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Home My WebLink AboutResolution - 2010-R0491 - Purchase Of Transplant Insurance Coverage - Medical Excess - 10/14/2010Resolution No. 2010-RO491 October 14, 2010 Item No. 5.2 z 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 Medical Excess, with first dollar coverage pursuant to the terms and conditions attached hereto as Exhibit "A," 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 October 14, 2010 TOM MARTIN, MAYOR ATTEST: ecreta APPROVED A�s TO CONTENT: l Leisa Hutcheson, Director of Human Resources Risk Management VED AS TO FORM: ttomey gs;ccdocs Medical Fxcess res 10 Resolution No. 2010-RO491 Medical Excess One MacArthur Place, Suite 620 South Coast Metro, CA 92707 Phone: (714) 436-3623 Toll Free: (800) 634-7462 Fax: (714) 436-3620 October 4, 2010 MHBT Employee Benefits 8144 Walnut Hill Lane, 16"' Floor Dallas, TX 75231 Attn: Travis L. Sartain, CBC RE: City of Lubbock Dear Travis: Our Organ & Tissue Transplant Proposal for the City of Lubbock is locked -in at the rates provided, as long as we receive written confirmation of renewal acceptance before November 1, 2010. If confirmation is received after this date, we reserve the right to revise our proposal based on information available at the time confirmation is received. Sincerely,�+-fl �f " Jim Colwell Underwriting Technician Resolution No. 2010-RO491 Medical Excess CHARTIS One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7462 Employer: CITY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 76370 Sales: Stanley Self Producer: McQueary Henry Bowles Troy, LLP Quote Date: 08/24/2010 Claims Admin.: Blue Cross and Blue Shield of Texas, a division of Quote Valid Until: 01/01/2011 Carrier: National Union Fire Insurance Effective Date: 01/01/2011 This proposal contemplates the utilization of the above captioned Claims Administrator Any deviation is a material change of fact rendering thrs proposal null and void 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 covered transplant -related costs, including organ procurement, when performed in -network. ' 80% of 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 : Pre -Ex is waived for current Participants (unless they are completing an established Pre -Ex Waiting Period). However, Participants added from the acquisition of a new group, affiliate, division, and/or subsidiary, are subject to a 12 month Pre -Ex Waiting Period that begins on the date the acquisition is covered under the Policy. A Pre -Existing Condition is any condition for which the Participant has within the past 24 months: been advised that a transplant may be necessary; had a transplant consultation, workup, or evaluation; been scheduled for a transplant consultation, workup, or evaluation; received or has been listed to receive a transplant; received dialysis treatments; or been diagnosed with Chronic Kidney Disease or End Stage Renal Disease. ' Other Coverage / Services : Rate : Please refer to policy specimen $ 6.33 Single Premium : $ 14.56 Family 320,665.59 Commission: Rates include 0% commission ' Rates and benefits are subject to state approval, and the 24 month Pre -Ex 'look -back" period may vary by state. Russ Jehs Vice President, Organ Transplant Product Management No coverage ofany kind is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter into contacts on behaffofthe company. Coverage will be effective only after. (f) a quotation Is Issued by the company; (2) a completed and signed application and disclosure Is received by the company; (J) the application Is approved by the company; (4) Written notice cont/rming effective coverage is Issued by the company. This proposal supersedes all others previously Issued to you, and all other Proposals and Rate Quotations previously Issued to you are void. JCOLWELL 08/24/2010 13:49:04 Page 1 of 2 Medical Excess Medical Excess CHARTIS This proposal contemplates the utilization of the above captioned Claims Administrator Any deviation is a material change of fact rendenng this proposal null and void Contingencies For All Producers / Groups Explanation of any upcoming significant census changes (20%) within 30 days of effective date. Contract period is for 12 months from effective date, unless otherwise stipulated. In the event that Plan participants are covered under a High Deductible Health Plan (as defined under Title 26, Subtitle A, Chapter 1, Subchapter B. Part VII. § 223 of the Internal Revenue Code), the Plan's Deductible Amount must be met prior to benefits being paid under the Organ and Tissue Transplant Policy. For Non -Select Groups: In addition to the Information requested above, please provide the following: (Attached Proposal is 'indication only' based on our Pooled Producer rates. The information requested below is to determine any variance from pooled rates in order to determine our final underwriting position) No coverage of any kind Is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter Into contracts on behalf of the company. Coverage will be effective only after. (f) a quotation is Issued by the company; (1) a completed and signed application and disclosure is received by the company; (3) the application Is approved by the company; (4) Written notice conRnning effective coverage Is Issued by the company. This proposal supersedes all others previously Issued to you, and all other proposals and Rate Quotations previously issued to you are void. Medical Excess JCOLWELL 08/24)2010 13:49:04 Page 2 of 2 One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7462 rGo Or .. Proposal Employer: CITY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 76370 Sales: Stanley Self Producer: McQueary Henry Bowles Troy, LLP Quote Date: 08/24/2010 Claims Admin.: Blue Cross and Blue Shield of Texas, a division of Quote Valid Until: 01/01/2011 Carrier: National Union Fire Insurance Effective Date: 01/01/2011 This proposal contemplates the utilization of the above captioned Claims Administrator Any deviation is a material change of fact rendenng this proposal null and void Contingencies For All Producers / Groups Explanation of any upcoming significant census changes (20%) within 30 days of effective date. Contract period is for 12 months from effective date, unless otherwise stipulated. In the event that Plan participants are covered under a High Deductible Health Plan (as defined under Title 26, Subtitle A, Chapter 1, Subchapter B. Part VII. § 223 of the Internal Revenue Code), the Plan's Deductible Amount must be met prior to benefits being paid under the Organ and Tissue Transplant Policy. For Non -Select Groups: In addition to the Information requested above, please provide the following: (Attached Proposal is 'indication only' based on our Pooled Producer rates. The information requested below is to determine any variance from pooled rates in order to determine our final underwriting position) No coverage of any kind Is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter Into contracts on behalf of the company. Coverage will be effective only after. (f) a quotation is Issued by the company; (1) a completed and signed application and disclosure is received by the company; (3) the application Is approved by the company; (4) Written notice conRnning effective coverage Is Issued by the company. This proposal supersedes all others previously Issued to you, and all other proposals and Rate Quotations previously issued to you are void. Medical Excess JCOLWELL 08/24)2010 13:49:04 Page 2 of 2 IMPORTANT NOTICE To obtain information or make a complaint: You may call Medical Excess LLC's toll free number for information or to make a complaint at: 1 (888) 449-2377 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1 (800) 252-3439 You may write the Texas Department of Insurance at: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: http//www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us PREMIUM OR CLAIM DISPUTES Should you have a dispute concerning your premium or about a claim, you should contact Medical Excess, LLC first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document. TX Notice AVISO IMPORTANTE Para obtener informacion o para someter una queja: Usted puede Ilamar al numero de telefono gratis de Medical Excess LLC para informacion o para someter una queja al: 1 (888) 449-2377 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1 (800) 252-3439 Puede escribir al Departamento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: http//www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us DISPUTAS SOBRE PRIMAS O RECLAMOS Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el Medical Excess LLC primero. Si no se resuelve la disputa, puede entonces comunicarse con el Departamento de Seguros de Texas. UNA ESTE "ISO A SU POLIZA Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. Resolution No. 2010—RO491 NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. Executive Offices: 175 Water Street, New York, NY 10038 (212) 770-7000 (a capital stock company, herein referred to as the Company) Administrative Office: Medical Excess LLC 8777 Purdue Road, #330 Indianapolis, Indiana 46268 (888) 449-2377 Organ & Tissue Transplant Policy POLICYHOLDER: City of Lubbock POLICYHOLDER ADDRESS: P.O. Box 2000, Lubbock, TX 79457 POLICY NUMBER: 280-8060 POLICY EFFECTIVE DATE: January 1,2010 POLICY ANNIVERSARY DATE: January 1 of each succeeding year PREMIUM DUE DATE: First premium payment is due on the Policy Effective Date above. Thereafter, each premium payment is due on the first day of the month. INITIAL ENROLLMENT: 2565 MINIMUM ENROLLMENT: 50 PREMIUMS PER MONTH: Single Employee $5.82 Family $13.37 $0.00 $0.00 National Union Fire Insurance Company of Pittsburgh, PA. will provide the Policy benefits to each Participant in consideration and acceptance of the Policyholder's signed Application and premium, and subject to all Policy