HomeMy WebLinkAboutResolution - 2014-R0388 - Transplant Insurance Coverage - AIG Benefit Solutions - 11/20/2014Resolution No. 2014-R0388
Item No. 6.15
November 20, 2014 RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the City Manager of the City of Lubbock is hereby authorized and directed
to renew for and on behalf of the City of Lubbock, transplant insurance coverage, by and
between the City of Lubbock and AIG Benefit Solutions, 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
fortes associated with said insurance coverage.
Passed by the City Council this November 20, 2014
GXZN C. ROBERTSON, MAYOR
ATTEST:
Ree a Garza, City Secretary
APP/ TO CONTENT:
Leisa Hutcheson
Director of Human Resources & Risk Management
APPR AS TO FORM:
Nflebell Satte a Irst Xssistant City Attorney
gs/ccdocsl ES.Risk Mgnst.AIG acneN Solutions
Oaob,, 31.2014
AIG Benefit Solutions
Kesollutlon tv o. Lu i 4-KUJ a 6
One MacArthur Place Suite 620, South Coast Metro, CA 92707 Tall Free: 800-634-7462
Organ Transplant (Specified Disease) Proposal
Employer: CITY OF LUBBOCK
Proposal: 137607
Producer: McQueary Henry Bowles Troy, LLP
Claims Admin,: Blue Cross and Blue Shield of Texas, a division of
Carrier: National Union Fire Insurance
Underwriter:
Josefina Panopio
Sales:
Guy Finley
Quote Date:
09107/2014
Quote Valid Until:
01101/2015 Exhibit 11A"
Effective Date:
01/01/2015
This proposal contemplates the utilization or the above captioned Claims Administrator. Any deviation is a material change of fact rendering (his 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 :
$300 per day, $15,000 maximum for patient and companion. Coverage includes a
separate ambulance benefit.
Experimental :
Coverage for all phases of NCI Clinical Trials
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 1 Services : Please refer to policy specimen
Rate : $ 6,08 Single
Russ Jehs
Premium: $
14.60 Family
341,614.08
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.
Vice President, Organ Transplant Product Management
No coverage of any kind Is node effective by this quote transmitted. Sales Representatives, and brokers or agents, have no autharfty to make oftoctivo coverage, or enter Into contracts on
behalf of the company. coverage will be olfoctive only after., (1) a quotation Is Issued by the company; (?) a complotod and slgnod appltcatlon and disclosure Is received by the company; (d) the
application is approved by the company; (4) *roan notico conRrming effocdvo cavorago Is Issued by the company. This proposal soporsodes all othersproviousty lssuod to you, and all othor
Proposals and Rata Quotations previously Issued to you are void.
JCOLWELL 09107/201417:05:10
AIG
Page 1 of 2
AIG Benefit Solutions
One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7462
Organ Transplant (Specified Disease) Proposal
Employer:
CITY OF LUBBOCK
Underwriter:
Josefina Panopio
Proposal:
137607
Sales:
Guy Finley
Producer:
McQueary Henry Bowles Troy, LLP
Quote Date:
09/07/2014
Claims Admin.:
Blue Cross and Blue Shield of Texas, a division of
Quote Valid Until:
01/01/2015
Carrier:
National Union Fire Insurance
Effective Date:
01/01/2015
This proposal contemplates the utilization of the above captioned Claims Administrator. Any deviation is a material change of /act rendering this proposal null and void.
Contingencies
For All Producers / Groups
• Explanation of any upcoming significant census changes (20%) within 30 days of effective date.
• Underwriting approval is required to increase the lifetime maximum.
• Proposal assumes at least 80% of the participants reside in Texas. Groups with employees in multi -state locations may be subject
to rate revision.
• Retirees are covered.
• Contract period is for 12 months from effective date.
• Our information Indicates the Licensed Agent for this quote/proposal is Travis Sartain with McQueary, Henry Bowles Troy, LLP. Only
appropriately licensed Agents can sell, solicit and negotiate insurance products with prospective AIG Benefit Solutions' customers.
