Attachment J.9 - AfterCoprs Coverage.pdf

Attachment J.9.

AfterCorps Coverage

Attachment J.9 - AfterCorps Coverage

SCHEDULE OF BENEFITS/LIMITS -

Subject to the Terms of this insurance, including without limitation the Deductible, Benefit Percentage, and limits and sub-limits set forth below, the Underwriters promise to provide the Insured Person the following benefits and coverage arising out of Injury or Illness incurred while this Certificate is in effect.

Benefit/Other - Limit/Sub-limit

Deductibles $250 per Insured Person per Calendar Year for Eligible Medical Expenses incurred within the Preferred Provider network.

$500 per Insured Person per Calendar Year for Eligible Medical Expenses incurred outside of the Preferred Provider network. An additional Deductible of $250 per Hospital admission ("Extra Deductible") will be applied for each admission to a U.S. Hospital that is not within the Preferred Provider network.

Family Deductible Limit $750 per Family per Calendar Year for Eligible Medical Expenses incurred within the Preferred Provider network.

$1500 per Family per Calendar Year for Eligible Medical Expenses incurred outside of the Preferred Provider network, and exclusive of any Extra Deductible.

Benefit Percentage The Underwriters will pay 90% of Eligible Medical Expenses, after the Deductible has been met, if incurred within the Preferred Provider network.

The Underwriters will pay 80% of Eligible Medical Expenses after the Deductible has been met, if incurred outside the Preferred Provider network.

Out-of-Pocket Limit When the Insured Person's Out-of-Pocket amount in excess of Deductible(s) is equal to $1000 in a Calendar Year, the Underwriters will pay 100% of Eligible Medical Expenses remaining and incurred during the same Calendar Year.

When a Family's Out-of-Pocket amount in excess of Deductible(s) is equal to $2000 in a Calendar Year, the Underwriters will pay 100% of the Family's Eligible Medical Expenses remaining and incurred during the same Calendar Year.

In-Network Office Visits $25/$35 Co-payment, then 100% of Usual, Reasonable and Customary charges for Office Visit expenses only.

Office Visit Co-payments are not included in the Out-of-Pocket Limit.

Emergency benefits $50 per urgent care visit $100 per emergency room visit

Maximum Limit $1,000,000 Lifetime

Pre-Existing Conditions Covered for Volunteer only.

Mental Health Disorders Covered for Volunteer only

Outpatient: $25 Co-Payment, then 100% of Eligible Medical Expenses, up to a maximum benefit of $70 per visit, with a Calendar Year maximum of 12 visits.

Mental Health co-payments are not included in the Out-of-Pocket Limit.

Maternity Covered for Volunteer only

$5,000 maximum per pregnancy with Normal Delivery, including prenatal care, delivery and postnatal care, provided conception occurs after the Close of Service Date.

$7,500 maximum per pregnancy with delivery by Cesarean section, including prenatal care, delivery and postnatal care, provided conception occurs after the Close of Service Date.

Hospital Room & Board The average semi-private room rate, including nursing service

Intensive Care Unit Usual, Reasonable and Customary

Physical Therapy $50 maximum charge per day

Eligible Medical Expenses Usual, Reasonable and Customary

Outpatient Prescription Drugs:

$25,000 maximum benefit per Calendar Year; subject to 3 tier formulary $10/30/50 co-payment;

subject to a maximum supply of 30 days per any one prescription.

Prescription Drug co-payments are not included in the Out-of-Pocket Limit.

Local Ambulance Expense Usual, Reasonable and Customary

Emergency Medical Evacuation $50,000 Calendar Year maximum. Must be approved in advance and coordinated by the Underwriters.

Return of Mortal Remains $5,000 per Insured Person for return of the Insured Person's mortal remains or ashes to their Home Country. Must be approved in advance and coordinated by the Underwriters.

Emergency Reunion Limited to $10,000 per Emergency reunion. Must be approved in advance and coordinated by the Underwriters.

Transportation to Country of Residence $5,000 maximum. Must be approved in advance and coordinated by the Underwriters.

Pre-Certification All Other: 50% reduction of Eligible Medical Expenses if Pre-Certification requirements are not met.

Transplants: No coverage if Pre-certification requirements are not met.

Wellness Routine Physical Exam:

$25 Co-payment with a maximum benefit of $110 per Calendar Year, covered for Volunteer only.

Screening Mammogram:

$25 Co-payment, then 100% to a maximum benefit of $110 per Calendar Year for females age 45 or older.

Well Child Care: Coverage for enrolled dependents under the age of 15 years, $25 co-payment, with a maximum benefit of $75 per office visit.

These Co-payments are not included in the Out-of-Pocket Limit.

Transplant Expense Subject to special Transplant Pre-certification Requirements. Covered Transplants are: heart, heart/lung, lung, kidney, kidney/pancreas, liver and allogenic and autologous bone marrow.

Second Surgical Opinion Subject to the Deductible and Benefit Percentage unless requested by the Underwriters or required under the Mandatory Second Surgical Opinion provision of the Master Policy and this Certificate. (Note, 50% penalty for failure to obtain a Second Surgical Opinion when required by the Underwriters).

With regard to the foregoing Schedule of Benefits/Limits, the references to "continuous coverage" mean continuous unbroken coverage under the CorpsCare plan. The applicable benefits described will become first available to the Insured Person only at the end of the continuous coverage period so specified.