provisions. This Policy becomes effective at 12:01 a.m. Standard Time on the Policy Effective Date shown above, and replaces any previous agreement relating to transplant services between the Policyholder and the Company. The first premium payment and all subsequent premium payments are due on the Premium Due Date shown above. THIS POLICY PROVIDES TRANSPLANT RELATED BENEFITS, ONLY. ITIS NOT INTENDED TO BE A MAJOR MEDICAL HEALTH PLAN. THIS IS NOTA POLICY OF WORKER'S COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON -SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON -SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. PLEASE READ THIS POLICY AND CERTIFICATE CAREFULLY FOR A FULL DESCRIPTION OF THE BENEFITS, EXCLUSIONS, AND LIMITATIONS. This Policy is signed for the Company by its Secretary and President. President OT -2009 -TX -ER a44.,�� #*&aUJ Secretary 1 of 28 (Rev. 3/2009) TABLE OF CONTENTS PROVISION PAGE POLICYHOLDERPROVISIONS..................................................................................................................................3 DEFINEDTERMS.................................................................................................................................................3 COVERAGE...........................................................................................................................................................3 PAYMENTOF PREMIUMS...................................................................................................................................3 GRACEPERIOD...................................................................................................................................................3 RIGHT TO AMEND RATES AND POLICY TERMS..............................................................................................3 INCONTESTABILITY.............................................................................................................................................3 REPRESENTATIONS NOT WARRANTIES..........................................................................................................3 EVIDENCE OF INSURABILITY.............................................................................................................................3 POLICYTERMINATION........................................................................................................................................4 NOTICE.................................................................................................................................................................4 LEGALACTION.....................................................................................................................................................4 INFORMATION RELEASE AND DATA CONFIDENTIALITY...............................................................................4 ENTIRECONTRACT.............................................................................................................................................4 AUDIT....................................................................................................................................................................5 CLERICALERROR...............................................................................................................................................5 CONFORMITY WITH STATUTES.........................................................................................................................5 SUBROGATION AND RIGHT OF REIMBURSEMENT........................................................................................5 SCHEDULEOF BENEFITS.........................................................................................................................................6 BENEFITPROVISIONS...............................................................................................................................................9 INSURINGAGREEMENT.....................................................................................................................................9 NOTIFICATION REQUIREMENTS.......................................................................................................................9 COVERED TRANSPLANT SERVICES.................................................................................................................9 PRE-EXISTING CONDITION LIMITATION.........................................................................................................11 MULTIPLE TRANSPLANTS................................................................................................................................11 NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES...........................................................11 TRANSPLANTNURSE ADVISOR......................................................................................................................11 TRAVEL, LODGING, AND MEALS BENEFIT.....................................................................................................12 DISABILITY, LEAVE OF ABSENCE, OR LAYOFF.............................................................................................12 CLAIMS......................................................................................................................................................................13 APPEAL AND GRIEVANCE PROCEDURES............................................................................................................14 COORDINATIONOF BENEFITS...............................................................................................................................15 EXCLUSIONS............................................................................................................................................................19 RIGHT TO AMEND RATES AND POLICY TERMS..................................................................................................21 TERMINATIONPROVISIONS...................................................................................................................................21 GENERALPROVISIONS...........................................................................................................................................22 DEFINITIONS.............................................................................................................................................................24 OT -2009 -TX -ER 2 of 28 (Rev. 3/2009) POLICYHOLDER PROVISIONS A. Defined Terms. Boldfaced terms have special meaning. Please refer to the Definitions section or Benefit Provision section of this Policy for a complete description of such terms. B. Coverage. Participants are entitled to coverage for Covered Transplant Services, subject to the terms, conditions, limitations, and exclusions set forth in this Policy as further described in Paragraph M below of this Provision. C. Payment of Premiums. All premiums must be paid by the Premium Due Date shown in the Policy Face Page. Premiums shall be remitted to us at the following address: Medical Excess LLC Dept. 2173 Los Angeles, CA 90084-2173 D. Grace Period. Unless we or the Policyholder have given written notice of cancellation, a grace period of 31 days shall apply for the payment of any premiums due (except the first premium payment which is due on the Policy Effective Date). At the end of the 31 -day grace period, we may cancel this Policy without further notice if premium has not been received. During the grace period, the contract will remain in force. Failure to pay the entire premium prior to the end of the grace period will result in cancellation. The Policyholder is liable to us for the payment of a pro rata premium for the time the Policy was in force during the Grace Period. It is possible that we may inadvertently accept premium payment from the Policyholder after the grace period has expired. This acceptance does not obligate us to reinstate this Policy. Unless this Policy is reinstated, the payment will be refunded within a reasonable time after the error is discovered E. Right To Amend Rates And Policy Terms. We may revise the premium rates or any other terms of this Policy on: 1. The date the Policyholder amends the Medical Plan. 2. The date a benefit change is made to this Policy at the Policyholder's request. 3. The date the Policyholder adds or deletes a subsidiary or affiliate. 4. The date an increase or decrease in the number of Participants exceeds 25% in any one month or 25% over any period of three consecutive months. The number of Participants will be derived from the Policyholder's monthly premium statements or any other reports obtained from the Policyholder or the Medical Plan's Administrator. 