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 mado ofectivo by this quoto transmitted. Solos Representatives, and brokers or agents, have no authority to make efectivo covorago, or enter Into contracts on
behalf or the company. Coverage will be ofoctivo only after. (1)s quotation Is Issued by tho company., (2) a completed and signed application and disclosuro is received by the company, (J) tho
appikatlon is approved by the company; (4) Written notico connrming ofectivo coverage Is Issued by the company. This proposal supersedes of others previously Issued to you, and all other
proposals and Rate Quotations previously Issued to you are void.
JCOLWELL 09107/2014 17:05:10 Page 2 of 2
IMPORTANT NOTICE
To obtain information or make a
complaint:
You may call AIG Benefit Solutions' 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:
C onsu merProtectio n@td i. state. tx. us
PREMIUM OR CLAIM DISPUTES
Should you have a dispute concerning
your premium or about a claim, you
should contact AIG Benefit Solutions
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 AIG Benefit Solutions
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:
Cons umerP rotection@td i. state.tx. us
DISPUTAS SOBRE PRIMAS O
RECLAMOS
Si tiene una disputa concerniente a su
prima o a un reclamo, debe
comunicarse con el AIG Benefit
Solutions primero. Si no se resuelve la
disputa, puede entonces comunicarse
con el Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA
Este aviso es solo para proposito de
informacion y no se convierte en parte o
condicion del documento adjunto.
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)
POLICYHOLDER:
POLICYHOLDER ADDRESS:
POLICY NUMBER:
Specified Disease Certificate
Organ & Tissue Transplant
City of Lubbock
1625 13th Street, Lubbock, TX 79401
949-7643
Administrative Office:
AIG Benefit Solutions
7330 Woodland Drive, Suite 250
Indianapolis, Indiana 46278
(888) 449-2377
National Union Fire Insurance Company of Pittsburgh, Pa. issues this Certificate as evidence of coverage
under the Policy issued to the Policyholder, subject to all Policy provisions. The Policy may be amended,
changed, cancelled or discontinued without the consent of any Participant.
THIS IS GROUP SPECIFIED DISEASE COVERAGE AND IS NOT INTENDED TO BE A MAJOR MEDICAL
HEALTH PLAN. THIS COVERAGE IS INTENDED TO QUALIFY AS AN "EXCEPTED BENEFIT"
UNDER FEDERAL AND STATE LAW.
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOTA POLICY OF WORKER'S
COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER
YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKER'S COMPENSATION SYSTEM.
PLEASE READ THIS CERTIFICATE CAREFULLY FOR A FULL DESCRIPTION
OF THE BENEFITS, EXCLUSIONS, AND LIMITATIONS.
This Policy is signed for the Company by its President and Secretary.
President
S D O T-2014 -CERT-TX- E R
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& ot
Secretary
TABLE OF CONTENTS
PROVISION
PAGE
SCHEDULEOF BENEFITS.........................................................................................................................................3
BENEFITPROVISIONS..............................................................................................................................................6
INSURING AGREEMENT.....................................................................................................................................6
NOTIFICATION REQUIREMENTS.......................................................................................................................6
COVERED TRANSPLANT SERVICES.................................................................................................................6
PRE-EXISTING CONDITION LIMITATION...........................................................................................................8
MULTIPLE TRANSPLANTS..................................................................................................................................9
NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES.............................................................9
TRANSPLANTNURSE ADVISOR........................................................................................................................9
TRAVEL, LODGING, AND MEALS BENEFIT.....................................................................................................10
AMBULANCE BENEFIT......................................................................................................................................10
DISABILITY, LEAVE OF ABSENCE, OR LAYOFF.............................................................................................10
CLAIMSPROVISIONS..............................................................................................................................................11
APPEAL AND GRIEVANCE PROCEDURES............................................................................................................12
.
COORDINATION OF BENEFITS..............................................................................................................................13
EXCLUSIONS............................................................................................................................................................17
RIGHT TO AMEND RATES AND POLICY TERMS..................................................................................................19
TERMINATIONPROVISIONS...................................................................................................................................19
GENERALPROVISIONS..........................................................................................................................................20
DEFINITIONS............................................................................................................................................................
