Hospital_Indemnity_Policy__94193-H_Policy.pdf

AMERICAN HERITAGE LIFE INSURANCE COMPANY

HOME OFFICE:

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

(904) 992-1776

A Stock Company

GVSEP2TX Page 1

GROUP HOSPITAL INDEMNITY INSURANCE POLICY

NON-PARTICIPATING

POLICYHOLDER: CITY OF ROSENBERG EMPLOYEE TRUST

POLICY NUMBER: 0000094193

POLICY EFFECTIVE DATE: October 1, 2017

POLICY ANNIVERSARY DATE: October 1, 2018 and the first day of October each calendar year thereafter.

GOVERNING JURISDICTION: the state of Texas and subject to the laws of that jurisdiction.

American Heritage Life Insurance Company will provide benefits under this policy. We make this promise subject to all of the provisions of this policy.

The policyholder should read this group policy carefully and contact us promptly with any questions. This group policy is delivered in and is governed by the laws of the governing jurisdiction and, to the extent applicable, by the Employee Retirement Income Security Act of 1974 (ERISA), and consists of:

1. all policy provisions and any amendments and/or attachments issued; and

2. the policyholder’s signed application.

This policy may be changed in whole or in part. The approval must be in writing, signed by one of our executive officers and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it.

Signed for American Heritage Life Insurance Company at its Home Office in Jacksonville, Florida on the policy effective date.

Secretary President

THIS IS A GROUP HOSPITAL INDEMNITY ONLY POLICY WHICH PROVIDES

LIMITED BENEFITS AS STATED OR OTHER BENEFITS SPECIFICALLY

DESCRIBED WITHIN THIS POLICY

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A

SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE

ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE

WORKERS COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED

NOTIFICATIONS THAT MUST BE FILED AND POSTED.

IMPORTANT NOTICE AVISO IMPORTANTE

TO OBTAIN INFORMATION OR MAKE A

COMPLAINT:

PARA OBTENER INFORMACION O

PARA SOMETER UNA QUEJA:

YOU MAY CALL AMERICAN HERITAGE

LIFE INSURANCE COMPANY'S TOLL-

FREE TELEPHONE NUMBER FOR

INFORMATION OR TO MAKE A

COMPLAINT AT

1-800-535-8086

USTED PUEDE LLAMAR AL NUMERO

DE TELEFONO GRATIS DE AMERICAN

HERITAGE LIFE INSURANCE

COMPANY'S PARA INFORMACION O

PARA SOMETER UNA QUEJA AL

1-800-535-8086

YOU MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE TO

OBTAIN INFORMATION ON

COMPANIES, COVERAGES, RIGHTS

OR COMPLAINTS AT

1-800-252-3439

PUEDE COMUNICARSE CON EL

DEPARTAMENTO DE SEGUROS DE

TEXAS PARA OBTENER INFORMATION

ACERCA DE COMPANIAS,

COBERTURAS, DERECHOS O QUEJAS

AL

1-800-252-3439

YOU MAY WRITE THE TEXAS

DEPARTMENT OF INSURANCE

P. O. BOX 149104

AUSTIN, TX 78714-9104

FAX #(512) 475-1771

PUEDE ESCRIBAR AL

DEPARTAMENTO DE SEGUROS DE

TEXAS

P. O. BOX 149104

AUSTIN, TX 78714-9104

FAX #(512) 475-1771

PREMIUM OR CLAIM DISPUTES:

SHOULD YOU HAVE A DISPUTE

CONCERNING YOUR PREMIUM OR

ABOUT A CLAIM YOU SHOULD

CONTACT THE COMPANY FIRST. IF

THE DISPUTE IS NOT RESOLVED, YOU

MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE.

DISPUTAS SOBRE PRIMAS O

RECLAMOS: SI TIENE UNA DISPUTA

CONCERNIENTE A SU PRIMA O A UN

RECLAMO, DEBE COMUNICARSE CON

EL COMPANIA PRIMERO. SI NO SE

RESUELVE LA DISPUTA, PUEDE

ENTONCES COMUNICARSE CON EL

DEPARTAMENTO (TDI).

ATTACH THIS NOTICE TO YOUR

POLICY: THIS NOTICE IS FOR

INFORMATION ONLY AND DOES NOT

BECOME A PART OR CONDITION OF

THE ATTACHED DOCUMENT.

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.

NENSPTX-GV

TABLE OF CONTENTS

POLICY SPECIFICATIONS

POLICYHOLDER PROVISIONS

GENERAL PROVISIONS......................................................................................................................................... 5 - 8

PORTABILITY

EXCLUSIONS

BENEFIT INFORMATION................................................................................................................................. 10 - 11

CLAIM INFORMATION..................................................................................................................................... 12 - 13

GLOSSARY....................................................................................................................................................... 14 - 17

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POLICY SPECIFICATIONS

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ELIGIBLE CLASS(ES):

All full-time active employees working 30 hours per week excluding those who are insured under any other hospital indemnity policy issued by American Heritage Life Insurance Company.