5. The date we are notified by the state in which the Policyholder is located of any state imposed tax or assessment for which we are obligated to pay. 6. The date of any change in the Policyholder's business that materially affects our risk. 7. The date it is discovered that there has been an intentional material misrepresentation or A nondisclosure of information that we could reasonably have expected to have been disclosed to us by the Policyholder or the Policyholder's Medical Plan Administrator. F. Incontestability. We may declare this Policy void back to the inception date of the Policy Year or cancel this Policy, if the Application contains an intentional material misrepresentation. However, this provision will not apply once this Policy has been continuously in effective for two years. G. Representations Not Warranties. A copy of the Application is attached to this Policy. All statements made by the Policyholder or by Participants applying for coverage will be considered representations and not warranties. No statement appearing on the Application will be used to contest the validity of the Policyholder's right to the benefits of this Policy, unless the Policyholder has been furnished a copy of the Application. H. Evidence of Insurability. We may ask the Policyholder for verification that a Participant is covered under the Policyholder's Medical Plan. OT -2009 -TX -ER 3 of 28 (Rev. 3/2009) POLICYHOLDER PROVISIONS (Continued) I. Policy Termination. This Policy may be cancelled by the Policyholder or us, for any reason, on the date specified in writing by either party, provided that the other party is notified not less than 31 calendar days in advance of the date of termination. If the Policyholder provides notice without a specified termination date, termination will be effective the first Premium Due Date following our receipt of the written notice of termination. if the Policy terminates during a Policy Year (other than a Policy Anniversary Date), coverage provided to Participants will be terminated immediately, regardless of whether a Participant is in the middle of an established Transplant Benefit Period. We may cancel this Policy if the Policyholder's enrollment drops below the Minimum Enrollment shown on the Policy Face Page. However, we must provide written notification to the Policyholder of such cancellation not less than ten (10) days in advance of the termination date. This Policy may be cancelled without notification, upon the earliest of the following dates: 1. The date the Medical Plan is discontinued. 2. The date the Policyholder's Medical Plan Administrator listed in the Schedule of Benefits is changed to an administrator that we have not authorized. 3. The date it is determined that the Policyholder's Medical Plan Administrator is not properly licensed as required by state law. 4. The date the Medical Plan is found to be in violation of federal or state law. We reserve the right to allow the Medical Plan 90 calendar days within which to achieve compliance. Failure to comply by such date will result in termination of this Policy. 5. Upon the Policy Effective Date, if the Policyholder fails to provide us (within the first 90 days of the Policy Effective Period) with requested materials or information necessary for our final review and approval of the premium rates. If this Policy is terminated under this provision, we will return the premium paid by the applicant for the current Policy Year, and we will have no liability under the terms of this Policy for the current Policy Year. 6. Upon the Premium Due Date if we do not receive premiums within the specified Grace Period. 7. The date the Policyholder becomes insolvent or files for bankruptcy, unless we and an appointed Trustee in Bankruptcy agree to continue the coverage during a period of reorganization. J. Notice. When we provide written notice to the Policyholder's last known address regarding the administration of this Policy, it is deemed to be notice to all affected parties including all Participants. The Policyholder is responsible for giving notice to Participants, if applicable. K. Legal Action. No legal action may be brought under this Policy within 60 days after we receive a claim. No action may be brought after 3 years from the date the claim is required to be furnished to us. L. Information Release and Data Confidentiality. The Policyholder and all Participants that need Covered Transplant Services must allow us access to medical information from all appropriate Providers. Such information is necessary in order for us to make proper benefit determinations. The information will not be used, disclosed, furnished, or made accessible to anyone other than our authorized employees and vendors contracted by us to carry out our obligations under this Policy. In accordance with the applicable law, we and the Policyholder agree to establish and maintain administrative, technical and physical safeguards to protect the security, confidentiality and integrity of the medical information. M. Entire Contract. This Policy (along with the Certificate) and the signed Application form the entire contract between the Policyholder and us. No amendment to this Policy shall be effective unless confirmed by a written Endorsement agreed to and issued by us. 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 us. OT -2009 -TX -ER 4 of 28 (Rev. 3/2009) POLICYHOLDER PROVISIONS (Continued) N. Audit. We shall have the right to inspect and audit all records and procedures (relating to the administration of this Policy) of the: 1) Policyholder; 2) its Medical Plan Administrator; or 3) any other organization involved in the administration or adjudication of claims. In addition, we shall have the right to require premium records, proof of eligibility, and claim payment information in a manner that meets our requirements. O. Clerical Error. A clerical error made by the Policyholder, the Policyholder's Medical Plan Administrator, or us will not void coverage that would otherwise be in force or continue coverage that would otherwise have terminated. Any clerical error in data provided to us must be corrected and promptly reported to us. We will make appropriate adjustments to premiums due and/or benefit determinations. Any refund in premium due to Policyholder error is limited to the 12 -month period prior to the date of the request for refund. P. Conformity with Statutes. Any provision of this Policy that, on the Policy Effective Date, is in conflict with the requirements of state or federal statutes or regulations (in the applicable jurisdiction) is hereby amended to conform to the minimum requirements of such statutes and regulations. Q. Right of Reimbursement. To the extent that benefits are provided or paid under the Policy, the Participant agrees that if he/she fully recovers his/her damages from a third party, then we will be reimbursed the portion of the damages recovered for the expenses incurred by the Participant that were provided or paid by us. Recovered amounts payable to us are exclusive of applicable legal fees incurred by the Participant. The following pages comprise the Certificate of Coverage delivered to the Policyholder for delivery to each Member. The Certificate of Coverage is part of this Policy. OT -2009 -TX -ER 5 of 28 (Rev. 3/2009) POLICY YEAR: COVERED TRANSPLANTS: SCHEDULE OF BENEFITS January 1, 2010 through December 31, 2010 ® Heart ® Lung/Double Lung ® Kidney (living or deceased donor) ® Pancreas ® Liver (living or deceased donor) ® Intestine TRANSPLANT BENEFIT PERIOD: ® Heart/ Lung ® Kidney/ Pancreas ® Kidney/Liver ® Liver/Intestine ® Pancreas/Intestine ® Liver/Pancreas/Intestine ❑ Other (specify): ® Autologous Bone Marrow Peripheral Stem Cell Including High Dose Chemo ® Allogeneic Bone Marrow Peripheral Stem Cell Including High Dose Chemo (related) ® Allogeneic Bone Marrow Peripheral Stem Cell Including High Dose Chemo (unrelated) The Transplant Benefit Period begins on the date of Transplant Evaluation for a Covered Transplant Procedure. The Transplant Benefit Period ends on the earliest of the following dates: 1. The end of the 365th day following the Covered Transplant Procedure; 2. The date the Participant's Lifetime Limit has been reached under the Policy or under the Medical Plan; 3. The date the Policy terminates, but only if: a. The Policyholder cancels the Policy prior to the last day of the current Policy Year; or b. The Participant's Transplant Benefit Period has begun, but such Participant has not received a Covered Transplant Procedure as of the date of termination of the Policy; or 4. The date the Participant's COBRA benefits terminate, if applicable. 5. The date established by the Non -Performance of Covered Transplant Procedures provision. If there is no Transplant Evaluation, the Transplant Benefit Period begins on the date of a Covered Transplant Procedure. For a Bone Marrow/Peripheral Stem Cell Tissue Transplant, the date the tissue is re -infused is deemed to be the date of the Covered Transplant Procedure. All benefits provided during a Transplant Benefit Period that extend beyond the Policy Year will be based on the Policy terms in effect at the start of the Transplant Benefit Period. A Transplant Benefit Period cannot begin prior to the date the Participant first becomes covered under the Policy. LIFETIME LIMIT: $1,000,000 for each Participant The following charges are included within and reduce each Participant's Lifetime Limit: 1. All benefits paid on behalf of the Participant (including covered donor charges) under the Policy and any preceding or succeeding Organ & Tissue Transplant Policy between us and the Policyholder; and 2. All benefits paid by us under the "Travel, Lodging, and Meals Benefit" provision. OT -2009 -TX -ER 6 of 28 (Rev. 3/2009) SCHEDULE OF BENEFITS (Continued) DEDUCTIBLE AMOUNT (APPLICABLE TO HIGH DEDUCTIBLE HEALTH PLANS ONL19: Although the Policy does not impose a Deductible Amount, if a Participant selects a high deductible health plan sponsored by the Policyholder, then the Deductible Amount set forth in such Policyholder's high deductible health plan must be paid by the Participant before benefits are payable under the Policy. This requirement is necessary in order for the Participant to remain eligible for the tax benefits afforded by the health savings account associated with the Policyholder's high deductible health plan. REIMBURSEMENT AMOUNTS: A. PARTICIPATING PROVIDER: ............ 100% of Covered Charges for Covered Transplant Services provided through a Participating Transplant Facility. (All Participants subject to a Deductible Amount must meet the Deductible Amount before Covered Charges are eligible for reimbursement.) B. NONPARTICIPATING PROVIDER: ...... 