22
APPENDIX — COVERED SPECIFIED DISEASES....................................................................................................27
SDOT-2014-CERT-TX-ER 2 of 28
SCHEDULE OF BENEFITS
POLICY YEAR: January 1, 2014 through December 31, 2014
COVERED TRANSPLANTS: The following transplant procedures are covered as long as the transplant is
the result of one of the Covered Specified Diseases set forth in the Appendix.
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)
® Cord Blood
Including High Dose Chemo
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, if applicable;
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.
S D OT -2 014 -CERT -TX- E R
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SCHEDULE OF BENEFITS
(Continued)
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.
REIMBURSEMENT AMOUNTS:
A. PARTICIPATING PROVIDER: ............ 100% of Covered Charges for Covered Transplant Services
provided through a Participating Transplant Provider.
B. NONPARTICIPATING PROVIDER:...... 80% of Covered Charges for Covered Transplant Services provided
through a Nonparticipating Transplant Provider with respect to the
type of Covered Transplant Procedure performed. Benefits for
Covered Transplant Services provided through a Nonparticipating
Transplant Provider will not exceed the Maximum Amounts stated
below:
COVERED TRANSPLANT PROCEDURE
MAXIMUM BENEFIT FOR ALL
COVERED TRANSPLANT
SERVICES PROVIDED BY A
NONPARTICIPATING
TRANSPLANT PROVIDER
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
Including 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.
SDOT-2014-CERT-TX-ER
4 of 28
SCHEDULE OF BENEFITS
(Continued)
ENDORSEMENTS: Yes ® No ❑
If yes, please specify:
Endorsement OFAC-1
POLICYHOLDER'S MEDICAL PLAN ADMINISTRATOR:
Blue Cross and Blue Shield of Texas, a division of Health Care Service Corp
SOOT -2014 -CERT -TX -ER 5 of 28
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 by a Transplant Provider that are directly related to a Covered
Transplant Procedure resulting from one of the Covered Specified Diseases set forth in the Appendix.
NOTIFICATION REQUIREMENTS FOR TRANSPLANTS AND POTENTIAL TRANSPLANTS:
We must be notified as soon as possible by you, the Policyholder, the Policyholder's Medical Plan
Administrator, 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 to the
Transplant Provider and services are rendered for any Transplant Consultation and/or Initial Transplant
Evaluation. Failure to provide this notification may result in benefits being paid at the Nonparticipating
Provider level. Notifications must be submitted to:
AIG Benefit Solutions
7330 Woodland Drive, Suite 250
Indianapolis, Indiana 46278
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 by a Transplant Provider, 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.
Initial Transolant Evaluation. Initial Transplant Evaluation means screening tests, labs, x-rays, scans,
procedures (including dental evaluations, x-rays, and examinations), and consultations for you (and any
applicable living donor) to determine if you are an appropriate transplant candidate.
1. Initial Transplant Evaluation. Initial Transplant Evaluation means screening tests, labs, x-rays, scans,
procedures (including dental evaluations, x-rays, and examinations), and consultations for you (and any
applicable living donor) to determine if you are an appropriate transplant candidate.
2. Ongoing Transplant Evaluation (after you have been approved for a transplant). Ongoing Transplant
Evaluation means screening tests, labs, x-rays, scans, procedures, and consultations that occur in order
for you to meet the listing requirements according to the United Network for Organ Sharing (LINOS) for
solid organ transplantation.
SDOT-2014-CERT-TX-ER 6 of 28
BENEFIT PROVISIONS
(Continued)
3. Work -Up. Work -Up means screening tests, labs, x-rays, scans, procedures, and consultations to
determine the appropriateness for your transplantation just prior to: a) beginning High Dose
Chemotherapy to be followed by bone marrow/stem cell transplantation; or b) admission for solid organ
transplantation.