ELIGIBILITY WAITING PERIOD:

None

BENEFITS:

First Day Hospital Confinement - $1,000.00 Daily Hospital Confinement - $500.00 per day Hospital Intensive Care - $500.00 per day

INITIAL RATE:

The following are the initial rates for all available coverage types:

Monthly rate of $37.18 per insured employee for Individual Coverage; or $87.49 per insured employee for Individual and Spouse Coverage; or $64.35 per insured employee for Individual and Child(ren) Coverage; or $97.50 per insured employee for Family Coverage

RATE GUARANTEE DATE:

October 1, 2019

PREMIUM DUE:

October 1, 2017 and the first day of each calendar month thereafter.

All premiums must be sent to us on or before the premium due date. The premium must be paid in United States dollars.

COST OF COVERAGE:

The insured employee or member pays the cost of coverage.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES:

These are the policyholder’s divisions, subsidiaries, or affiliates listed below. The policyholder may act for and on behalf of any and all of these in all matters that pertain to this policy. Every act done by, agreement made with, or notice given to the policyholder will be binding on them.

Name Location (City and State)

None

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POLICYHOLDER PROVISIONS

RATE GUARANTEE

A change in premium rate will not take effect before the Rate Guarantee Date except for reasons which affect the risk assumed including those reasons shown below:

1. a change occurs in this plan design; or

2. a division, subsidiary, or affiliated company is added or deleted; or

3. the number of insured employees or members changes by 25% or more; or

4. a new law or a change in any existing law is enacted which applies to this policy; or

5. less than 10% of those eligible for coverage are participating.

We will notify the policyholder in writing at least 30 days before a premium rate is changed. A change may take effect on an earlier date when both we and the policyholder agree in writing.

PREMIUM INCREASES OR DECREASES

Premium increases or decreases may take effect any time subject to the RATE GUARANTEE provision. If they take effect during a policy month, they are adjusted and due on the next premium due date following the change. Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

INFORMATION REQUIRED FROM THE POLICYHOLDER

The policyholder must provide us with the following on a regular basis:

1. information about employees or members:

a. who are eligible to become insured; and

b. whose coverage changes; and/or

c. whose coverage ends; and

2. any information that may be required to manage a claim; and

3. any other information that may be reasonably required.

Policyholder records that have a bearing, in our opinion, on this policy will be available for review by us at any reasonable time.

CANCELING POLICY

This policy can be canceled:

1. by us; or

2. by the policyholder.

We may cancel or offer to modify this policy, with at least 30 days written notice to the policyholder, if:

1. less than 10% of those eligible for coverage are participating; or

2. this policy has been in effect more than 12 months; or

3. the policyholder does not promptly provide us with information that is reasonably required; or

4. the policyholder fails to perform any of its obligations that relate to this policy; or

5. fewer than 10 employees or members are insured; or

6. premiums are not received within the 31 day grace period.

If the premiums are not received during the grace period, this policy will terminate automatically at the end of the grace period. Premiums are required for coverage during the grace period. All premiums due must be paid to us for the full period this policy is in force.

The policyholder may cancel this policy by written notice delivered to us at least 31 days prior to the cancellation date.

When both the policyholder and we agree, this policy can be canceled on an earlier date. If canceled, coverage will end at 12:00 midnight on the last day of coverage.

If this policy is canceled, the cancellation will not affect a payable claim incurred prior to cancellation.

GENERAL PROVISIONS

EFFECTIVE DATE OF COVERAGE

Coverage to each eligible employee will be effective at 12:01 a.m. on the effective date shown on page 3 of the certificate of insurance issued to that employee provided he or she is actively employed on that date.

If the employee is not actively employed on that date due to temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date he or she returns to active employment. This applies to initial coverage, as well as any increase in coverage that occurs after the employee’s initial coverage is effective.

For any change in coverage, the change is effective on the date we receive such request for change.

Any decrease in coverage will take effect on the first day of the calendar month that next follows the date the employee applies for the decrease, but will not affect a payable claim that occurs prior to the effective date of the decrease.

CERTIFICATES OF INSURANCE

We will furnish to the policyholder a certificate of insurance for delivery to each insured employee. The certificate will provide a description of the insurance provided by this policy and will state:

1. the essential features of the insurance coverage; and

2. to whom benefits are payable.

If there is any discrepancy between the provisions of any certificate and the provisions of this policy, the provisions of this policy govern.

WHEN AN ELIGIBLE EMPLOYEE CAN ENROLL, CHANGE OR DISCONTINUE COVERAGE

1. The employee may apply for coverage during:

a. the initial enrollment period; or

b. a re-enrollment period.

