Legion Limited Medical

Health Benefit Indemnity Insurance

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Legion Limited Medical

Underwritten by: AXIS Insurance Company

A limited medical health benefit indemnity plan that can pay you a fixed benefit payment amount of money when you incur costs due to specific covered losses, due to accident or sickness, or services with doctors and hospitals. That money can help you deal with those doctor and hospital expenses or other related ones. Your Legion Limited Medical coverage is a benefit of association membership.

What is included?

Hospital Stays Benefits

This plan includes a hospital stays benefit - which means you will receive a set amount when you are confined in a hospital. The benefits are paid directly to you or your designee.

  • Inpatient Hospital Stay :$500/day
  • Maximum Benefit Days (per Plan Year): 30
  • Maximum Benefit Amount (per Plan Year): $15,000

Doctor Visits Benefits

This plan includes a doctor visit benefit - which means you will receive a set amount if you have to visit the doctor. The benefits are paid directly to you or your designee.

  • Physician Office Visit: $100/visit
  • Maximum Visits (per Plan Year): 3
  • Maximum Benefit Amount (per Plan Year): $300

Also included

Teladoc

A telemedicine solution that solves the three biggest issues in healthcare: Access, Cost, and Quality:

  • 24/7 availability
  • Available in all states

How it works

  1. Request a visit with a doctor 24 hours a day, 365 days a year, by web, phone, or mobile app. Want to see the doctor? Choose “video” as the method for your visit. Feeling camera shy? Choose “phone.” Got a busy schedule? Select a time that’s best for you by choosing “schedule” instead of “as soon as possible.” We’ll search our national network of U.S. board- certified physicians, dermatologist and therapists and pair you with a doctor licensed in your state. The doctor will review your medical records. Your medical history provides valuable information to the doctor regarding past conditions, medications, allergies as well as information about your family’s medical history.
  2. Talk to the doctor. Take as much time as you need…. there’s no limit! We lead the market with the industry’s most comprehensive suite of telehealth services. You can receive convenient, quality care from a variety of licensed healthcare professionals.
  3. If medically necessary, a prescription will be sent to the pharmacy of your choice. Receive the treatment you need in a timely, expedient manner. In addition, you have the ability to send your visit results to your primary care physician.

Just call 1-800-Teladoc and provide your Teladoc account information.

Karis360

Karis360 takes the hassle out of healthcare by helping members with questions about insurance claims, medical billing, and where to go for care:

  • Concierge services for members so they don’t have to deal with their healthcare questions and issues alone.
  • Unlimited assistance from a Personal Advisor who works directly with a member’s healthcare providers to help reduce their out-of-pocket medical bills.

Who is it for?

Legion Limited Medical is ideal for people who are looking for:

  • A wellness visit for an insured child under age 4: If you have a young child, this plan will provide an annual office visit with a $50 copay to monitor and maintain your child’s health.
  • Access to a national provider network to minimize out-of-pocket costs: First Health has access to more than 5,000 hospitals, over 90,000 ancillary facilities, and over 1 million health care professional service locations in the United States
  • Diagnostic, X-ray, and Laboratory benefits: Two days of coverage for class I and II and one day for class IV. Benefit payout is $50/day.

Benefits and Exemptions

Plan Benefits

This is a brief summary of Legion Limited Medical Plan. Benefits are subject to the policy limitations and exclusions. Refer to the policy, certificate, and riders for complete details.

Inpatient Benefits
Inpatient Daily$500 per day x 30 days
ICU (5 days)$500 per day x 5 days
Inpatient Surgery$500 per day x 2 days
Outpatient Benefits
Office Visits$100 per day x 3 days
Wellness Visit Benefits$50 per day x 1 day
Wellness Visit Baby Benefits$50 per day x 1 day
ER Sickness$100 per day x 2 days
Outpatient Surgery$500 per day x 1 day
Diagnostic, X-ray and Laboratory
Class 1: Laboratory-Blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests

Maximum number of days for laboratory tests including blood work, comprehensive metabolic panel, lipid panel, all other lab per Plan Year
$50 per day x 2 days
Class II: Radiology, Ultrasound, Mammogram, Sonogram, Angiogram$50 per day x 2 days
Class III: Imaging CT, PETNone
Class IV: Other Diagnostic tests- Endoscopy, Bronchoscopy, Colonoscopy without Biopsy, MRI$50 per day x 1 days

Exclusions and Limitations

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 be used 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.

Frequently Asked Questions

Are there any waiting periods for non-insurance Association benefits?

No. You can begin using your non-insurance benefits as soon as your payment is accepted and approved.

Are there any waiting periods for insurance benefits?

There are no waiting periods for benefits. You can begin accessing your insurance benefits once your payment is accepted and approved. However, Pre-existing Conditions are not covered for twelve (12) months after your membership’s Effective Date.

When will my association and insurance benefits start?

If you submit your application today, you can select your plan to be effective as early as 12:01am tomorrow. All coverage is subject to approval of your application and receipt of your first payment. Please refer to the plan limitations and exclusions for details.

What if I change my mind after I purchase coverage?

If for any reason you are not satisfied with your coverage and you have not filed a claim, you can cancel within 30 days of the date of the Welcome letter and we will refund any premium paid and your Limited Medical coverage will be null and void.

Do I have to use a MultiPlan provider?