4. Clinical Trials. Clinical Trials means those services including and directly related to a Covered
Transplant Procedure associated with your participation in a clinical trial which includes coverage for all
Routine Patient Costs associated with Phases I, II, III and IV clinical trials that are federally funded or
approved by one or more of the following:
a. The National Institutes of Health, including the National Cancer Institute (NCI).
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.
e. Cooperative group or center of any of the entities described in a. through d. or the Department of
Defense or the Department of Veterans Affairs.
f. A qualified non-governmental research entity identified in the guidelines issued by the National
Institutes of Health for center support grants.
g. The Department of Energy.
h. The study or investigation is conducted under an investigational new drug application reviewed by the
Food and Drug Administration.
L The study or investigation is a drug trial that is exempt from having such an investigational new drug
application.
Clinical trial coverage is subject to either federal or state law, whichever provides the greater benefit level.
If you are not participating in a clinical trial, the proposed treatment plan, protocol, supply, service or drug
will be subject to the Experimental and/or Investigational Treatment definition. In either case, coverage
is dependent on being Medically Necessary.
5. Solid Organ 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.
6. 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. Mobilization and collection of bone marrow and/or stem cells including prescription drugs used to
mobilize stem cells; and
f. 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
g. Bone marrow/stem cell registry search expenses such as from the National Marrow Donor program
(NMDP).
7. Covered Transplant Procedure. Covered Transplant Procedure means a Medically Necessary adult or
pediatric human organ and tissue transplant: a) resulting from one of the Covered Specified Diseases set
forth in the Appendix; and b) listed as a Covered Transplant in the Schedule of Benefits that is not
Experimental and/or Investigational Treatment.
SOOT -2014 -CERT -TX -ER 7 of 28
BENEFIT PROVISIONS
(Continued)
8. 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
and includes Work -Up. Hospitalization of living solid organ donors is covered. For bone marrow/stem cell
transplants, coverage begins with the Work -Up 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.
9. Follow -Up. Follow -Up means Hospital services (inpatient and outpatient), Physician services, labs, x-
rays, procedures, and other diagnostic tests rendered by a Transplant Provider to determine the status of
the transplanted organ or tissue after discharge from a Transplant Hospitalization.
10. Complications after Transplant for Recipient. Complications after Transplant for Recipient means
services, supplies, and prescription drugs 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.
11. Acute Rehabilitation or Non -Acute Rehabilitation after Discharge from Transplant Hospitalization. We will
pay for up to a total of 15 days/visits for physical rehabilitation, whether inpatient, outpatient, or in the
home. In addition, for heart or lung transplant patients, we will pay for up to an additional 36 outpatient
cardiac and/or pulmonary rehabilitation sessions.
12. 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.
13. Durable Medical Eguipment 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.
14. 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.
SDOT-2014-CERT-TX-ER 8 of 28
BENEFIT PROVISIONS
(Continued)
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 the required prior authorization of all transplant related
services, transplant coverage determinations, access to transplant facilities, and ongoing patient support
related to transplantation during the Transplant Benefit Period. All Covered Transplant Services require pre-
authorization through your assigned Transplant Nurse Advisor. We may, in certain circumstances in our sole
discretion, provide benefits for Medically Necessary services, supplies or drugs that would otherwise be
excluded from coverage. Such services, supplies or drugs may be covered as a result of changes in standards
of care and/or emerging technology not addressed in the Policy. 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.
SDOT-2014-CERT-TX-ER 9 of 28
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; and train. 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 $300 per day per Covered Transplant
Procedure
Lodging and meals for living donor and companion Up to $300 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
$15,000 per Covered Transplant Procedure. These travel, lodging, and meal benefits are included within
and reduce our Lifetime Limit.
AMBULANCE BENEFIT:
In the event you require immediate, Medically Necessary ground or air (jet or helicopter) ambulance
transportation to a Transplant Provider for treatment related to a Covered Transplant Procedure, we will
pay the Reasonable and Customary travel expenses, as determined by us, up to the Benefit Limit specified
below, for services rendered within the United States by a licensed professional ambulance service, regularly
scheduled airline, air ambulance, or railroad. Ambulance transportation (ground or air) requires our prior
approval.