2. The insured employee may increase coverage at the next re-enrollment period.

3. The insured employee may decrease coverage at the next re-enrollment period.

4. The insured employee may discontinue coverage at the next re-enrollment period.

ELIGIBILITY OF DEPENDENTS

Eligible dependents are the insured employee’s:

1. legal spouse or domestic partner; and

2. children and domestic partner’s children.

A child is a person under age 26 who is:

1. the insured employee’s or his or her domestic partner’s natural or adopted son or daughter, stepson or stepdaughter;

or

2. a foster child who is placed with the insured employee or his or her domestic partner by an authorized placement agency or by judgment, decree or other order of any court of competent jurisdiction; or

3. the insured employee’s or his or her domestic partner’s dependent grandchild.

A child born to the insured employee or his or her spouse or domestic partner, will be eligible for coverage. This coverage begins at the moment of birth of such child and benefits will be the same as provided for any other child insured under this policy. No additional premium will be required for newborns added if the insured employee already has children or family coverage in force at the time the newborn is added.

GENERAL PROVISIONS (Continued)

ELIGIBILITY OF DEPENDENTS (Continued) If the employee does not already have children or family coverage in force, or does not have coverage in force that covers more than one child, newborn children are automatically covered from the moment of birth for a period of 31 days. If the insured employee desires uninterrupted coverage for a newborn child, he or she must notify the policyholder within 31 days of that child’s birth. Upon notice to us, we will change the coverage to include the additional child and provide notification of the additional premium due. If the insured employee does not notify the policyholder within 31 days of the birth of the child, the temporary automatic coverage ends.

If the insured employee marries and desires coverage for his or her spouse, he or she must notify the policyholder of the marriage within 31 days of the marriage. Upon notice to us, we will change the coverage to include the insured employee’s spouse and provide notification of the additional premium due.

If the insured employee enters into a domestic partnership and desires coverage for his or her domestic partner, he or she must notify the policyholder of the domestic partnership within 31 days of the date the domestic partnership was formed.

Upon notice to us, we will change the coverage to include the insured employee’s domestic partner and provide notification of the additional premium due.

An adopted child or child pending adoption will be covered as follows:

1. Coverage is retroactive from the moment of birth for a child with respect to whom a decree of adoption by the insured employee has been entered within 31 days after the date of birth.

2. If adoption proceedings have been instituted by the insured employee within 31 days after the date of birth and he or she has temporary custody, coverage is provided from the moment of birth.

3. Coverage shall begin from the moment of placement.

Coverage will be provided as long as the insured employee has custody of the child pursuant to decree of the court and required premiums are paid.

If the insured employee does not already have children or family coverage in force, or does not have coverage in force that covers more than one child, adopted children or children pending adoption are automatically covered as described above for a period of 31 days. If the insured employee desires uninterrupted coverage for an adopted child or child pending adoption, he or she must notify the policyholder within 31 days of the moment of placement. Upon notice to us, we will change the coverage to include the additional adopted child or child pending adoption and provide notification of the additional premium due.

No additional premium will be required for an adopted child or foster child added if the insured employee already has children or family coverage in force at the time the adopted child or foster child is added.

TERMINATION OF COVERAGE

The insured employee’s coverage under this policy ends on the earliest of:

1. the date this policy is canceled; or

2. the last day of the period for which any required premium payments were made; or

3. the last day the insured employee is actively employed with the employer that is the policyholder, except as provided under the TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE provision; or

4. the date the insured employee is no longer in an eligible class; or

5. the date the insured employee’s class is no longer eligible; or

6. our discovery of fraud or material misrepresentation in the presentation of a claim under this policy.

We will provide coverage for a payable claim that occurs while a covered person is covered under this policy.

If the insured employee’s spouse is a covered person, the spouse’s coverage ends upon valid decree of divorce or the insured employee’s death.

If the insured employee’s domestic partner is a covered person, the domestic partner’s coverage ends upon termination of the domestic partnership or the insured employee’s death.

Coverage for a child will end on the issue day of the month that follows when the insured employee dies or the child: (a) reaches age 26; or (b) otherwise does not meet the requirements of an eligible dependent.

Coverage for a dependent grandchild will not terminate solely because they are no longer dependent on the insured employee for federal tax income purposes.

TERMINATION OF COVERAGE (Continued) Coverage does not end for an incapacitated dependent child who:

1. is incapable of self-sustaining employment by reason of mental or physical incapacity; and

2. became so incapacitated prior to the attainment of the limiting age of eligibility under this policy; and

3. is chiefly dependent upon the insured employee for support and maintenance.

Coverage for an incapacitated dependent child continues as long as this policy remains in force and the child remains in such condition. Proof of the incapacity and dependency of the child must be furnished, in writing, to us when the child reaches the limiting age of eligibility. Thereafter, such proof must be furnished as often as may be required, but no more often than annually after child’s attainment of the limiting age for eligibility.

If we accept a premium for coverage extending beyond the date, age or event specified for termination as to a covered person, such premium will be refunded, coverage will terminate and claims will not be paid. There may be no refund due if the insured employee has coverage in force that covers more than one child and there are other eligible dependents still insured under this policy.

