24-D9 - Group Medical Bridge Plan Documents Combined.pdf

ColonialLife.com

Group Hospital Indemnity Insurance Plan 1 (HSA-Compliant)

PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefit

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

We will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; (h) war, or

(i) giving birth within the first nine months after the effective date of the certificate. (j) We will not pay benefits for hospital confinement or daily hospital confinement, if included, of a newborn child following his birth unless he is injured or sick. (k) The policy may have additional exclusions and limitations which may affect any benefits payable.

PRE-EXISTING CONDITION LIMITATIONS

(l) We will not pay benefits for loss during the first 12 months after the certificate effective date due to a pre-existing condition.

(m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate effective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement and Specified Critical Illness.

This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may affect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). Coverage may vary by state and may not be available in all states. This form is not complete without form #101733.

GMB7000 – PLAN 1 | 10-19 | 101917-1

Health savings account (HSA) compatible

This plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be offered to employees who do not have HSAs.

Colonial Life & Accident Insurance Company’s Group Medical Bridge offers an HSA-compatible plan in most states.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Group Medical BridgeSM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,000 per day

Maximum of one day per covered person per calendar year

Waiver of premium Available after 30 continuous days of a covered confinement of the named insured

Daily hospital confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 per day

Maximum of 365 days per covered person per confinement. Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

For more information contact

Debi Olson at 214-686-1940

Exclusions and Limitations

STATE-SPECIFIC EXCLUSIONS

AK: (a) Replaced by intoxicants and narcotics CA: (k) Additional exclusions include intoxicants and controlled substances CT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (f) Exclusion does not apply DE: (a) Exclusion does not apply IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (f) Exclusion does not apply; (g) Exclusion does not apply KS: (a) Replaced by intoxicants and narcotics; (h) Replaced by war or armed conflict; (i) Exclusion does not apply KY: (a) Replaced by intoxicants, narcotics and hallucinogenics LA: (a) Replaced by intoxicants and narcotics MI: (g) Exclusion does not apply MO: (a) Replaced by drug addiction; (d) Replaced by illegal activities MS: (a) Replaced by intoxicants and narcotics NC: (i) Exclusion does not apply ND: (a) Exclusion does not apply; (e) Exclusion does not apply NV: (a) Exclusion does not apply OH: (f) Exclusion does not apply; (i) Replaced by 270 days PA: (a) Replaced by intoxicants and narcotics; (c) Replaced by cosmetic surgery; (e) Replaced by mental, nervous or emotional disorders; (h) Replaced by war or armed conflict SD:(a) Exclusion does not apply TN: (f) Exclusion does not apply TX: (a) Replaced by intoxicants and narcotics VA: (i) Pregnancy resulting from the rape of any covered person, which was reported to the police within seven days following its occurrence, will be covered to the same extent as any other covered accident. The seven-day requirement will be extended to 180 days in the case of an act of rape or incest of a female under 13 years of age.

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

IN, SD, and WY: (m) applies within the six months before the certificate effective date.

CA: (m) A pre-existing condition is a sickness or physical condition for which a covered person was diagnosed or treated within 12 months before the coverage effective date.

FL: (m) A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage effective date. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information.

IL: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing by a legally qualified physician or, received medical advice, produced symptoms or had taken medication within 12 months before the coverage effective date.

KS: (n) Surgical Procedure replaces Outpatient Surgical Procedure ME: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, or received medical advice within 12 months before the coverage effective date.

MI: (l) Applies during the first six months after the certificate effective date (m) applies within the six months before the certificate effective date.

MO: (m) A pre-existing condition means having a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date of this certificate.

NC: (m) A pre-existing condition is those conditions, whether diagnosed or not, for which a covered person received medical advice, diagnosis, care or treatment that was received or recommended within the one-year period immediately preceding the coverage effective date. If you are 65 or older when this certificate is issued, pre-existing conditions will include only conditions specifically eliminated by a rider.

