTS YES ❑ NO
If yes, please specify
ADMINISTRATOR OF HEALTH PLAN:
American Administrative Group
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Organ & Tissue Transplant Certificate
NOTICE
THIS CERTIFICATE 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 CERTIFICATE HAS
CERTAIN PRO VISIONSAND REQUIREMENTS UNIQUE TOIT, AND MAYBE DIFFERENTFROM OTHER POLICIES
YOU MAY HA VE PURCHASED.
PLEASE READ THE ENTIRE CERTIFICATE CAREFULLY TO DETERMINE YOUR RIGHTS AND DUTIES, AND
WHAT IS AND IS NOT COVERED. VARIOUS PROVISIONS THROUGHOUT THE POLICY/CERTIFICATE RESTRICT
OR EXCLUDE COVERAGE.
DEFINED TERMS ARE CAPITALIZED. PLEASE REFER TO SECTION II TO EXAMINE THE APPLICABLE
DEFINITIONS
SECTION l: SCHEDULE OF BENEFITS FOR ORGAN AND TISSUE TRANSPLANT
A. INSURING AGREEMENT:
Subject to the Declarations Page, the Schedule of Insurance, and all terms, conditions, definitions, provisions, limitations
and exclusions of this Certificate, this Certificate provides benefits for Covered Charges for Covered Transplant Services
that are directly related to Covered Transplant Procedures performed on a Participant within a Transplant Facility.
B. NOTIFICATION:
The Company or its designee must be notified in a manner designated by the Company when a Participant's Physician
advises a Participant that a Covered Transplant Procedure is being considered, and before referral is made. Failure to
notify the Company in the designated manner may result in the decrease or denial of benefits. The Company's designee
shall be Medical Excess, LLC, 8777 Purdue Road, #330, Indianapolis, Indiana 46268, (888) 449-2377.
C. TRANSPLANT BENEFIT PERIOD:
The Transplant Benefit Period for a Participant 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/Certificate Effective Date or prior to the Participant's first day of coverage under this
Certificate if the Participant first becomes covered after the Policy/Certificate Effective Date.
Benefits for a Participant continue beyond the Policy/Certificate Expiration Date only if the Participant:
a. has established a Transplant Benefit Period prior to the Policy/Certificate Expiration Date, and
b. has undergone transplantation prior to the Policy/Certificate 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/Certificate 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.
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2. Nonpart'tcipatimd Transplant Facili . 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.
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
E. LIFETIME LIMIT:
The maximum dollar amount the Company will pay for any Participant under this Certificate (and any preceding or
succeeding Organ and Tissue Transplant Certificate between the Insured and the Company) is the Lifetime Limit as shown
on the Declarations Page. The limit shown for transportation costs under Section II.G.e. is included in and accrues toward
this Lifetime Limit.
F. NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES:
If a Covered Transplant Procedure is not performed as scheduled due to the Intended Recipient's medical condition or the
Intended Recipient's death, benefits will be paid for Covered Transplant Services up to and until the earlier of:
1. the Intended Recipient's death; or
2. the date the decision is made by the Intended 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.
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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.
SECTION II: 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 Period.
F. Covered Transplant Procedures — means the following Medically Necessary adult and pediatric human organ and tissue
transplants:
(a) Bone marrow/peripheral stem cell
Including High Dose Chemotherapy
(b) Heart
(c) Heart/Lung
(d) Lung (g) Kidney/Pancreas
(e) Liver (h) Small Bowel
(f) Pancreas (i) Kidney
G. Covered Transplant Services — means the following services when provided to a Participant, performed within a
transplant facility, and which are directly related to a Covered Transplant Procedure:
a. Inpatient and outpatient hospital services.
b. Services of a Physician for diagnosis, treatment, and surgery.
c. Diagnostic Services.
d. Procurement of an organ or tissue, including services provided to a living donor of an organ or tissue for
procurement of an organ or tissue, compatibility testing, procurement expenses, donor's surgical procedure to
remove the organ or tissue, and inpatient and outpatient services.
e. Reasonable and necessary transportation costs, as determined 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 S200.00 per day for lodging and meals per Covered Transplant Procedure and
S 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.