Coverage may be eligible for continuation as outlined in the PORTABILITY PRIVILEGE provision.

TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE

If the insured employee ceases active employment because of a temporary layoff or leave of absence while coverage is in force, we will continue the coverage in accordance with the personnel practices of the policyholder, if premium payments continue and the policyholder approved the leave in writing. Coverage will be continued for 3 months following the date the insured employee ceased active employment.

If the insured employee’s coverage ends while on a Family and Medical Leave of Absence, the coverage will be reinstated when he or she returns to active status.

DISCRETIONARY AUTHORITY, IF GOVERNED BY ERISA

The following applies only when the administration of the policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq.:

We may construe disputed or seemingly inconsistent provisions of the policy and make decisions regarding eligibility and/or entitlement to coverage or benefits.

LEGAL ACTION

No legal action may be brought to obtain benefits under this policy:

1. for at least 60 days after proof of loss has been furnished; or

2. after the expiration of ;3 years from the time written proof of loss is required to have been furnished.

INCONTESTABILITY

After 2 years from the effective date of the policy, no misstatement, made in writing, can be used to void coverage or deny a claim for a loss incurred. After 2 years, the validity of the coverage may not be contested except for nonpayment of premiums.

CLERICAL ERROR

Clerical error on the part of the policyholder or us will not invalidate insurance otherwise in force nor continue insurance otherwise terminated. Upon discovery of any error, an adjustment will be made in the premiums and/or benefits available.

Complete proof must be supplied by us or the policyholder documenting any clerical errors.

AGENCY

For purposes of this policy, the policyholder acts on its own behalf or as the insured employee’s agent. Under no circumstances will the policyholder be deemed the agent of American Heritage Life Insurance Company.

ENTIRE CONTRACT

The contract consists of the following items:

1. the group policy; and

2. any amendments and endorsements; and

3. the applications and other written statements of the policyholder; and

4. any individual applications, enrollments or other statements made by a covered person.

Any statements made by the policyholder or by a covered person are representations and not warranties. Only written statements signed by the policyholder or a covered person will be used in defense of a claim. A copy of any written statement, if applicable, will be furnished to the policyholder or the covered person or his or her personal representative, if any, if such written statement will be used in defense of a claim.

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PORTABILITY PRIVILEGE

We will provide portability coverage, subject to these provisions.

Such coverage will not be available for an insured employee, unless:

1. coverage under the policy terminates under the TERMINATION OF COVERAGE provision; and

2. we receive a written request and payment of the first premium for the portability coverage no later than 30 days after such termination; and

3. the request is made for that purpose.

No portability coverage will be provided for any person, if his or her insurance under the policy terminated due to his or her failure to make required premium payments.

PORTABILITY COVERAGE

The benefits, terms and conditions of the portability coverage will be the same as those provided under the policy when the insurance terminated. Portability coverage may include any eligible dependents who were covered under the policy. Any change made to the policy after a person is insured under the portability privilege will not apply to that covered person unless it is required by law.

Portability coverage will be effective on the day after insurance under the policy terminates.

PORTABILITY PREMIUMS

Premiums for portability coverage are due and payable in advance to us at our home office. Premium due dates are the first day of each calendar month. The portability premium rate may differ from the premium rate in effect for insured employees and may change on any premium due date. Written notice will be given at least 60 days before a change is to take effect.

GRACE PERIOD

The grace period, as defined, will apply to each certificate holder of portability coverage as if such insured employee is the policyholder.

TERMINATION OF INSURANCE

Insurance under this portability privilege ends on the earliest of:

1. The date the person again becomes eligible for insurance under the policy.

2. The last day for which premiums have been paid, if the insured employee fails to pay premiums when due, subject to the grace period.

3. With respect to insurance for dependents:

a. the date the insured employee’s insurance terminates; or

b. the date the dependent ceases to be an eligible dependent, as defined.

4. 36 months after the date portability coverage became effective.

A dependent child whose portability coverage terminates when he or she reaches the age limit may apply for portability coverage in his or her own name, if he or she is otherwise eligible.

Portability coverage will remain in effect for no longer than 36 months.

TERMINATION OF THE POLICY

If the policy terminates, the insured employee and his or her covered dependents will be eligible to exercise the portability privilege on the termination date of the policy. Portability coverage may continue beyond the termination date of the policy, subject to the timely payment of premiums. Benefits for portability coverage will be determined as if the policy had remained in full force and effect.

