Benefits and Exemptions

Plan Benefits

This is a brief summary of benefits. Benefits are subject to the policy Limitations and Exclusions. Refer to the policy certificate, riders for complete details.

Benefit Provisions

DAILY HOSPITAL CONFINEMENT BENEFIT

The Company will pay the Daily Hospital Confinement Benefit Amount shown in the insurance certificate if an Insured Person is Hospital Confined and all of the following conditions are met:

1. The Hospital Stay is the direct result, from no other causes, of Covered Injuries sustained in a Covered Accident, or is a Covered Sickness; and
2. The Hospital Stay begins within the days shown in the Schedule of Benefits

Benefit payments will end on the first of the following dates:

1. The date the Hospital Stay ends;
2. The date the Insured Person dies;
3. The date the Maximum Benefit for this benefit is payable; or
4. The date insurance under the Policy ends.

DAILY INTENSIVE CARE UNIT BENEFIT

The Company will pay the Daily Intensive Care Unit Benefit Amount shown in the insurance certificate if the Insured Person is confined in the Intensive Care Unit of a Hospital and all of the following conditions are met:

1. The Intensive Care Unit stay is the direct result, from no other causes, of Covered Injuries sustained in a Covered Accident or a Covered Sickness; and
2. The Intensive Care Unit stay begins within the days shown in the Schedule of Benefits

Benefit payments will end on the first of the following dates:

1. The date the Intensive Care Unit stay ends;
2. The date the Insured Person dies;
3. The date the Maximum Benefit for this benefit is payable; and
4. The date insurance under the Policy ends.

This Daily Intensive Care Unit Benefit is payable in addition to any benefits payable under the Daily Hospital Confinement Benefit.

PHYSICIAN OFFICE VISIT BENEFIT

The Company will pay the Physician Office Visit Benefit Amount shown in the insurance certificate for each day that an Insured Person visits a Physician’s office for treatment, care or advice due to a Covered Injury or a Covered Sickness, up to the Maximum Benefit shown in the Schedule of Benefits.

ANNUAL PHYSICAL WELLNESS VISIT BENEFIT

The Company will pay the Annual Physical Wellness Visit Benefit Amount shown in the insurance certificate for each day that care is provided by, or supervised by, a single Physician during the course of that day that includes:

1. A history and routine physical examination;
2. X-rays and laboratory tests including, but not limited to, a Pap test, colorectal screening, prostate cancer screening, mammography and bone density screening; and
3. Immunizations for children age 4 and under up to the Maximum Benefit shown in the Schedule of Benefits.

COVERED SICKNESS EMERGENCY ROOM VISIT BENEFIT

The Company will pay the Emergency Room Visit Benefit Amount shown in the insurance certificate for each day that an Insured Person requires Hospital emergency room treatment or services for an Emergency Medical Condition caused by a Covered Sickness, up to the Maximum Benefit shown in the insurance certificate.

OUTPATIENT LABORATORY TEST AND X-RAY BENEFIT

The Company will pay the Outpatient Laboratory Test and X-ray Benefit Amount shown in the insurance certificate for each day of laboratory tests and x-rays, up to the Maximum Benefit shown in the Schedule of Benefits, if the following conditions are met.

1. The Insured Person is not confined in a Hospital; and
2. The diagnostic x-rays or laboratory tests, as shown on the Schedule of Benefits, are ordered by a Physician for Covered Injuries resulting from a Covered Accident or for a Covered Sickness, and are performed by an appropriately licensed technician.

SURGERY AND ANESTHESIA BENEFIT

The Company will pay the Surgery and Anesthesia Benefit amount shown in the Schedule of Benefits, for each day that an Insured Person is ordered by a Physician to undergo Surgery due to a Covered Injury or Covered Sickness, up to the Maximum Benefit shown in the Schedule of Benefits. If a Covered Injury or Covered Sickness requires multiple surgical procedures during the same day, the Company will pay only the Surgery Benefit Amount for that day. The Company will pay the Anesthesia Benefit Amount shown in the Schedule of Benefits for each day of the administration of anesthesia during a surgical procedure, up to the Maximum Benefit shown in the Schedule of Benefits. Outpatient laboratory tests are not covered under this benefit.

OUTPATIENT ACCIDENT MEDICAL COVERAGE

The Company will pay a maximum of $10,000 per benefit year for covered outpatient treatment resulting from an accident. There is no deductible and this benefit is subject to policy exclusions and limitations.

CRITICAL ILLNESS COVERAGE

The Company will pay a maximum of $10,000 for the diagnosis of the following: Alzheimer’s, Heart Attack; In Situ Cancer, Invasive Cancer, Kidney (Renal) Failure, Lou Gehrig’s Disease, Multiple Sclerosis, and Stroke (as is defined in the policy certificate).

Exclusions and Limitations

Inpatient Hospital Benefits

Benefits in connection with a Pre-existing Conditions occurring within the first twelve (12) months of coverage are not payable. “Pre-existing Condition” means an illness, disease, or other condition of the Covered Person, that was treated, diagnosed or required medications in the six (6) month period before the Covered Person’s coverage became effective under this Policy. This Pre-Existing Condition Limitation shall not apply after the end of the Limitation Period shown in the Schedule of Benefits, commencing on the Insured Person’s Coverage Effective Date.