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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.
I. Home health care.
H. Custodial Care -- Care that is not Skilled Care.
1. Dependent -- means the following persons covered under the Insured'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; or (iii) unmarried adopted children of 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 the Policy/Certificate 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 determine a definite condition or disease: (i)
radiology, ultrasound, and nuclear medicine; (ii) laboratory and pathology; and (iii) EKGs, EEGs, and other electronic
diagnostic medical procedures.
L. Effective Date — means the date coverage begins under this Policy/Certificate.
M. Experimental Treatment — means any drug, device, procedure, facility, equipment, treatment, supply or service (i) that is
deemed to be experimental or investigational in nature by an appropriate technological assessment body established by
any state or federal govemment, or (ii) where the Company, in its sole discretion, determines that, at the time it is used,
one or more of the following conditions is present:
1. Its use requires approval by the appropriate federal or other governmental agency which has not been granted,
such as, but not limited to the Federal Drug Administration (FDA).
2. Its use is not yet recognized as acceptable medical practice throughout the United States to treat that illness or
injury; or is subject to either:
a) a written investigational or research protocol; or
b) a written informed 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
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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/stern 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.
5. 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/Participant 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/or
Participant, 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 organization, any other coverage provided
because of sponsorship by or membership in any other association, union, or similar organization, any government
program except Medicare or Medicaid, the medical payments and/or no-fault provisions of automobile insurance, and any
other group type coverage as permitted by law.
P. High Dose Chemotherapy — means the use of a chemotherapeutic agent or agents for treating, or for preventing
recurrence of, cancer or cancer -like illness, with or without irradiation, in doses which exceed the FDA approved or
commonly recognized dosage range for the drug or drugs employed, and which is expected to result in effects upon the
bone marrow which would likely be lethal if untreated.
Q. Insured — means the named Policyholder listed on the Declarations Page of this Certificate.
R. Intended Recipient — means a Participant for whom a Physician has properly authorized a Covered Transplant Procedure
but who has not yet received such Covered Transplant Procedure.
S. Limiting Age — means the end of the calendar 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:
i. 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
5. 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.
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U. Medicare — means the programs of health care for the aged and disabled established by Title XV1I1 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.
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 the Policy/Certificate as an Eligible
Person.
X. Policy Period — means the period from the Effective Date of the Policy/Certificate to the Expiration Date or earlier
termination date, if any, of the Policy/Certificate.
Y. 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-hour nursing service by or under the
supervision of registered nurses. Surgical facilities may be either on premises or in facilities available to the
Hospital on a prearranged basis.
(c) Nonparticipating Transplant Facility — means a Hospital that has not contracted with the Company or its
designee(s) through an applicable transplant network, to provide Covered Transplant Procedures. A Hospital
may be a Nonparticipating Transplant Facility with respect to: (1) certain Covered Transplant Procedures; or (2)
all Covered Transplant Procedures.
(d) Participating Transplant Facility -- Any Hospital contracting with the Company or its designee(s) through an
applicable transplant network, to provide Covered Transplant Procedures. A Hospital may be a Participating
Transplant Facility with respect to: (1) certain Covered Transplant Procedures; or (2) all Covered Transplant
Procedures.
(e) Pharmacy — means a facility licensed as a Pharmacy by the state in which it operates.
(2) Provider Individuals — means any of the following individuals:
(a) Occupational Therapist — means a person who is licensed as an Occupational Therapist by the state in which
he or she practices. If that state 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.
Z. 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
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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 l: SCHEDULE OF
BENEFITS.
AA. 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.
BB. Spouse -- The person recognized as the Member's spouse or dependent under the group health plan, as defined above,
maintained by the Insured.
SECTION III; EXCLUSIONS
The Policy/Certificate 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 the Policy/Certificate and this
Certificate.
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.
H. Services, supplies, or Hospital care which, in the judgment of the Company's medical consultants, are not medically
necessary for the treatment of illness, injury, diseased condition, or impairment, except as specifically stated as covered.