EXCLUSIONS

We will not pay benefits for any loss caused by or resulting from (directly or indirectly):

1. any act of war whether or not declared, during military service; or

2. participation in a riot, insurrection or rebellion; or

3. suicide, or any attempt at suicide, whether sane or insane; or

4. injury incurred while committing or attempting to commit a felony; or

5. dental or plastic surgery for cosmetic purposes except when such surgery is required to: (a) treat an injury; or (b) correct a disorder of normal bodily function; or (c) congenital defects; or

6. intentionally self-inflicted injuries; or

7. confinement that begins before the covered person’s effective date of coverage; or

8. the reversal of a tubal ligation or vasectomy; or

9. artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician services, unless required by law; or

10. participation in any form of aeronautics (including parachuting and hang gliding) except as a fare-paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports; or

11. a newborn child’s routine nursing or routine well baby care during the initial confinement in a hospital; or

12. mental or nervous disorders; or

13. alcoholism, drug addiction or dependence upon any controlled substance.

GENERAL BENEFIT INFORMATION

We pay the following benefit(s) for service and treatment administered to or received by a covered person. Such service or treatment must be: (a) incurred by a covered person while coverage under this policy is in force on that person; and (b) provided for the care and treatment of sickness or injury of a covered person. Any loss not stated in the policy is not covered under this policy. Treatment must be received in the United States or its territories, except in the case of an emergency.

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BENEFIT INFORMATION

First Day Hospital Confinement: We pay the amount stated on page 3 for the first day a covered person is confined in a hospital. This benefit is payable only once per continuous confinement in a hospital per covered person.

This benefit is not payable for a newborn child’s initial confinement in a hospital. A newborn child’s initial confinement in a hospital includes any transfers to another hospital before such child is discharged to his or her home.

The covered person must provide proof that a hospital room and board charge is incurred.

(First Day Hospital Confinement)

Daily Hospital Confinement: We pay the amount stated on page 3 per day when a covered person is confined in a hospital.

If the First Day Hospital Confinement benefit is payable, this benefit pays for each day after the first day of a continuous confinement in a hospital for a maximum of 29 days. If the First Day Hospital Confinement benefit is not payable, this benefit pays for each day of a continuous confinement in a hospital for a maximum of 30 days.

This benefit is not payable for:

1. any day for which the First Day Hospital Confinement benefit is payable; or

2. a newborn child’s routine nursing or routine well baby care during the initial confinement in a hospital.

The covered person must provide proof for each day that a hospital room and board charge is incurred.

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Page 11A (Daily Hospital Confinement)

Hospital Intensive Care: We pay the amount stated on page 3 for each day a covered person is confined in a hospital intensive care unit. This benefit is paid in addition to the First Day Hospital Confinement benefit and Daily Hospital Confinement benefit.

The maximum number of days this benefit is payable is 30 days for each continuous confinement in a hospital intensive care unit.

The covered person must provide proof for each day that a hospital room and board charge is incurred.

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Page 11B (Hospital Intensive Care)

CLAIM INFORMATION

NOTICE OF CLAIM

We encourage the insured employee to notify us of a claim as soon as possible so that a claim decision can be made in a timely manner. Written notice of claim must be given to us within 20 days after the occurrence or commencement of any benefit covered by this policy, or as soon as reasonably possible. Notice given to us by, or on behalf of, the insured employee or the beneficiary at 1776 American Heritage Life Drive, Jacksonville, Florida 32224-6687, or to any authorized agent of ours, with the insured employee’s name and certificate number, is notice to us.

The claim form can be requested from us. If the form is not received within 15 days of the request, written proof of the claim may be sent to us without waiting for the form.

FILING A CLAIM

The insured employee must complete all applicable sections of the claim form and then give it to the attending physician.

The physician should complete his or her section of the form and send it directly to us.

PROOF OF CLAIM

Written proof must be given to us within 90 days after each loss. If it is not possible to give us written proof in the time required, we will not reduce or deny any claim for this reason, as long as the proof is filed as soon as reasonably possible.

In any event, the proof required must be given to us no later than 1 year from the time specified unless the insured employee is legally incapacitated.

PHYSICAL EXAMINATION AND AUTOPSY

We have the right, at our own expense, to have any covered person examined by a physician of our choosing, as often as may be reasonably required while a claim is pending. We may have an autopsy performed during the period of contestability, where it is not forbidden by law.

PAYMENT OF CLAIMS

After receiving written proof of loss, we pay all benefits then due under this policy. We will make payments to the insured employee unless such payments are assigned. Any amounts unpaid at the insured employee’s death may, at our option, be paid either to the named beneficiary or to the insured employee’s estate.

If benefits are payable to the insured employee’s estate or a beneficiary who cannot execute a valid release, we can pay benefits up to $1,000, to someone related to the insured employee or beneficiary by blood or marriage whom we consider to be entitled to the benefits. We will be discharged to the extent of any such payment made in good faith. There may be cases where a law requires that any benefits to be paid, be paid to an agency of government. We will abide by any such law that may apply. We will not be liable to the insured employee or anyone else for such benefits to the extent we are required by the law to pay them to such agency.

ASSIGNMENT

An assignment of the coverage under this policy is not binding on us, unless:

1. it is a written request; and

2. it is received and recorded by us at our home office.