BENEFIT LIMIT: Up to $25,000 per Transplant Benefit Period.
DISABILITY, LEAVE OF ABSENCE, OR LAYOFF:
If you are not actively at work as a result of a disability, leave of absence, Family Medical Leave (as defined by
the Family Medical Leave Act of 1993), 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.
SDOT•2014-CERT-TX-ER 10 of 28
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.
SDOT-2014-CERT-TX-ER 11 of 28
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:
1. 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.
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.
SOOT -2014 -CERT -TX -ER 12 of 28
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 provide 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.
SDOT-2014-CERT-TX-ER 13 of 28
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.
SOOT -2014 -CERT -TX -ER 14 of 28
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.
SDOT-2014-CERT-TX-ER 15 of 28
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.
SDOT-2014-CERT-TX-ER 16 of 28
EXCLUSIONS
We will not pay, in whole or in part, for any of the following:
FA. Any service or supply not directly related to a Covered Transplant Procedure. This includes any service,
supply, or prescription drug rendered to monitor or treat the underlying disease and/or an unrelated disease
before or after transplant (that is not part of the actual Covered Transplant Procedure).
B. Services, supplies, and prescription drugs 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. Services, supplies and prescription drugs required to meet Transplant Provider's patient transplant listing
requirements including, but not limited to, programs for: chemical dependency; alcoholism; smoking cessation;
and weight loss.
D. Nutritional supplements including, but not limited to, full or partial oral or intravenous nutrition after discharge
from a transplant hospitalization or outpatient transplant procedure.
E. Charges for any transplant related services or supplies incurred prior to the Policy Effective Date.
F. Charges for any transplant related services or supplies related to a transplant that results from an accident or
any disease not specified in the Appendix.
G. Charges for prescription drugs incurred prior to a Covered Transplant Procedure, except for prescription
drugs used in mobilization and/or High Dose Chemotherapy that is part of a Covered Transplant Service.
H. Charges for prescription drugs incurred after discharge from a transplant hospitalization, except for
immunosuppressants, prophylactic antibiotics, prophylactic antivirals, prophylactic antifungals, and/or
prescription drugs used to treat complications directly related to a Covered Transplant Procedure.
I. Chemotherapy and/or surgery prior to beginning High Dose Chemotherapy (including bone marrow/stem cell
transplantation).
J. Services provided for the removal of a transplanted solid organ, unless the removal is provided during a
Covered Transplant Procedure.
K. Services, supplies, and/or drugs provided after: 1) a transplanted solid organ has been removed from the
transplant recipient; 2) a transplanted solid organ ceases to function; 3) disease has returned in a solid organ
or bone marrow/stem cell transplant recipient; or 4) prescription drugs, chemotherapy, radiation or other
treatment has been rendered to treat the return of disease or as a prophylactic to the return of disease.
L. 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.
M. Services and supplies for immunizations.
N. Animal organ or artificial organ transplants.
O. Charges for a stand-by Physician, unless otherwise approved by us.
P. Services of a Provider who is a member of your Immediate Family.
Q. Services, supplies, or Hospital care which we determine are not Medically Necessary for the treatment of
illness, diseased condition, or impairment, except as specifically stated as covered.
R. Custodial Care.
S. Hospice care.
T. Charges for any Experimental and/or Investigational Treatment, except as specifically stated in the Policy.
U. Charges paid or payable under Workers' Compensation.
V. 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.
W. Research studies or screening examinations.
X. Services or supplies to the extent you are not legally obligated to pay for them.
Y. Expenses incurred before the Policy Year begins or after it ends, except as stated in the Policy.
Z. Rest cures or sanitarium care.
AA. Services or supplies furnished by any Provider acting beyond the scope of such Provider's license.
BB. Any service or supply that is a Medicare Part A. Part B, or Part D liability.
CC. Services or supplies received from a dental or medical department maintained by or on behalf of the
Policyholder.
DD. Services provided by any governmental agency to the extent that you are not charged for them, unless
otherwise required by state or federal law.