I. Custodial care.
J. Charges for any Experimental Treatment, except as specifically stated in the Policy and this Certificate.
K. Charges paid or payable under Workers' Compensation.
L. Preventive or routine care, including physicals, premarital examinations, and 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 result of an act of war or terrorism.
O. Services or supplies to the extent Participant is not legally obligated to pay for them-
P. Expenses incurred before the Policy Period begins or after it ends, except as stated as covered.
Q. Rest cures or sanitarium care.
R. Services or supplies furnished by any Provider acting beyond the scope of such Provider's license.
S. Any service or supply that is a Medicare Part A or Part B liability.
T. Services or supplies received from a dental 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.
V. 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. The Policy and this Certificate 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.
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FF. Biological and/or Mechanical devices used as a bridge to transplant unless specifically included on the Declarations Page.
GG. Charges for any transplant -related services or supplies incurred during the Policy Period when the transplant procedure
occurred prior to the Effective Date of the Policy/Certificate, 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.
SECTION IV: TERMINATION
A. The Policy may be canceled by the Insured by returning the Policy to the Company or its designee. The Insured can also
cancel the Policy by written notice to the Company stating at what future date cancellation is to be effective. The
Company may cancel the 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 in the Policy. The Company may cancel the 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 31-day grace period, the Company may
cancel the Insured's Policy without further notice. During the grace period, the contract will remain in force; however, the
Company is not obligated to pay any claims incurred by a Participant during the grace period, until the premium due is
received. It is possible that the Company inadvertently may accept payment from the Insured after the grace period has
expired. This acceptance does not obligate the Company to reinstate the Policy. Unless the Policy is reinstated, the
payment will be refunded within a reasonable time after the mistake is discovered.
B. Incontestability. The Company may declare the Policy null or cancel it, if the Policy application contains a material
misrepresentation. However, this provision will not apply more than two years after the Policy becomes effective.
C. Representations Not Warranties. A copy of the Organ and Tissue Transplant Application is attached to the Insured's
Policy. All statements made by the Insured or by individual Participants in applying for coverage will be considered
representations rather than warranties. No statement appearing on an application will be used to contest the validity of the
Insured's right to the benefits of the Policy, unless the Insured has been furnished a copy of the application.
D. Evigence 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 not 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.
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G. Claim Payment. Company will pay benefits for all Covered Charges in accordance with the terms of the Policy and this
Certificate 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.
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 the Policy/Certificate's coverage
is payable before or after Additional Organ Transplant Coverage. The Policy and this Certificate'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 the Policy/Certificate and Additional
Organ Transplant Coverage, the Policy/Certificate is secondary if: (1) the Additional Organ Transplant Coverage does not
have rules coordinating its benefits with the Policy/Certificate; or (2) the Additional Organ Transplant Coverage's rules,
the Policy/Certificate's rules, or both, require the Policy/Certificate'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 order in which the Insured should file claims when
the Participant is covered under Additional Organ Transplant Coverage, using the first of the rules which applies:
The Additional Organ Transplant Coverage covering the Participant as a subscriber is obligated to pay before the
Policy/Certificate covering the Participant as a Dependent.
When the parents of a Dependent child are neither separated nor divorced:
a. The Insured must file first under the Policy/Certificate or Additional Organ Transplant Coverage covering
the Dependent child of the Participant whose birthday falls, earlier in the year; then file under the
Policy/Certificate or Additional Organ Transplant Coverage of the parent whose birthday falls later in the
year; but
b. if both Participants have the same birthday, the Insured must file first under the Policy/Certificate or
Additional Organ Transplant Coverage, which has covered the Participant for the longer period of time, and
then under Policy/Certificate, or Additional Organ Transplant Coverage of the other parent.
EXCEPTION: If the Additional Organ 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.
When the parents of a Dependent are separated or divorced:
a. The Insured must file first under the Policy/Certificate 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/Certificate 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/Certificate 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 Health Plan which covers the child as a Dependent of the parent with
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such financial responsibility; then
b. file under the Health 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.