80% of Covered Charges for Covered Transplant Services provided through a Nonparticipating Transplant Facility with respect to the type of Covered Transplant Procedure performed. (All Participants subject to a Deductible Amount must meet the Deductible Amount before Covered Charges are eligible for reimbursement.) Benefits for Covered Transplant Services provided through a Nonparticipating Transplant Facility will not exceed the Maximum Amounts stated below: COVERED TRANSPLANT PROCEDURE MAXIMUM BENEFIT FOR ALL COVERED TRANSPLANT SERVICES PROVIDED BY A NONPARTICIPATING TRANSPLANT FACILITY Heart $437,000 Lung (Single) $261,000 Lung Double $363,000 Kidney (living or deceased donor $156,000 Pancreas $163,000 Liver(living or deceased donor $196,000 Intestine $626,000 Heart/Lung $495,000 Kidney/Pancreas $200,000 Kidney/Liver $419,000 Liver/Intestine $700,000 Pancreas/Intestine $668,000 Liver/Pancreas/Intestine $716,000 Autologous Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy $175,000 Allogeneic Bone Marrow/Peripheral Stem Cell Inc u ing High Dose Chemotherapy - related $297,000 Allogeneic Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy- unrelated $380,000 C. SECONDARY PAYOR: ..................... When benefits under the Policy are considered secondary, as determined by the Coordination of Benefits provisions, benefit payments will be based on the lesser of: a) Covered Charges; or b) the negotiated amount established between the primary payor and the Provider. OT -2009 -TX -ER 7 of 28 (Rev. 3/2009) SCHEDULE OF BENEFITS (Continued) ENDORSEMENTS: Yes ❑ No If yes, please specify: POLICYHOLDER'S MEDICAL PLAN ADMINISTRATOR: Blue Cross Blue Shield of Texas OT -2009 -TX -ER 8 of 28 (Rev. 3/2009) BENEFIT PROVISIONS Boldfaced terms have special meaning. Please refer to the Definitions section or Benefit Provision section for a complete description of such terms. INSURING AGREEMENT: Subject to all terms, conditions, limitations, and exclusions, we will pay Covered Charges incurred by you for Covered Transplant Services performed in a Transplant Facility that are directly related to a Covered Transplant Procedure. NOTIFICATION REQUIREMENTS: We must be notified as soon as possible by you, the Policyholder, or your Physician that a Covered Transplant Procedure is being considered in order for you to maximize your benefits under the Policy. Notification must occur before the referral is made and services are rendered for any Transplant Consultation and/or Transplant Evaluation. Failure to provide this notification may result in benefits being paid at the Nonparticipating Provider level. Notifications must be submitted to: Medical Excess LLC 8777 Purdue Road, #330 Indianapolis, IN 46268 Attention: Transplant Nurse Advisor (888) 449-2377 COVERED TRANSPLANT SERVICES: The following services require our prior approval in order for you to maximize your benefits, and are eligible for coverage if they are provided to you, performed within a Transplant Facility, and directly related to a Covered Transplant Procedure. Complications of donation experienced by the living donor are not covered. You will be notified of our approval no later than two (2) business days following our receipt of all required information necessary to complete a review. Adverse determinations will be issued verbally within: a. One (1) business day following our receipt of all required information necessary to complete a review for emergency care or a continued hospitalization; b. Three (3) business days following our receipt of all required information necessary to complete a review for all other appeals. We will also provide a written determination within three (3) business days following our verbal communication. 1. Transplant Consultation. Transplant Consultation means a consultation with a transplant Physician to determine if your condition is such that you qualify for further evaluation according to the Transplant Facility's established Transplant Evaluation protocol. 2. Transplant Evaluation. Transplant Evaluation means tests, labs, x-rays, scans, procedures (including dental evaluations, x-rays, and examinations), and consultations for you (and any applicable living donor) that are in compliance with the Transplant Facility's established transplant program protocol. 3. Solid Or-gan Procurement. Solid Organ Procurement means compatibility testing and procurement expenses for living and deceased donors; donor's surgical procedure to remove the organ or tissue; and inpatient and outpatient services for living donor. OT -2009 -TX -ER 9 of 28 (Rev. 3/2009) BENEFIT PROVISIONS (Continued) 4. Bone Marrow or Stem Cell Procurement. Bone Marrow or Stem Cell Procurement means expenses for: a. Procurement from you for autologous bone marrow/stem cell transplant; b. Procurement from a living donor for allogeneic bone marrow/stem cell transplant, including compatibility testing of relatives; c. Testing/typing of potential unrelated donors; d. Tests related to the procurement of bone marrow/stem cells, including human leukocyte antigen typing; e. Collection and storage (for up to 6 months) of bone marrow/stem cells (autologous or allogeneic) for future use, as long as a bone marrow/stem cell transplant has been scheduled to occur within the same 6 months; and f. Bone marrow/stem cell registry search expenses such as from the National Marrow Donor program (NMDP). 5. Covered Transplant Procedure. Covered Transplant Procedure means a Medically Necessary adult or pediatric human organ and tissue transplants listed as a Covered Transplant in the Schedule of Benefits that is not Experimental and/or Investigational Treatment. 6. Transplant Hospitalization. Transplant Hospitalization means the hospitalization for the Covered Transplant Procedure including inpatient Hospital services, Physician services and ancillary services. For solid organ transplantation, coverage begins twenty-four (24) hours prior to the transplant procedure. Hospitalization of living solid organ donors is covered. Such services must be provided according to the Transplant Facility's established transplant program protocol. For bone marrow/stem cell transplants, coverage begins with the workup immediately prior to beginning High Dose Chemotherapy to include subsequent infusion of autologous or allogeneic bone marrow/stem cells. Bone marrow/stem cell transplantation may be performed as an inpatient or outpatient. 7. Follow -Up. Follow -Up means Hospital services (inpatient and outpatient), Physician services, labs, x- rays, procedures, and other diagnostic tests rendered by or at the Transplant Facility to determine the status of the transplanted organ or tissue after discharge from a Transplant Hospitalization. Such services must be provided according to the Transplant Facility's established transplant program follow-up guidelines or protocol. 8. Complications after Transplant for Recipient. Complications after Transplant for Recipient means services to treat complications experienced by the transplant recipient after transplant, such as: a. Rejection of a solid organ; b. Surgical complications; and c. Graft versus host disease of transplanted bone marrow or stem cells. Services may be rendered during the Transplant Hospitalization or after discharge from Transplant Hospitalization. 9. Acute Rehabilitation or Non -Acute Rehabilitation after Discharge from Transplant Hospitalization. We will pay for up to a total of 15 days/visits for home rehabilitation and physical therapy (inpatient or outpatient). 10. Home Health Care after Discharge from Transplant Hospitalization. We will pay for up to a total 15 home health care visits by a registered nurse to administer intravenous drugs, train the patient (and/or family) for self -administration of drugs, wound care, or similar procedures. 11. Durable Medical Equipment after Discharge from Transplant Hospitalization. We will pay for rental of durable medical equipment after discharge from the Transplant Hospitalization. This benefit is limited to the lesser of a total 15 days of rental or the purchase price of such equipment. OT -2009 -TX -ER 10 of 28 (Rev. 3/2009) BENEFIT PROVISIONS (Continued) 12. Prescription Drugs. We will pay for immunosuppressants, prophylactic antibiotics, prophylactic antivirals and prophylactic antifungals that are Medically Necessary after discharge from the Transplant Hospitalization for up to 365 days after the date of transplantation. Drugs used to treat conditions not directly related to the Covered Transplant Procedure are not covered. PRE-EXISTING CONDITION LIMITATION: If you have a Pre-existing Condition on the Policy Effective Date (referred to in the Renewal Endorsement as the Original Policy Effective Date), you are not eligible for benefits under the Policy for the first 12 months that the Policy is in force. The Pre-existing Condition Limitation does not apply if you become eligible for coverage after the Policy Effective Date (or Original Policy Effective Date, if applicable), unless you are added to the Medical Plan as a result of the Policyholder acquiring a new group, affiliate, division, and/or subsidiary. If you receive a transplant during the time that the Pre -Existing Condition Limitation applies to you, that transplant and all related charges are excluded from coverage under the Policy. MULTIPLE TRANSPLANTS: If you require more than one Covered Transplant Procedure, benefits are determined as follows: 1. Covered Transplant Procedures that are due to related causes are subject to the same Transplant Benefit Period established by the first Covered Transplant Procedure. However, if the related Covered Transplant Procedures are separate by at least 90 days, a separate Transplant Benefit Period will be established for each procedure. 2. Covered Transplant Procedures that are due to unrelated causes will each have their own Transplant Benefit Period. 