We are not responsible for the validity of any assignment. An assignment is subject to any payment we make or other action we take before we record the assignment. An assignee may not change the owner or beneficiary.

CLAIM INFORMATION (Continued)

OVERPAID CLAIM

We have the right to recover any overpayments due to:

1. fraud; or

2. any error we make in processing a claim.

The insured employee must reimburse us in full. We will work with such insured employee to develop a reasonable method of repayment if he or she is financially unable to repay us in a lump sum.

We will not recover more money than the amount we overpaid.

UNPAID PREMIUM

Any unpaid premium that is due may be deducted from the payment of the covered person’s claim.

CLAIM REVIEW

If a claim is denied, we will give written notice of:

1. the reason for denial; and

2. the policy provision that relates to the denial; and

3. the right to ask for a review of the claim; and

4. any additional information that might allow us to change our decision.

The insured employee may, upon written request, read any reports that are not confidential. For a small fee, we will make copies of those reports for his or her use.

APPEALS PROCEDURE

Prior to filing any lawsuit and within 60 days after denial of a claim, the insured employee or his or her beneficiary must appeal any denial of benefits under the policy by making a written request for review of the denial.

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GLOSSARY

(Glossary may contain terms that are not included in the coverage selected)

Accident means a sudden, unforeseen and unexpected event which occurs without the covered person’s intent which results in an injury to the covered person independent of disease, infirmity or any other cause.

Active employment means the employee is working for the employer for earnings that are paid regularly and that he or she is performing the material and substantial duties of his or her regular occupation. For the purposes of this policy:

1. the employee must be working at least the minimum number of hours as described under the Eligible Class(es); and

2. the employee will be deemed to be in active employment on a day which is not the employer’s scheduled work days only if he or she was actively employed on the preceding scheduled work day.

The employee’s work site must be:

1. the employer’s usual place of business; or

2. an alternative work site at the direction of the employer; or

3. a location to which the job requires such employee to travel.

Normal vacation is considered active employment. However, if vacation days are used to cover sickness or injury, those days are not considered active employment. Temporary and seasonal workers are excluded from coverage.

Ambulatory surgical center means a licensed surgical center consisting of an operating room, facilities for the administration of general anesthesia and a post surgery recovery room in which the patient is admitted to, and discharged from, within a period of less than 24 hours.

Calendar year means a consecutive 12 month period beginning on January 1st of each year and ending on December 31st of the same year.

Complications of pregnancy mean any of the following:

1. a condition whose diagnosis is distinct from pregnancy but that is adversely affected by or caused by pregnancy, such as acute nephritis or nephrosis, cardiac decompensation, missed abortion, or similar medical and surgical conditions of comparable severity; and

2. a non-elective caesarean section; and

3. termination of ectopic pregnancy; and

4. spontaneous termination of pregnancy during a period of gestation in which a viable birth is not possible.

Complications of pregnancy do not include: false labor; or occasional spotting; or morning sickness; or body aches; or body pains; or prescribed rest; or hyperemesis gravidarum; or pre-eclampsia; or premature births; or multiple births (twins, triplets, etc.); or any condition caused by the pregnancy that places the covered person or the pregnancy at risk.

Confined or confinement means admitted to and confined as an inpatient in an institution for which a room and board charge is made by the institution. It does not include confinement for an observation room.

Continuous confinement means one continuous confinement or two or more confinements not separated by more than 24 hours. If there are more than 24 hours between confinements, they are considered separate confinements.

Cosmetic means surgery or other treatment to improve a person’s appearance which is not required for treatment of a sickness or injury.

Coverage year means a consecutive 12 month period during which an insured employee’s insurance is in force. The first coverage year begins on the effective date of the insured employee’s insurance under the group policy and ends after 12 consecutive months of coverage. Dependents added later will have the same coverage year as the insured employee.

GLOSSARY (Continued)

Covered person means any of the following:

1. any eligible family member (including the employee) named on the enrollment form and acceptable for coverage by us;

or

2. any eligible family member added by endorsement after the effective date; or

3. a newborn child or adopted child.

Day means a 24 hour period.

Domestic partner means the insured employee’s same-sex or opposite-sex partner who is eligible for coverage provided that:

1. both the insured employee and his or her same-sex or opposite-sex partner must be considered as domestic partners according to the law of the insured employee’s state of residence; or

2. if the insured employee’s state of residence has no domestic partnership law, he or she must satisfy the definition of domestic partner as defined by the policyholder.

Eligibility waiting period means the continuous period of time that the employee must be in active employment in an eligible class before he or she is eligible for coverage.

Emergency treatment center means the emergency room of a hospital or ambulatory surgical center, or satellite emergency center of a hospital.

Employee means a person who is: (a) a citizen or resident of the United States or one of its territories; and (b) in active employment employed with the employer named as the policyholder.