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, the Policy/Certificate 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/Certificate or Additional Organ Transplant Coverage which has covered the Participant for the longer
period of time, then under the Policy/Certificate or Additional Organ Transplant Coverage which has covered the
Participant for the shorter period of time.
D. Effect on the Policy/Certificate'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/Certificates's benefits according to the Order -of -Benefit -Determination Rules. The Policy/Certificate's benefit
payments will not be affected when it is primary. However, when this Policy/Certificate 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 Company will release or obtain information
regarding a claim from any insurance company, organization, or person. Participants 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 failure to coordinate benefits. If the Company pays full
benefits on a claim for which it has only secondary liability, the Company may recover the difference from the Participant
or from any other appropriate party.
G. Information Release and Data Confidentiality. When a Participant makes a claim for benefits, the Company or its
designated contractors may need more information. The Insured must notify all Participants that by claiming benefits
under this Policy/Certificate, the Participant allows the Company to obtain information for a claim for the Participant and
Dependents. Also, the Company may furnish such information to other entities providing similar benefits. In the normal
course of business, the Company may furnish to the Insured, or to the designated contractors of both the Insured and the
Company, historical data setting forth the volume, nature, and cost of health care services paid by the Company. The
Insured agrees that all information will be treated as confidential.
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/Certificate 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.
1. Entire Contract; Amendments. This Policy and Certificate are the entire contract between the Insured and the
Company, No amendment to this Policy/Certificate shall be effective unless confirmed by an endorsement issued to form
a part of this Policy/Certificate. No agent or representative of the Company, other than an executive officer, may change
the Policy/Certificate 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 (I) 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.
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K. Right of Recovery. If the Company makes any payment that according to the terms of the Policy/Certificate 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.
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 he or she may have to take legal
action arising from the Covered Transplant Procedure to recover any sums paid under the Policy/Certificate on behalf of
the Participant), or (b) recover from the Participant or his or her legal representative any benefits paid under the
Policy/Certificate 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 the Policy/Certificate for Covered
Charges plus the amount of all future benefits which may become payable under the Policy/Certificate which result from
the Covered Transplant Services. The Company will have the right to offset or recover such benefits from the amount
received from any other party.
If the Participant, or his or her legal representative, makes any recovery from any other party and fails to reimburse the
Company for any Covered Charges then the Participant, or his or her legal representative, will be personally liable to the
Company for the Covered Charges paid under the Policy/Certificate. The Company may reduce future benefits payable
under the Policy/Certificate for any Covered Charges by the payment that the Participant or his or her legal representative
has received from any other party.
The Company's first lien rights will not be reduced due to the Participant's own negligence; or due to the Participant not
being made whole; or due to attorney's fees and costs. The Company is secondary to any excess insurance policy,
including, but not limited to, school and/or athletic policies. The Company has the right to recover interest at the rate of
1/2% per month commencing on the date the Participant or his or her legal representative recovers any funds from an
Other Party. The Company is not subject to any state law doctrines, including, but not limited to, the common fund
doctrine, which would purport to require the Company to reduce its recovery by any portion of a Participant's attorney's
fees and costs.
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/Certificate
takes secondary status. The Policy/Certificate 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/Certificate 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 Policy/Certificate, the affected provisions of this
Policy/Certificate will be administered in accordance with the new laws despite anything in this Policy/Certificate to the
contrary.
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SECTION 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 appeal or a clinical issue will include a
Provider who has appropriate expertise. The Second Level Review will be conducted within 45 days after the request
for such review is received. The Company will issue a written decision to the Insured.
c) Expedited Review. An Expedited Review of a Grievance may be requested orally or in writing by the Insured or its
designee. This level of review is available only in situations where the timeframes for the Informal Review, First
Level Review or Second Level Review would seriously jeopardize the life or health of a Participant or would
jeopardize a Participant's ability to regain maximum function. The Company must conduct the review and
communicate its decision within four days after receiving all necessary information to complete the review.
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