3. In no event will benefits provided under the Policy exceed the Participant's Lifetime Limit shown in the Schedule of Benefits, regardless of the number of Covered Transplant Procedures performed. NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES: If you have established a Transplant Benefit Period, but the Covered Transplant Procedure is not performed as scheduled due to your medical condition or death, benefits will be paid for Covered Transplant Services up to and until the earlier of: 1. Your death; or 2. The date your Physician decides not to perform the Covered Transplant Procedure. TRANSPLANT NURSE ADVISOR: We will assign a transplant nurse advisor to facilitate transplant coverage determination, access to transplant facilities, and ongoing patient support related to transplantation during the Transplant Benefit Period. These services are included without any additional charge. OT -2009 -TX -ER 11 of 28 (Rev. 3/2009) BENEFIT PROVISIONS (Continued) TRAVEL, LODGING, AND MEALS BENEFIT: Your Benefit. We will reimburse reasonable and necessary travel expenses, as determined by us, incurred by you and one companion (two companions if you are a minor) during a Transplant Benefit Period for travel related to a Covered Transplant Procedure. Travel expenses include transportation, lodging, and meals and are subject to the limits shown below. Living Donor Benefit. We will reimburse reasonable and necessary travel expenses, as determined by us, incurred by a living donor and one companion during a Transplant Benefit Period for travel related to a Covered Transplant Procedure. Travel expenses include transportation, lodging, and meals and are subject to limits shown below. Transportation includes: automobile; boat; airplane; train; ground ambulance; and air ambulance (jet or helicopter). Ambulance transportation (ground and air) requires our prior approval. Automobile mileage reimbursement is based on current federal guidelines for mileage reimbursement. Reimbursement for travel expenses will only be provided once we have received itemized receipts and a completed Travel Expense Form (as supplied by us). DESCRIPTION BENEFIT LIMIT Lodging and meals for you and companion(s) Up to $200 per day per Covered Transplant Procedure Lodging and meals for living donor and companion Up to $200 per day per Covered Transplant Procedure The Maximum Travel Benefit for all eligible travel expenses (transportation, lodging, and meals) incurred by you, a living donor, and all eligible companions are limited to a combined Maximum Travel Benefit of $10,000 per Covered Transplant Procedure. These travel, lodging, and meal benefits are included within and reduce our Lifetime. Limit.DISABILITY, LEAVE OF ABSENCE, OR LAYOFF: If you are not actively at work as a result of a disability, leave of absence, or layoff, eligibility for benefits provided under the Policy will only be extended to you through the earliest of: 1. The continuance period established by the underlying Medical Plan for such absences; or 2. The 12 month period immediately following the date your disability, leave of absence or layoff first began. This provision does not apply to Retirees covered under the Medical Plan and the Policy, or individuals continuing benefits under COBRA or any other federally mandated program. OT -2009 -TX -ER 12 of 28 (Rev. 3/2009) CLAIMS PROVISIONS A. Filing Claims. The Policy provides coverage for claims that are incurred within the Policy Year and submitted for payment within twelve (12) months following the Date of Service. Unless otherwise stated in the Policy, claims will not be considered for payments if received after twelve (12) months following the Date of Service. Claims must be filed in a manner approved by us, and must include the following information: 1. Your name and address; 2. Your ID Number; 3. Provider's name, address, and Tax ID Number; 4. Itemized bill that includes the CPT codes or description of each charge; and 5. Diagnosis. B. Claim Payment. We will pay benefits for all Covered Charges in accordance with the terms of the Policy within 60 days after receiving all necessary information. Benefits are paid to you or to your assignee or designee. We may pay benefits directly to the Provider or to any relative we deem appropriate if a benefit is payable and you are: 1) a minor; 2) legally incapable of giving valid receipt and discharge of payment; or 3) deceased. OT -2009 -TX -ER 13 of 28 (Rev. 3/2009) APPEAL AND GRIEVANCE PROCEDURES A. Appeal Process. An appeal is a formal request for review of our determinations regarding transplant related services, including but not limited to our payment(s) and/or coverage denials. The following reviews are available to you upon filing an appeal: Standard Review. A standard review of an appeal is available on a prospective or retrospective basis and must be requested by you, your designee, or your Provider. A standard review is available in situations wherein the timeframe for the review does not jeopardize your life or health. Retrospective appeals must be submitted for consideration within 180 days of the date of our payment (if the appeal is based upon our payment) or within 180 days of the date of our denial of coverage. Prospective appeals may be submitted at any time while you are covered under the Policy. We will conduct the review and provide a written determination within thirty (30) business days after receiving all necessary information to complete the review. 2. Expedited Review for Denial of Emergency Care or Continued Hospitalization. An expedited review of an appeal is only available on a prospective basis and must be requested by you, your designee, or your Provider. An expedited review is only available if the timeframe for the review could seriously jeopardize your life or health. We will coordinate the review and communicate the determination verbally within one (1) business day after receiving all necessary information to complete the review. 3. Independent Review. If requested, an appeal can be performed by an Independent Review Organization certified by the Texas Insurance Department. If you have a life-threatening condition, you are not required to exhaust the Standard Review requirements set forth, above. However, if you do not have a life- threatening condition, you must first exhaust the Standard Review requirements set forth above. The cost of an Independent Review is our responsibility. All appeals are reviewed and determined by a Peer Reviewer, including the Independent Review. Peer Reviewers are Physicians who: 1. Are clinical peers; 2. Hold an active, unrestricted license to practice medicine; 3. Are in a similar specialty as typically manages the medical condition, procedure, or treatment as the treating Physician; and 4. Are neither the individual nor a subordinate of the individual who made the original coverage determination or denial. A. B. Grievance Process. Grievances regarding our services or product may be submitted at any time during the Policy Year. A grievance or complaint is an expression of dissatisfaction regarding our products or services. You or your designee may submit a grievance verbally or in writing. Depending on the nature of the grievance and whether or not a response is requested, we will respond verbally and/or in writing within thirty (30) business days following receipt of the grievance. Grievances will be considered when measuring the quality and effectiveness of our products and services. OT -2009 -TX -ER 14 of 28 (Rev. 3/2009) COORDINATION OF BENEFITS A. APPLICABILITY This Coordination of Benefits (COB) provision applies to this plan when a Participant has medical coverage under more than one plan. The terms "plan" and "this plan" are defined below. If this COB provision applies, the "Order of Benefit Determination Rules" should be reviewed first. Those rules determine whether the benefits of this plan are determined before or after those of another plan. The benefits of this plan: 1. Shall not be reduced when this plan determines its benefits before another plan; but 2. May be reduced when another plan determines its benefits first. B. DEFINITIONS For purposes of this provision, the following terms apply: Plan. The term "plan" is any of these which provides benefits or services for, or because of, medical or dental care or treatment: 1. Group insurance or group -type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident -type coverage. It does not include the Policyholder's underlying self-funded plan for which this contract is providing transplant benefits. 2. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended). Each contract or other arrangement for coverage under 1 or 2 is a separate plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan. This Plan. The term "this plan" shall refer to the Policy that we issued to the Policyholder. Primary Plan/Secondary Plan. The "Order of Benefit Determination Rules" state whether this plan is a primary plan or secondary plan covering the Participant. When this plan is a primary plan, its benefits are determined before those of the other plan and without considering the other plan's benefits. When this plan is a secondary plan, its benefits are determined after those of the other plan and may be reduced because of the other plan's benefits. When there are more than two plans covering the person, this plan may be a primary plan as to one or more other plans, and may be a secondary plan as to a different plan or plans. Allowable Expense. The term "allowable expense" means a necessary, reasonable and customary item of expense for health care, when the item of expense is covered at least in part by one or more plans covering the Participant for whom claim is made. The difference between the cost of a private hospital room and the cost of a semi -private hospital room is not considered an allowable expense under the above definition, unless the patient's stay in a private room is necessary either in terms of generally accepted medical practice, or as specifically defined in the plan. When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an