EE. Services or supplies not specifically stated as covered.
SDOT-2014-CERT-TX-ER 17 of 28
EXCLUSIONS
(Continued)
FF. Telephone consultations, charges for failure to keep a scheduled visit, or charges for completing a claim form.
GG. Recreational or diversional therapy.
HH. Materials used in occupational therapy.
II. Personal hygiene and convenience items, such as air conditioners, humidifiers, hot tubs, whirlpools, or
physical exercise equipment, even if a Provider prescribes such items.
JJ. 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.
KK. 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.
LL. 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.
MM. Prescription Drugs for the treatment or prevention of a rejected organ or tissue following the end of the
Transplant Benefit Period.
NN. 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.
00. Biological and/or mechanical devices used as a bridge to transplant unless specifically included in the
Schedule of Benefits.
PP. 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.
SDOT-2014-CERT-TX-ER 18 of 28
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. The date the Policyholder requests a benefit change in the Policy.
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.)
SDOT-2014-CERT-TX-ER 19 of 28
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 effect 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.
I. 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.
SDOT-2014-CERT-TX-ER 20 of 28
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.
SDOT-2014-CERT-TX-ER 21 of 28
DEFINITIONS
A. Additional Medical Coverage — means any other insurance, other than the Medical Plan, 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
transplant: a) resulting from one of the Covered Specified Diseases set forth in the Appendix; and b) listed as a
Covered Transplant in the Schedule of Benefits that is not Experimental and/or Investigational Treatment.
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 that is, in our
sole discretion, determined 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 is subject to either:
a) A written investigational or research protocol or treatment plan; or
b) A written informed consent or protocol used by a Transplant Provider 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.
SDOT-2014-CERT-TX-ER 22 of 28
DEFINITIONS
(Continued)
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 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.
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.
N. Medically Necessary — means those prescription drugs, devices, procedures, treatments, services or supplies,
provided by a Provider, which are required for treatment of the Covered Specified Disease set forth in the
Appendix that requires the Covered Transplant, 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 by a Provider 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.
SDOT-2014-CERT-TX-ER 23 of 28
DEFINITIONS
(Continued)
O. Medicare — means the programs of. health care for the aged and disabled established by Title XVIII of the
Social Security Act of 1865, 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 evaluation or transplant may be needed
(regardless of the timeframe to transplant evaluation or 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.
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:
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. Pharmacy — means a facility licensed as a Pharmacy by the state in which it operates.
SDOT-2014-CERT-TX-ER 24 of 28
DEFINITIONS
(Continued)
d. Transplant Provider — means the following facilities:
L Nonparticipating Transplant Provider — Any Provider Facility or Provider Individual that has
not contracted with us through an applicable transplant network to provide Covered Transplant
Procedures. A Provider Facility or Provider Individual may be a Nonparticipating Transplant
Facility with respect to: (1) certain Covered Transplant Procedures; or (2) all Covered
Transplant Procedures.
ii. Participating Transplant Provider — Any Provider Facility or Provider Individual contracting
with us through an applicable transplant network to provide Covered Transplant Procedures. A
Provider Facility or Provider Individual 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. Respiratoryllnhalation 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.
X. Routine Patient Costs — means those covered Transplant Services associated with participation in a clinical
trial including and directly related to a Covered Transplant Procedure. Routine Patient Costs does not
include:
1. The investigational item, device, or service, itself,
2. Items and services that are provided solely to satisfy data collection and analysis needs and that are not
used in the direct clinical management of the patient; or
3. A service that is clearly inconsistent with widely accepted and established standards of care for a particular
diagnosis as established by us.
Y. Skilled Care — means the recognition and utilization of professional methods and procedures in the
assessment, observation, or treatment of an illness. Skilled care must be performed by or under the
supervision of Provider Individuals.
Z. Spouse — means a person recognized as the Member's spouse under the Medical Plan.
SDOT-2014-CERT-TX-ER 25 of 28
FWe,
DEFINITIONS
(Continued)
eans National Union Fire Insurance Company of Pittsburgh, Pa.