In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section of the insurance certificate:

1. Intentionally self-inflicted injury, suicide or any attempt while sane or insane;
2. ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.
3. Declared or undeclared war or act of war;
4. Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;
5. An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;
6. Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency;
7. Flight in, boarding or alighting from an Aircraft except as: a fare-paying passenger on a regularly scheduled commercial or charter airline; a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;
8. Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may beused as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
9. Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;
10. Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
11. The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;
12. An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;
13. Alcoholism, drug addiction or the use of any illegal drug or narcotic except as prescribed by a Physician unless specifically provided herein;
14. Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;
15. Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
16. Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.
17. Mental and nervous disorders.
18. Elective surgery or cosmetic surgery, except for reconstructive surgery needed as the result of a Covered Injury or Covered Sickness
19. Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.
20. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
21. Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery.
22. Services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness.
23. Treatment or services provided by a private duty nurse.
24. Organ or tissue transplants and related services.
25. Personal comfort or convenience items.
26. Rest or custodial cures.
27. Hearing aids.
28. An Injury or Sickness for which the Insured Person is paid benefits under any Workers’ Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

1. Employed or retained by the Policyholder;
2. Living in the Insured Person’s household;
3. An Immediate Family Member of either the Insured Person or the Insured Person’s Spouse;
4. The Insured Person.

Outpatient Benefits

In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section:

1. Intentionally self-inflicted injury, suicide or any attempt while sane or insane;
2. ILLEGAL OCCUPATION: the insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.
3. Declared or undeclared war or act of war;
4. Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;
5. An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;
6. Flight in, boarding or alighting from an Aircraft except as a fare-paying passenger on a regularly scheduled commercial or charter airline;
7. Travel in any aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
8. Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
9. Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice unless it occurs during treatment of injuries sustained in a Covered Injury;
10. The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officers report, or similar items will be considered proof of the Insured Person’s intoxication;
11. Aggravation or re-injury of a prior injury the Insured Person suffered prior to His Coverage Effective Date, unless the Company receives a written medical release from the Insured Person’s Physician;
12. Sickness, disease or any bacterial infection, except one that results from an Accidental cut or wound, or pyogenic infections that result from Accidental ingestion of contaminated substances.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

1. employed or retained by the Policyholder;
2. living in the Insured Person’s household;
3. an Immediate Family Member of either the Insured Person or the Insured Person’s spouse;
4. the Insured Person.

Excluded Expenses

In addition to the Common Exclusions, The Company will not pay Outpatient Accident Medical Expense Benefits for any Covered Medical Expense, treatment or services resulting from or contributed to by:

1. treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances;
2. treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appendicitis;
3. osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness;
4. detached retina unless caused by a Covered Accident;
5. mental disorder or psychological or psychiatric care or treatment whether or not caused by a Covered Accident;
6. pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions;
7. mental and nervous disorders;
8. damage to or loss of dentures or bridges, or damage to existing orthodontic equipment;
9. expenses incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial disorders;
10. injury covered by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder.
11. all surgery, including cosmetic and elective surgery;
12. any elective treatment, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States;
13. eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices;
14. expenses payable by any automobile insurance policy without regard to fault;
15. conditions that are not caused by a Covered Accident; or
16. any treatment, service or supply not specifically covered by the Certificate.
17. injuries paid under medical payment coverage or no-fault coverage contained in an automobile insurance policy or liability insurance policy.

Critical Illness Benefits

Benefits under this Certificate are not payable in connection with a Pre-Existing Condition.

This Pre-Existing Condition Limitation shall not apply to a Diagnosis commencing after the earlier of:

1. the end of a continuous period of 24 months commencing on or after the Insured Person’s Coverage Effective Date, during all of which the Insured Person has received no medical advice or treatment in connection with such disease or physical condition; and
2. the end of the two year period commencing on the Insured Person’s Coverage Effective Date.

Effect of a Pre Existing condition on an Increase in Benefits

If there is an increase in an Insured Person’s benefits due to an amendment of the plan or the Insured Person’s enrollment in another option, a benefit limit will apply if the Insured Person’s Critical Illness or Critical Procedure is due to a Pre-existing Condition.

Benefits will be limited to the benefits the Insured Person had on the day before the increase if the Insured Person’s Critical Illness or Critical Procedure begins within 24 months of the date the Insured Person’s increase in benefits under the Policy becomes effective.

In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section:

1. the Insured Person’s suicide or intentional self inflicted injury or Sickness, while sane or insane;
2. the Insured Person’s being under the influence of any narcotic unless administered on the advice of a physician;
3. ILLEGAL OCCUPATION: The insurer shall not be liable for any loss which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation;
4. any illness, loss or condition specifically excluded from the definition of any Critical Illness;
5. a Critical Illness that was initially Diagnosed before the Coverage Effective Date;
6. war, whether declared or not;
7. balloon angioplasty, laser relief of an obstruction, and/or other intra-arterial procedure unless covered under this Certificate; or
8. any injury or Sickness covered under any state or federal Worker’s Compensation, Employer’s Liability law or similar law.

Frequently Asked Questions

Health Benefit Indemnity Insurance Definitions

Guide

Claims

Sometimes a provider will not submit the claim on your behalf. If this occurs, you can submit the claim yourself by followingthese steps:

1. Obtain a paid-in-full receipt from the provider that displays CPT/diagnosis code(s), date-of-service(s), amount chargedper code, and total amount paid.
2. Write a letter stating that you (the insured) should be the one reimbursed for the services provided.
3. Send a copy of your receipt and a copy of your letter to
   WEB-TPA
   PO Box 99906
   Grapevine, TX 76099
   EDI Payor ID: 75261

For claims and questions about your benefits, please call WEB-TPA at: 1-855-457-8178

For policies purchased on or before July 1st 2018:

• Administrative Concepts Inc.
• 994 Old Eagle School Rd., Ste. 1005
• Wayne, PA 19087
• EDI Payor ID: 22384

For claims and questions about your benefits, please call Administrative Concepts Inc. at: 1-877-301-5421

Preferred Provider (PPO) Network Access
First Health Network
firsthealthlbp.com