Employer means the individual, company or corporation where the employee is in active employment employed, and includes any division, subsidiary, or affiliated company named in this policy.

Family coverage means coverage that includes the insured employee, as defined, his or her eligible spouse or domestic partner and children.

Grace period means a period of 31 days following the premium due date during which premium payment may be made.

Hospital means a legally operated institution with established facilities (either on its premises or available to the hospital on a contractual, pre-arranged basis and under the supervision of a staff of one or more duly licensed physicians), for the care and treatment of sick and injured persons for diagnosis, surgery, and 24 hour nursing service. Hospital does not include:

1. any institution which is mainly a rest home, nursing home, convalescent home, or home for the aged; or

2. any institution which is mainly for the care and treatment of alcoholics or drug addicts, or mental or nervous disorders.

Hospital intensive care unit means a hospital area of special care, including cardiac and coronary care units, surgical intensive care units or cardiovascular intensive care units, which at the time of admission are separate and apart from the surgical recovery room, or other rooms, beds or wards normally used for patient confinement. In addition, such a unit must provide the following:

1. 24 hour continuous nursing care and attendance by nurses assigned to the unit on a full-time basis; and

2. direction and/or supervision by a full-time physician director or a standing “intensive care” committee of the medical staff; and

3. special medical apparatus used to treat the critically ill.

The following do not qualify as “Hospital intensive care units”:

1. progressive care units;

2. sub-acute intensive care units;

3. intermediate care units;

4. private rooms with monitoring;

5. step-down units; or

6. any other lesser care treatment units.

Individual and child(ren) coverage means coverage that includes only the insured employee, as defined, and eligible children.

Individual and spouse coverage means coverage that includes only the insured employee, as defined, and his or her eligible spouse or domestic partner.

Individual coverage means coverage that includes only the insured employee, as defined.

Initial enrollment period means one of the following periods during which the employee may first apply in writing for coverage under this policy:

1. if the employee is eligible for coverage on the policy effective date, a period before the policy effective date as set by us and the policyholder; or

2. if the employee becomes eligible for coverage after the policy effective date, the period ending 31 days after the date he or she is first eligible to apply for coverage.

Injury means accidental bodily injury to a covered person, as the result of an accident while coverage under this policy is in force, and the injury is the direct cause of the loss independent of disease, bodily infirmity or any other cause. All injuries sustained in any one accident and all complications and recurrences of complications are considered to be a single “injury”.

Inpatient means a covered person who is a resident patient using the room and board facilities of an institution.

Insured employee means the employee accepted for coverage by us who has completed and signed the enrollment form and whose name appears on the certificate specification page.

Issue day means the same day of the month as the effective date of coverage.

Material and substantial duties mean duties that:

1. are normally required for the performance of the employee’s regular occupation; and

2. cannot be reasonably omitted or modified, except that if the employee is required to work on average in excess of 40 hours per week. We will consider him or her able to perform that requirement if he/she is working or has the capacity to work 40 hours per week.

Mental or nervous disorder means a psychiatric or psychological condition regardless of cause, such as schizophrenia, depression, manic depressive or bipolar illness, anxiety, post traumatic stress disorder, personality disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs or other similar methods.

Nurse means any one of the following who is not a member of the covered person’s immediate family:

1. licensed practical nurse (L.P.N.); or

2. licensed vocational nurse (L.V.N.); or

3. graduate registered nurse (R.N.).

Payable claim means a claim for which we are liable under the terms of this policy.

Physician means:

1. a person performing tasks that are within the limits of his or her medical license; and

2. a person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or

3. a person who is a legally qualified medical practitioner according to the laws and regulations of the state he or she practices in.

We will not recognize the insured employee, his or her spouse or domestic partner, children, parents, or siblings as a physician for a claim.

Policyholder means the legal entity to whom this policy is issued.

Re-enrollment period means a period of time as set by the policyholder and us during which the insured employee may apply, in writing, for coverage under the policy, or change coverage under the policy if currently enrolled.

Residential treatment facility means an institution which provides coordinated inpatient treatment of mental or nervous disorders or chemical dependency by trained medical personnel and counselors pursuant to a written treatment plan approved and monitored by a physician. The institution must also be affiliated with a hospital under a contractual agreement with an established system for patient referral, be accredited as a treatment facility by the Joint Commission on Accreditation of Hospitals, and licensed, certified or approved as a mental health or chemical dependency treatment program or center by any federal, state or municipal agency having legal authority to so license, certify or approve.

Sickness means an illness or disease, including complications of pregnancy, that must begin while the covered person is insured under this policy.

Skilled nursing facility means an institution that meets all of the following standards:

1. it is licensed by the state in which it is located; and

2. it is a separate facility or a distinct part of another facility physically separated from the rest of such facility; and

3. it provides confined nursing care to individuals who are not able to care for themselves and who require nursing care;

and

4. its primary function is to provide nursing care, and room and board; and the facility charges for these services. The care must be performed under the direction of a licensed physician or licensed nurse; and

5. it is not a hospital, a home for the aged, a retirement home, a rest home, a community living center, or a place mainly for the treatment of alcoholism, mental illness or drug abuse.