ND: (m) A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

NV: (m) applies within the six months before the certificate effective date. Additionally, pre-existing condition does not include genetic information in the absence of a diagnosis of the condition related to such information.

OR: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated by a doctor, received advice from a physician or had taken medication prescribed by a doctor within the 12 months period immediately preceding the coverage effective date.

PA: (m) A pre-existing condition is a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage effective date. (n) Hospital Confinement Admission replaces Hospital Confinement.

CA Lic # (if applicable): _________________

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states.

The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where used, for example: GMB7000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without base form 101917 or 101918.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved.

Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GMB7000 – EXCLUSIONS AND LIMITATIONS | 11-20 | 101733-4

ColonialLife.com

Additional Plan Enhancements

The additional benefits indicated below have been added by your employer to help enrich your Group Medical BridgeSM coverage.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where used, for example: GMB7000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without a base form (101731, 101732, 101917 or 101918).

GMB7000 – ADDITIONAL PLAN ENHANCEMENTS | 11-20 | 101726-3

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Observation room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 per day

Maximum of two days per covered person per calendar year

Rehabilitation unit confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 per day

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

For more information contact

Debi Olson at 214-686-1940

Account Name:

Date:

Situs State:

By electing coverage, you confirm to have received and read the enrollment materials found in the links, including statements regarding eligibility for coverage, possible delayed effective dates, benefit provisions, costs, exclusions, limitations, terminations and benefit reductions, offsets and any required outlines of coverage and I acknowledge and agree to them and the statements below.

You consent to the electronic delivery of insurance documents, including legally required disclosure and policy documents. You have an email address and an electronic device such as a computer or a smart phone to access the internet and view and retain PDF documents. You can withdraw your consent; update your email address and request, free of charge, a paper copy of any document at any time by contacting Co lonial Life &

Accident Insurance Company.

You are actively at work at the time of enrollment and working at least 20 hours per week.

If you or any covered family members are Medicare eligible, you attest to having access to the Important Notice to Persons on Medicare document. You may also reference the official US government Medicare handbook at https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf.

Group Critical Care:

o You attest that you have not used any tobacco products (cigarettes, cigars, snuff, dip, chew, pipe) and/or any nicotine delivery system with in the last 12 months if applying for a non-tobacco policy.

o You attest that if covering a spouse and/or eligible dependents, coverage is no more than 50% of the employee’s face amount.

o The Face Amount will reduce by 50% on the certificate anniversary date after the named insured’s

75th birthday.

You attest to receipt of the following Colonial Life documents within the enrollment site:

o Colonial Life Disclosures, Limitations & Exclusions o Colonial Life Group Accident Brochure o Colonial Life Group Critical Care Brochures o Colonial Life Group Medical Bridge Brochures o Important Notice to Persons on Medicare

City of Burleson

5/18/2022

Texas

Colonial Life Disclosures, Limitations and Exclusions https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE

According to your application and the information you have furnished, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by the Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

1. Health conditions which you may presently have, may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2. Any benefits you have accrued under your present policy may not be payable or transferrable under the new policy.

3. If you are transferring from individual coverage to group coverage, the circumstances under which you may continue your coverage may be limited or no longer available.

4. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage.

5. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketi ng brand. Similar policies, if approved, are underwritten in New York by The Paul Revere Life Insurance Company. Colonial Life &

Accident Insurance Company is a subsidiary of Unum Corporation.

Medicare Notice 69828-1 Hospital Confinement

This is not Medicare Supplement Insurance

This insurance pays a fixed amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance.

This insurance duplicates Medicare benefits when:

any expenses or services covered by the policy are also covered by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization physician services outpatient prescription drugs if you are enrolled in Medicare Part D hospice other approved items and services

Check the coverage in all health insurance policies you already have.

For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program.

Before You Buy This Insurance

Important Notice to Persons on Medicare This Insurance Duplicates Some Insurance Benefits

GMB7000 Addtl Plan Enhancements Fmtd