allowable expense and a benefit paid. When benefits are reduced under a primary plan because a Participant does not comply with the plan provisions, the amount of such reduction will not be considered an allowable expense. Examples of such provisions are those related to second surgical opinions or precertification of admissions or services. OT -2009 -TX -ER 15 of 28 (Rev. 3/2009) COORDINATION OF BENEFITS (Continued) Claim Determination Period. The term "claim determination period" means a calendar year. However, it does not include any part of a year during which a Participant has no coverage under this plan, or any part of a year before the date this COB provision or a similar provision takes effect. C. ORDER OF BENEFIT DETERMINATION RULES General When there is a basis for a claim under this plan and another plan, this plan is a secondary plan which has its benefits determined after those of the other plan, unless: 1. The other plan has rules coordinating its benefits with those of this plan; and 2. Both those rules and this plan's rules require that this plan's benefits be determined before those of the other plan. Rules This plan determines its order of benefits using the first of the following rules that applies: 1. Non-Dependent/Dependent - The benefits of the plan which cover the Participant as an employee, a member, or a subscriber are determined before those of the plan that cover the Participant as a dependent; except that, if the Participant is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security and implementing regulations, Medicare is: a. Secondary to the plan covering the Participant as a dependent; and b. Primary to the plan covering the Participant as other than a dependent (e.g. a retired employee); then the benefits of the plan covering the Participant as a dependent are determined before those of the plan covering that Participant as other than a dependent. 2. Dependent Child/Parents Not Separated or Divorced - Except as stated in Rule 3 below, when this plan and another plan cover the same child as a dependent of different persons, called parents: a. The benefits of the plan of the parent whose birthday occurs earlier in a calendar year are determined before those of the plan of the parent whose birthday occurs later in that year; but b. If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the plan which covered the other parent for a shorter period of time. However, if the other plan does not include the rule described in 2(a) immediately above, but instead has a rule based on gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. 3. Dependent Child/Separated or Divorced - If two or more plans cover a Participant as a dependent child of divorced or separated parents, benefits for the child are determined in this order: a. First, the plan of the parent with custody of the child. b. Then, the plan of the spouse of the parent with custody. c. Finally, the plan of the parent not having custody of the child. OT -2009 -TX -ER 16 of 28 (Rev. 3/2009) COORDINATION OF BENEFITS (Continued) However, if the specific terms of a court decree state that one of the parents is responsible for the health care expense of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the secondary plan. This rule does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. 4. Joint Custody - If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the "Order of Benefit Determination Rules" outlined in Rule 2. 5. Active/Inactive Employee - The benefits of a plan which cover a Participant as an employee who is neither laid off nor retired are determined before those of a plan which cover that Participant as a laid off or retired employee. The same would hold true if a Participant is a dependent of a person covered as a retiree and an employee. If the other plan does not include this rule, and if, as a result, the plans do not agree on the order of benefits, this Rule 5 does not apply. 6. Continuation Coverage - If a Participant whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following shall be the order of benefit determination: a. First, the benefits of a plan covering the Participant as an employee, a member or a subscriber (or as that Participant's dependent). b. Second, the benefits under the continuation coverage. If the other plan does include this rule, and if, as a result, the plans do not agree on the order of benefits, this Rule 6 does not apply. 7. Longer/Shorter Length of Coverage - If none of the above rules determine the order of benefits, the benefits of the plan which covered an employee, a member, or a subscriber longer are determined before those of the plan which covered that Participant for the shorter term. D. EFFECT ON THE BENEFITS OF THIS PLAN When This Section Applies This section applies when this plan is the secondary plan in accordance with the "Order of Benefits Determination Rules" outlined above. In that event, the benefits of this plan may be reduced under this section. OT -2009 -TX -ER 17 of 28 (Rev. 3/2009) COORDINATION OF BENEFITS (Continued) Reduction in this Plan's Benefits The benefits of this plan will be reduced when the sum of: 1. The benefits that would be payable for the allowable expense under this plan in the absence of this COB provision; and 2. The benefits that would be payable for the allowable expense under the other plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made; exceeds the allowable expenses in a claim determination period. In that case, the benefits of this plan will be reduced so that they and the benefits payable under the other plans do not total more than the allowable expenses. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan. E. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION Certain facts are needed to apply these COB rules. We may get material facts from each person claiming benefits and also gather material facts from, or give them to, any other insurance company or health benefit plan administrator with whom we coordinate benefits. F. FACILITY OF PAYMENT A payment made under another plan may include an amount which should have been paid under this plan. If it does, we may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under this plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services. If the amount of the payments made by us is more than we should have paid under this COB provision, we may recover the excess from one or more of: 1. The persons we have paid or for whom we have paid; 2. Insurance companies; or 3. Other organizations. The "amount of the payments made" include the reasonable cash value of any benefits provided in the form of services. OT -2009 -TX -ER 18 of 28 (Rev. 3/2009) EXCLUSIONS We will not pay, in whole or in part, for any of the following: A. Any service or supply not directly related to a Covered Transplant Procedure. This includes any service or supply rendered to treat the underlying disease before or after transplant (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 us to be the immediate and direct result of a Covered Transplant Procedure. C. Charges for any transplant related services or supplies incurred prior to the Policy Effective Date. D. Charges for prescription drugs incurred prior to a Covered Transplant Procedure, except for High Dose Chemotherapy that is part of a Covered Transplant Service. E. Charges for prescription drugs incurred after discharge from a transplant hospitalization, except for immunosuppressants, prophylactic antibiotics, prophylactic antivirals and prophylactic antifungals. F. Chemotherapy and/or surgery prior to beginning High Dose Chemotherapy (including bone marrow/stem cell transplantation). G. Services provided for the removal of a transplanted solid organ, unless the removal is provided during a Covered Transplant Procedure. H. Services provided after: 1) a transplanted solid organ has been removed from the transplant recipient; or 2) disease has returned in a bone marrow or stem cell transplant recipient. I. Services for human leukocyte antigen typing of you or your relatives, compatibility testing, unrelated bone marrow/stem cell searches on registries, and harvest and/or storage of bone marrow/stem cells when bone marrow/stem cell transplant has not been reviewed and approved by us. J. Services and supplies for immunizations. K. Animal organ or artificial organ transplants. L. Charges for a stand-by Physician, unless otherwise approved by us. M. Services of a Provider who is a member of your Immediate Family. N. Services, supplies, or Hospital care which we determine are not Medically Necessary for the treatment of illness, injury, diseased condition, or impairment, except as specifically stated as covered. O. Custodial Care. P. Hospice care. Q. Charges for any Experimental and/or Investigational Treatment, except as specifically stated in the Policy. R. Charges paid or payable under Workers' Compensation. S. Preventive or routine care (including physicals, premarital examinations, any other routine or periodic examinations), dental services and supplies, education and training, except as specifically stated as covered. T. Research studies or screening examinations. U. Treatment of any illness or injury sustained as a result of an act of war. V. Services or supplies to the extent you are not legally obligated to pay for them. W. Expenses incurred before the Policy Year begins or after it ends, except as stated in the Policy. X. Rest cures or sanitarium care. Y. Services or supplies furnished by any Provider acting beyond the scope of such Provider's license. Z. Any service or supply that is a Medicare Part A or Part B liability. AA. Services or supplies received from a dental or medical department maintained by or on behalf of the Policyholder. BB. Services provided by any governmental agency to the extent that you are not charged for them, unless otherwise required by state or federal law. CC. Services or supplies not specifically stated as covered. DD. Telephone consultations, charges for failure to keep a scheduled visit, or charges for completing a claim form. EE. Recreational or diversional therapy. FF. Materials used in occupational therapy. GG. Personal hygiene and convenience items, such as air conditioners, humidifiers, hot tubs, whirlpools, or physical exercise equipment, even if a Provider prescribes such items. HH. 