1313. You, Your — means the Participant, as defined in the Policy.
SDOT-2014-CERT-TX-ER 26 of 28
APPENDIX - COVERED SPECIFIED DISEASES
Heart - Adult or Pediatric
Congenital heart defects or disease
Cardiomyopathy
Severe coronary artery disease
Valvular disease
Intestinal — Adult
Crohn disease
Superior mesenteric artery thrombosis
Superior mesenteric vein thrombosis
Short Bowel Syndrome
Desmoid tumor
Volvulus
Pseudo-obstruction
Massive resection secondary to tumor
Radiation enteritis
Kidney — Adult
Chronic Kidney Disease
End Stage Renal Disease
Glomerulonephritis
Polycystic Kidney Disease
Renal Cell Carcinoma
Kidney/Pancreas or Pancreas — Adult or Pediatric
Insulin dependent (type 1, juvenile)
End stage renal disease
Chronic Severe Pancreatitis
Liver - Adult
Chronic active hepatitis
Primary biliary hepatitis
Schlerosing cholangitis
Cryptogenic cirrhosis
Hemochromatosis
Hepatacellular cancer
Wilson's Disease
Alpha -One trypsin deficiency
Chronic Budd-Chiari Syndrome
Alcoholic cirrhosis
Glycogen storage disease
Fulminant liver failure
S DOT -2014 -CERT -TX -ER
Heart/Lung - Adult or Pediatric
Eisenmenger syndrome
Cystic fibrosis with compromised cardiac function
Sarcoidosis involving only the heart and lungs
Irreversible right -heart failure secondary to
pulmonary hypertension
Intestinal - Pediatric
Intestinal atresia
Gastroschisis
Crohn disease
Microvillus involution disease
Necrotizing enterocolitis
Midgut Volvulus
Chronic intestinal pseudo-obstruction
Massive resection secondary to tumor
Hirschsprung disease
Short Bowel Syndrome
Kidney - Pediatric
Congenital Nephrotic Syndrome
Polycsystic Kidney Disease
Glomerulonephritis
Wilm's Tumor
Blocked urine flow and reflux
Alport Syndrome
Lupus and other autoimmune diseases
Liver - Pediatric
Biliary atresia and similar malformations
Glycogen storage disease
Familial cholestasis (Byler's Disease)
Intrahepatic bile duct paucity (Alagille's Syndrome)
Metabolic disease
Chronic active hepatitis
Alpha -One trypsin deficiency
Wilson's Disease
Tyrosinemia
27 of 28
APPENDIX - COVERED SPECIFIED DISEASES
(Continued)
Luna - Adult or Pediatric
Chronic obstructive pulmonary disease
Emphysema
Primary pulmonary fibrosis
Primary pulmonary hypertension
Cystic fibrosis
Infectious pulmonary disease with bronchiectasis
Eisenmenger's syndrome
Bronchiolitis obliterans
Multi -Organ (Other)
Combinations of disease types
Autologous Bone Marrow or Peripheral Stem Cell
Hodgkin's Lymphoma
Multiple Myeloma
Non -Hodgkin's Lymphoma
Testicular Cancer
Amyloidosis
Neuroblastoma
Allogeneic Bone Marrow or Peripheral Stem Cell (Related. Unrelated. Cord Blood)
Acute Myeloid Leukemia
Acute Lymphocytic Leukemia
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Hodgkin's Lymphoma
Non -Hodgkin's Lymphoma
Acquired Hematologic Diseases (non-malignant)
Aplastic Anemia
Fanconi's Anemia
Diamond -Back Syndrome
Severe Aplastic Anemia
Genetic and Immunodeficiency Diseases
Severe Combined Immunologic Deficiency Syndrome (SCIDS)
Thalassemia
Sickle Cell Disease
Mucopolysaccharidosis
Wiskott-Aldrich Syndrome
Niemann-Pick Disease
Osteopetrosis
Other metabolic storage diseases
Myelodysplastic/Myeloproliferative Syndromes
SOOT -2014 -CERT -TX -ER 28 of 28