Members under this plan may choose to be treated within or outside of the MultiPlan Network.MultiPlan has almost 800,000 healthcare providers under contract, an estimated 57 millionconsumers accessing the network products, and 40 million claims processed through the networks each year, giving them more of the experience and resources healthcare payers and providers need to face today’s unprecedented cost and competitive pressures. As part of your Membership plan, an arrangement has been negotiated between the Association and MultiPlan to treat individuals within the MultiPlan Network for a reduced fee over the customary fees of non-Network Providers.

How do I access/receive my fulfillment package and policy documents?

After you complete your purchase and your payment is approved, your fulfillment package, ID card, association documents, insurance certificate and any other plan documents are available to you online under your Customer Login. A copy of your Welcome letter and ID cards will arrive by mail within 7-10 business days after payment is received and approved. If you are unable to access, you can request a copy of your certificate by calling 877.353.0962.

What is Fixed Indemnity Insurance?

Fixed-indemnity insurance plans offer a cash benefit payout in case you suffer from specific illnesses or injuries covered by your policy. It is not major medical insurance, it does not include all ten of the essential health benefits of the Affordable Care Act (Obamacare) and if you do not have Obamacare, you may be subject to an additional tax.

What is first dollar coverage?

An insurance policy feature that provides coverage without a deductible. Typically, first dollar coverage exists all the way up to the full amount on the policy.

Health Benefit Indemnity Insurance Definitions

Accident

An unexpected, unforeseen occurrence that may result in bodily Injury.

Accident Medical Benefits

Defined amounts which provide lump-sum cash payments to cover expenses resulting from a medical related accident.

Accident Insurance

Supplemental medical insurance that pays a set amount when you have a covered accident to cover expenses that may be incurred.

Claim Provisions

Clauses within an insurance contract that set forth the procedure to be followed in the submission and administration of claims.

Critical Illness Benefits

Defined coverage amounts to be paid in lump-sum cash payments to cover specific life-threatening conditions, if the diagnosis occurs during the policy period.

Critical Illness Insurance

Supplemental medical insurance that pays a set amount of money to help cover bills associated with some of the most common critical illnesses that you may experience.

Emergency Room

A specified area in a Hospital which is designated for the emergency care of Sickness or Injury.

Emergency Care

Medical attention provided after the acute onset of symptoms relating to Sickness or Injury, including severe pain, which symptoms are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following: Health would be placed in serious jeopardy;
Bodily function would be seriously impaired;
or There would be serious dysfunction of a bodily organ or part.

Exclusions

Defined risks that are specifically not covered by an insurance policy or contract.

First Dollar Coverage

An insurance policy feature that provides full coverage for the entire value of a loss without a deductible or other cost sharing.

Fixed Indemnity Insurance

A fixed-dollar plan that pays a predetermined amount on a per-period or per-incident basis, regardless of the total charges incurred.

Hospital

An institution operated by law for the care and treatment of injured or sick persons; has organized facilities for diagnosis and surgery or has a contract with another hospital for these services; and has 24-hour nursing service.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care in some situations.

Hospital Inpatient Care

Care of patients whose condition requires admission to a hospital.

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

Health Benefit Indemnity Insurance

Health insurance plan that offers financial protection for commonly needed medical services, including hospital and doctor benefits. When you experience a covered medical event, health benefit indemnity insurance pays a set fee, directly to you or a provider designated by you.

Hospital Benefits

The hospital limits stated within the Hospital portion of a health benefit indemnity insurance plan.

Hospital Insurance

A plan which provides coverage for hospital confinement due to illness, accidents, intensive care and recovery.

Ours: This benefit pays fixed amounts upon the diagnosis of a covered critical condition such as cancer or a heart attack.

Inpatient Care

Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

Illness

Sickness or disease of a Covered Person.

Injury

A bodily injury sustained which Is directly caused by an accident, independent of all other causes.

Intensive Care Unit

A specialized department within a Hospital that provides advanced and highly specialized care to medical or surgical patients, whose conditions are life-threatening and require comprehensive care and monitoring.

Plan Provisions

An insurance contract that defines policy details such as coverage periods, exclusions, riders, start dates, and other important information.

Preventive care

Care you receive to prevent illnesses or diseases. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy.

Supplemental Medical Insurance

Supplemental medical insurance adds a layer of protection to your medical insurance by paying a set amount when you experience an accident or critical illness covered by the plan. Supplemental medical insurance plans are designed to work as a complement to your major medical insurance (Obamacare or Short Term Health Plans) or Health Benefit Indemnity Insurance plans.

Supplemental Health Products

By including additional insurance and services, supplemental health products add value to your overall health care benefit package. Supplemental health products are designed to be purchased in addition to a major-medical health plan (such as a short term or an ACA/Obamacare health plan) or a health benefit indemnity insurance plan and are categorized in two basic types: supplemental health insurance or non insurance supplemental health products.

Guide

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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
    P.O. 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

Customer Service and Billing

For customer service or billing questions please contact us at:

For simple transactions such as a payment error where you payment information needs to be updated or if you want a refund inside the “free-look period” which is 10 days in most states, this can be done in the member portal @ www.AgileHealthInsurance.com/customers

For other payment errors where you need to process a payment, you need to call Agile at (877) 353-0962 to process the payment.

Other refund requests will have to be escalated, please call (877) 353-0962 for other requests and they will be addressed on a case by case basis in accordance with each individual insurance company’s policy.

AGILE SERVICE PLEDGE

We pledge to be:

  • Responsive
  • Experts Knowledgeable in Short-Term Medical Insurance
  • Accountable
  • Transparent

Legion Limited Medical

Health Benefit Indemnity Insurance