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. OT -2009 -TX -ER 19 of 28 (Rev. 3/2009) EXCLUSIONS (Continued) II. Services and supplies for treatment of complications or diseases incurred by a living donor, including, but not limited to, increase length of hospitalization or the costs to treat any complication or disease. JJ. Services and supplies incurred by any COBRA continuee whose COBRA continuation coverage was not offered and/or elected, and premiums were not paid, within the time frames required by COBRA. KK. Prescription Drugs for the treatment or prevention of a rejected organ or tissue following the end of the Transplant Benefit Period. LL. Services and supplies of any Provider located outside the United States of America, except for organ or tissue procurement services, unless otherwise prohibited by United States federal law. MM. Biological and/or mechanical devices used as a bridge to transplant unless specifically included in the Schedule of Benefits. NN. Charges for any transplant -related services or supplies incurred during the current Policy Year when the transplant procedure occurred prior to the Policy Effective Date. However, we will make an exception to this Exclusion for Covered Charges related to a Covered Transplant Procedure you received under a previous Organ & Tissue Transplant Policy issued by us to the Policyholder, as long as: 1. There has been no break in coverage between the Transplant Policies issued by us; and 2. The Covered Charges are for services or supplies incurred within the Transplant Benefit Period for the Covered Transplant Procedure. We may, in certain circumstances for purposes of overall cost savings or efficiency and in our sole discretion, provide benefits for services that would otherwise be excluded from coverage. If we provide any benefit not covered under the Policy, this fact shall not be used against us in any similar case and we shall not be required to extend this benefit to any other Participant. OT -2009 -TX -ER 20 of 28 (Rev. 3/2009) RIGHT TO AMEND RATES AND POLICY TERMS We may revise the premium rates or any other terms of the Policy on the occurrence of any of the following: A. The date the Policyholder amends the Medical Plan. B. A benefit change is made to this Policy at the Policyholder's request. C. The date the Policyholder adds or deletes a subsidiary or affiliate. D. The date an increase or decrease in the number of Participants exceeds 25% in any one month or 25% over any period of three consecutive months. The number of Participants will be derived from the Policyholder's monthly premium statements or any other reports obtained from the Policyholder or the Medical Plan's Administrator. E. The date we are notified by the state in which the Policyholder is located of any state imposed tax or assessment for which we are obligated to pay. F. The date of any change in the Policyholder's business that materially affects our risk. G. The date it is discovered that there has been an intentional material misrepresentation or a nondisclosure of information that we could reasonably have expected to have been disclosed to us by the Policyholder or the Policyholder's Medical Plan Administrator. TERMINATION PROVISIONS We may, at any time, cancel benefits under the Policy for the reasons specified in the Policy. In addition, your coverage shall automatically terminate on the earliest of the following dates: A. The date the Policy is terminated, as specified in the Policy. (The Policyholder is responsible for notifying you of the termination of the Policy.) B. The date you cease to be a covered Participant. C. The date we receive written notice from you or the Policyholder instructing us to terminate your coverage. (Coverage will terminate on the date specified in the notice, if provided.) OT -2009 -TX -ER 21 of 28 (Rev. 3/2009) GENERAL PROVISIONS A. Defined Terms. The Policy contains certain defined terms that have been capitalized. Please refer to the Definitions section of the Policy for a complete description of such terms. B. Incontestability. We may declare the Policy null or cancel it, if the Application contains an intentional material misrepresentation. However, this provision will not apply once the Policy has been in effective for two years. C. Representations Not Warranties. A copy of the Application is attached to the Policy. All statements made by the Policyholder or by Participants applying for coverage will be considered representations and not warranties. No statement appearing on the Application will be used to contest the validity of the Policyholder's right to the benefits of the Policy, unless the Policyholder has been furnished a copy of the Application. D. Evidence of Insurability. The Policyholder is required to provide us with verification that you are covered by the Policyholder's Medical Plan. E. Notice. When we provide written notice to the Policyholder's last known address regarding the administration of the Policy, it is deemed to be notice to all affected parties. The Policyholder is responsible for giving you notice, if applicable. F. Legal Action. No legal action may be brought under the Policy within 60 days after we receive a claim. No action may be brought after 3 years from the date the claim is required to be furnished to us. G. Information Release and Data Confidentiality. The Policyholder and all Participants that need Covered Transplant Services must allow us access to medical information from all appropriate Providers. Such information is necessary in order for us to make proper benefit determinations. The information will not be used, disclosed, furnished, or made accessible to anyone other than our authorized employees and vendors contracted by us to carry out our obligations under the Policy. We and the Policyholder agree to establish and maintain administrative, technical and physical safeguards to protect the security, confidentiality and integrity of the medical information. H. Entire Contract. The Policy and the signed Application form the entire contract between the Policyholder and us. No amendment to the Policy shall be effective unless confirmed by an Endorsement issued to form a part of the Policy. No agent or representative of the Company, other than an executive officer, may change the Policy or waive any of its provisions. No verbal statement by any executive officer or other employee of the Company is binding on us. 1. Clerical Error. A clerical error made by the Policyholder, the Policyholder's Medical Plan Administrator, or us will not void coverage that would otherwise be in force or continue coverage that would otherwise have terminated. Any clerical error in data provided to us must be corrected and promptly reported to us. We will make appropriate adjustments to premiums due and/or benefit determinations. Any refund in premium due to Policyholder error is limited to the 12 -month period prior to the date of the request for refund. J. Conformity with Statutes. Any provision of the Policy that, on the Policy Effective Date, is in conflict with the requirements of state or federal statutes or regulations (in the applicable jurisdiction) is hereby amended to conform to the minimum requirements of such statues and regulations. K. Not Liable for Provider Acts or Omissions. We are not responsible for the quality of care you receive from any Provider. The Policy does not give anyone any claim, right, or cause of action against us based on what a Provider of health care or supplies does or does not do. L. Right of Recovery. If we make any payment that according to the terms of the Policy should not have been made, including payment made in error, we may recover that incorrect payment from any appropriate party, whether or not it was due to our error. If the incorrect payment was made directly to you, we may deduct it when making future payments directly to you. OT -2009 -TX -ER 22 of 28 (Rev. 3/2009) GENERAL PROVISIONS (Continued) M. Right of Reimbursement. To the extent that benefits are provided or paid under the Policy the Participant agrees that if he/she fully recovers his/her damages from a third party, then we will be reimbursed the portion of the damages recovered for the expenses incurred by the Participant that were provided or paid by us. Recovered amounts payable to us are exclusive of applicable legal fees incurred by the Participant. OT -2009 -TX -ER 23 of 28 (Rev. 3/2009) DEFINITIONS A. Additional Medical Coverage — means any other insurance that provides you with medical benefits covered under the Policy. B. Application — means the Policyholder's completed Organ & Tissue Transplant Application. C. Company — means National Union Fire Insurance Company of Pittsburgh, PA. D. Covered Charges — means charges incurred during a Transplant Benefit Period that are Reasonable and Customary, in our judgment, for Covered Transplant Services. With respect to Providers, a charge will not be considered Reasonable and Customary if it is not 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 Transplant Procedure — means a Medically Necessary adult or pediatric human organ and tissue transplants listed as a Covered Transplant in the Schedule of Benefits. F. Covered Transplant Services — means the services shown as Covered Transplant Services in the Benefit Provisions. G. Custodial Care — means care and services that assist in the