Surgery means manual procedures involving cutting of body tissue, debridement or permanent joining of body tissue for repair of wounds, treatment of fractured bones or dislocated joints, endoscopic procedures, and other manual procedures, when used in lieu of cutting for purposes of removal, destruction or repair of body tissue.

Temporary layoff or leave of absence or family and medical leave of absence means the insured employee is absent from active employment for a period of time that has been agreed to in advance in writing by the current employer.

Normal vacation time or any period of disability is not considered a temporary layoff or leave of absence.

We, us and our means American Heritage Life Insurance Company.

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

(904) 992-1776

A Stock Company

THIS IS A GROUP HOSPITAL INDEMNITY ONLY POLICY WHICH PROVIDES

LIMITED BENEFITS AS STATED OR OTHER BENEFITS SPECIFICALLY

DESCRIBED WITHIN THIS POLICY

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE

EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE

ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE

WORKERS COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED

NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Important Privacy Policy Notice

At Allstate Benefits (“AB”), we value you as a customer. We also share your concerns about privacy. We are sending this notice to explain how we treat personal information (“customer information”) that is not public. This is information that we obtain from you or other sources when we provide you with products and services.

We want you to know that: we respect your privacy; and we protect your information.

• We do not sell customer information.

• We do not share your information with: persons; companies; or organizations outside of AB that would use that information to contact you about their products and services.

• We expect persons or organizations that provide services on our behalf to keep your information confidential. We also expect them to use your information only to provide the services we’ve asked them to perform.

• We communicate to our employees about the need to protect your information. We have established safeguards (these are physical, electronic and procedural) to protect this information.

Below are answers to questions that you might have about privacy. You may be wondering...

What do we do with your information?

AB does not sell your customer or medical information to anyone. We do not share it with companies or organizations outside of AB that would use that information to contact you about their own products and services.

If this were to change, we would offer you the option to opt out of this type of information sharing. Also, we would obtain your consent before we share medical information for marketing purposes.

Your agent or broker may use your information to help you with your insurance needs. We may also communicate with you about products, features, and options in which you have expressed an interest. Without your consent, we may provide your information to persons or organizations in and out of AB. This would be done as permitted or required by law. We may do this to:

• Fulfill a transaction you have requested.

• Service your policy.

• Market our products to you.

• Investigate or handle claims.

• Detect or prevent fraud.

• Participate in insurance support organizations (Information from a report by an insurance support organization may be retained by that organization and distributed to other persons.).

• Comply with lawful requests from regulatory and law enforcement authorities.

These persons or organizations may include:

• Our affiliated companies.

• Companies that perform services, including marketing, on our behalf.

• Other financial institutions with which we have an agreement for the sale of financial products.

• Other insurance companies to perform their role in an insurance transaction involving you.

• Businesses that conduct actuarial or research studies.

• Persons requesting information pursuant to a subpoena or court order.

• Your agent or broker.

• An employer, if your premiums are payroll deducted.

• The creditor who sold you insurance, if your policy is credit insurance.

GLBNAHL 8/11

What kind of customer information do we have, and where did we get it?

Much of the information that we have about you comes from you. When you perform certain transactions, you may give us information such as your name, address, and Social Security number. These transactions include when you submit: an application for insurance; a request for insurance; a request for products and services we offer; or a request for an insurance quote. We may have contacted you by telephone or mail for additional information. We keep information about the types of services you purchase from us and our affiliates. Examples of this include premiums, fund values, and payment history. We may collect information from outside sources such as consumer reporting agencies and health care providers. The information we collect may include the following:

• Motor vehicle reports.

• Credit reports.

• Medical information.

How do we protect your customer information?

We expect any company with whom we share your information to use it only to provide the service we have asked them to perform. Information about you is also available within AB to those individuals who may need to use it to fulfill and service the needs of our customers. We communicate the need to protect your information to all employees and agents. We especially communicate this need to individuals who have access to it. Plus, we have established physical, electronic, and procedural safeguards to protect your information. Note that if your relationship with us ends, your information will remain protected. This protection will be provided according to our privacy practices outlined in this Important Notice.

How can you find out what information we have about you?

You may request to see, or obtain by mail, the information about you in our records. If you believe that our information is incomplete or inaccurate, you may request that we correct, add to, or delete from the disputed information. In order to fulfill your request, we may make arrangements to copy and disclose your information to you on our behalf. This may be done with an insurance support organization or a consumer reporting agency.

You may also request a more complete description of the entities to which we disclose your information, or the conditions that might warrant such disclosures. Please send any of the requests listed above in writing to:

AB

Policyholder Services (Privacy Section) 1776 American Heritage Life Drive Jacksonville, FL 32224-6687

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