activities of daily living. Examples include: assistance in walking, getting in or out of bed, bathing, dressing, and using the toilet; feeding or preparation of special diets; and supervision of medication that usually can be self-administered. Custodial Care includes all homemaker services, respite care, convalescent care or extended care not requiring skilled nursing. H. Date of Service — means the date when the service was actually provided or the date on which the purchase was made. I. Diagnostic Services — means the following procedures that are directly related to a Covered Transplant Procedure and 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. J. Experimental and/or Investigational Treatment — means any drug, device, procedure, facility, equipment, treatment plan, protocol, supply or service directly related to a Covered Transplant Procedure (i) that is deemed to be experimental or investigational in nature by an appropriate technological assessment body established by any state or federal government, or (ii) where we, in our sole discretion, determine 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 Food & 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 treatment plan; or b. A written informed consent or protocol used by the Transplant Facility in which reference is made to the drug, device, procedure, protocol, or treatment plan as being experimental, investigative, educational, for a research study, a pilot 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. OT -2009 -TX -ER 24 of 28 (Rev. 3/2009) DEFINITIONS (Continued) For individuals participating or eligible to participate in clinical trials, the following will be considered Experimental and/or Investigational: 1. Clinical trials that are a single institution or investigator study. Clinical trials performed at a National Cancer Institute (NCI) designated Comprehensive Cancer Center are exempt from this requirement. 2. With regard to adult bone marrow/stem cell transplants: a. All Phase I or II clinical trials; and b. All Phase III clinical trials that are not sponsored by the NCI or similar national oncology cooperative body. 3. With regard to pediatric bone marrow/stem cell transplants: a. All Phase I-IV clinical trials that are not sponsored by the Children's Oncology Group. 4. All "off protocol" treatment wherein you are not actually enrolled in a clinical trial. Drugs, devices, procedures, facilities, equipment, treatment plans, supplies, and services that fall into the categories listed above are not considered Experimental and/or Investigational if their use is required by state law or recognized as acceptable medical practice throughout the United States to treat your illness as a result of - 1 . f:1. The positive endorsement, recommendation, or publication of standards of care by national medical bodies or panels, including but not limited to, National Comprehensive Cancer Network (NCCN), NCI, or the National Institutes of Health; or 2. Multiple published peer review articles, in recognized professional medical journal(s), concerning such drug, device, procedure or treatment plan and reflecting its reproducibility by non-affiliated sources which we determine to be authoritative; or 3. Trial results (that adequately demonstrate safety and efficacy), which indicate the drug, device, procedure, protocol, or treatment plan is at least as clinically effective and cost effective as current standard therapy; or 4. Specific state mandated coverage requirements. K. High Dose Chemotherapy — means the use of a chemotherapeutic agent or agents to treat 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. In order to be considered as an eligible expense, High Dose Chemotherapy must: 1. Be part of a protocol or treatment plan that includes the reinfusion of autologous bone marrow or stem cells, or infusion of allogeneic bone marrow or stem cells, immediately after the High Dose Chemotherapy regimen is completed; and 2. Be expected to result in effects upon the bone marrow which would likely be lethal if left untreated. All drugs and/or radiopharmaceuticals are subject to the Experimental and/or Investigational Treatment definition in the Policy. L. Immediate Family — means your spouse, parent, child, sibling, grandparent, or grandchild. M. Medical Plan — means a plan of major medical benefits maintained by the Policyholder. It includes, but is not limited to coverage provided under: group health insurance; health maintenance organizations; self-insured plans; 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. Medical Plan does not include benefits provided under a limited health care benefit plan (such as a critical illness, specified disease, or "mini-med"), nor benefits provided under a: dental; vision; outpatient prescription drug; and/or short-term disability plan. OT -2009 -TX -ER 25 of 28 (Rev. 3/2009) DEFINITIONS (Continued) N. Medically Necessary or Medical Necessity — means those drugs, devices, procedures, treatments, services or supplies, provided by a Provider, which are required for treatment of illness, injury, diseased condition, or impairment, and are: 1. consistent with your diagnosis or symptoms and you are 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 you or the Provider. 4. not an Experimental and/or Investigational 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 your 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. O. 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. P. Member — means an individual who is eligible for, and covered by, the Policyholder's Medical Plan, either as an employee, a retiree, a COBRA continuee, a member, or as a subscriber. Member does not include a dependant. Individuals that have exceeded their lifetime maximum benefit for medical benefits under the Medical Plan are not eligible for coverage under the Policy. Q. Participant — means an individual who is eligible for, and covered by, the Policyholder's Medical Plan, either as an employee, a retiree, a COBRA continuee, a Member, a subscriber, or a dependent who is also covered under the Policy. Individuals that have exceeded their lifetime maximum benefit for medical benefits under the Medical Plan are not eligible for coverage under the Policy. R. Premium Due Date — means the date the Policyholder's premium is due. The Premium Due Date is shown in the Policy Face Page. S. Policy Effective Date — means the Policy Effective Date as shown on the Policy Face Page which is the date that coverage begins under the Policy. T. Policy Year — means the period of time shown in the Schedule of Benefits during which the Policy is in effect. The Policy Year is subject to early termination as set forth in the Termination Provisions. U. Pre-existing Condition — means any condition for which you have, within the 12 months prior to the Effective Date of the Policy: 1. Been advised by an attending Physician that a transplant may be needed (regardless of the timeframe to transplant and regardless of the Participant's decision to move forward or not move forward with a Transplant Consultation or Transplant Evaluation; 2. Had a Transplant Consultation and/or Transplant Evaluation (regardless of the outcome); 3. Been scheduled to have a Transplant Consultation and/or Transplant Evaluation (regardless of when the Transplant Consultation and/or Transplant Evaluation was to be done and regardless of the outcome); and/or 4. Received, or has been listed to receive, an organ or tissue transplant. In addition, if you have, within the 12 months prior to the Policy Effective Date of the Policy, received dialysis treatments or been diagnosed with Chronic Kidney Disease or End Stage Renal Disease (ESRD), you will be deemed to have a Pre-existing Condition. OT -2009 -TX -ER 26 of 28 (Rev. 3/2009) DEFINITIONS (Continued) If you are added subsequent to the Policy Effective Date as a result of the acquisition of a new group, affiliate, division, and/or subsidiary, Pre-existing Condition will mean those conditions listed above that occurred within the 12 months prior to your effective date of coverage under the Policy. V. Provider— means any of the facilities and individuals listed below: 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. Pharmacy — means a facility licensed as a Pharmacy by the state in which it operates. d. Transplant Facility — means the following facilities: i. Nonparticipating Transplant Facility — Any Hospital that has not contracted with us 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. ii. Participating Transplant Facility — Any Hospital contracting with us 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. 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) optometrist; or (5) 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. W. Reasonable and Customary — means with respect to the word customary, the amount charged by a majority of Providers in the same geographic region for similar services or supplies and/or is relative to the value and worth of similar services; and with respect to the word reasonable, a charge that meets the above criteria and, that in our judgment, 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. Due to the lack of insurance, if a Provider accepts as full payment an amount less than Reasonable and Customary, the lesser amount will be determined to be the maximum Reasonable and Customary amount. Benefits will be based on the lesser of the actual billed charge or the Reasonable and Customary charge. OT -2009 -TX -ER 27 of 28 (Rev. 3/2009) DEFINITIONS (Continued) X. Skilled Care — means 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. Y. Spouse — means a person recognized as the Member's spouse under the Medical Plan. Z. We, Us, Our — means National Union Fire Insurance Company of Pittsburgh, PA. AA. You, Your — means the Participant, as defined in the Policy. OT -2009 -TX -ER 28 of 28 (Rev. 3/2009)