PRE-CERTIFICATION PROVISIONS/REQUIREMENTS -

(1) General Requirements: To comply with the Pie-certification requirements of this insurance, the Insured Person or his/her Physician must:

(a) Contact the Plan Administrator at the telephone numbers printed on the ID card:

(i) As soon as possible before the expense is to be incurred; and

(ii) For maternity Pre-certification, contact the Plan Administrator as soon as possible but always within the first 90 days of pregnancy; and

(iii) For transplant Pre-certification, contact the Plan Administrator as soon as possible but always within 72 hours of becoming a candidate for a Covered Transplant; and

ELIGIBLE MEDICAL EXPENSES - Subject to the Terms of this insurance, including without limitation the Deductible, Benefit Percentage, and limits and sub-limits set forth in the Schedule of Benefits/Limits, and the Exclusions set forth in Section K, the Underwriters will reimburse the Insured Person for the following costs, charges and expenses incurred by the Insured Person with respect to an Illness or Injury suffered or sustained by the Insured Person while this Certificate is in effect, so long as the costs, charges or expenses are Usual, Reasonable and Customary ("Eligible Medical Expenses"):

1. Charges incurred at a Hospital for:

(a) Daily room and board and nursing services not to exceed the average semi-private room rate;

and

(b) Daily room and board and nursing services in Intensive Care Unit; and

(c) Use of operating, Treatment or recovery room; and

(d) Services and supplies which are routinely provided by the Hospital to persons for use while Inpatient; and

(e) Emergency Treatment of an Injury or illness, even if Hospital confinement is not required; and

2. Charges incurred for Surgery at an Outpatient Surgical facility, including services and supplies; and

3. Charges incurred from a Physician for professional services, including Surgery; provided, however, that charges by or for an assistant surgeon will be limited and covered at the rate of 20% of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage; and

4. Charges incurred for:

(a) Dressings, sutures, casts or other supplies which are Medically Necessary; and

(b) Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, behavioral and educational testing are not included); and

(c) Basic functional artificial limbs, eyes or larynx, or breast prosthesis, but not the replacement or repair thereof; and

(d) Reconstructive Surgery directly related to a Surgery which is covered under this insurance;

(e) Radiation therapy or Treatment and chemotherapy; and

(f) Hemodialysis and the charges by a Hospital for processing and administration of blood or blood components, but not the cost of the actual blood or blood components; and

(g) Oxygen and other gasses and their administration; and

(h) Anesthetics and their administration by a Physician; and

(i) Drugs which require prescription by a Physician for Treatment of Injury or Illness or for contraceptive purposes, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 30 days of any one prescription; and

G) Care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital;

(k) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from Inpatient acute care; and

(1) Emergency local ambulance transport necessarily incurred in connection with Injury or Illness resulting in Hospitalization; and

(m) Emergency Dental Treatment and Dental Surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident which is covered under this insurance; and

(n) Routine and Medically Necessary care of a Newborn of a Volunteer, if the delivery of the Newborn and the charges incurred are eligible for coverage and are covered under the Terms of this insurance, provided the Newborn is properly enrolled for this insurance within 31 days of birth; and

(o) Pre-natal care, delivery of a Newborn, and post-natal care, including complications thereof;

provided conception occurs after the Close of Service date; and

(p) Treatment of Mental Health Disorders for Volunteers only; and

(q) Physical therapy prescribed by a Physician and performed by a professional physical therapist, and necessarily incurred to continue recovery from a covered Injury or covered Illness;

(r) Medically Necessary rental of a standard basic Hospital bed, a standard basic wheelchair, and/or Durable Medical Equipment that is therapeutic in nature, up to the purchase price.

WELLNESS EXPENSES - Subject to the Terms ofthis insurance, the Underwriters will reimburse the Insured Person for the following wellness expenses incurred by a Volunteer and/or eligible dependent only:

Routine Physical Exam:

Co-payment of $25 per visit, 100% of wellness expenses to a maximum benefit of $110 per Calendar Year

Screening Mammograms:

After a copayment of $25, 100% of expenses for routine mammograms to a maximum benefit of $110 per Calendar Year, for emolled members who are female and are at least age 45.

Well Child Care:

Co-payment of $25 per visit, 100% of wellness expenses to a maximum benefit of $75 per Office Visit for emolled dependents under the age of 15 years.

TRANSPLANT EXPENSES - Subject to the Terms of this insurance, including without limitation the Deductible, Benefit Percentage, and limits and sub-limits set forth in the Schedule of Benefits/Limits, and the Exclusions set forth in Section K, the Underwriters will reimburse the Insured Person for the following costs, charges and expenses incurred by the Insured Person with respect to a Covered Transplant obtained or received by the Insured Person while this Certificate is in effect, so long as such costs, charges or expenses are Usual, Reasonable and Customary:

(1) Eligible Medical Expenses incurred by a live donor will be treated as if they were the expenses of the Insured Person receiving a Covered Transplant if the Insured Person received an organ or tissue of the live donor and

(2) Organ procurement and harvesting costs, excluding acquisition or purchase of the actual organ or tissue

(3) Charges incurred for pre-transplant evaluation, the Covered Transplant procedure, re-transplantation (if incurred during the initial Covered Transplant hospitalization), and post-transplant care; and

(4) Reasonable travel and lodging expenses of the Insured Person if travel of more than 50 miles is necessary to receive the Covered Transplant treatment and services from a PPO Provider, EXCLUSIONS - All charges, costs, expenses and/or claims (collectively, "Charges") incurred by the Insured Person relating to or arising from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, Treatments (including diagnoses, tests and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Underwriters shall provide no benefits and shall have no liability therefore:

1. War and Terrorism: Notwithstanding any provision to the contrary within this insurance or any rider attached hereto, it is agreed that this insurance excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss:

A. war, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; or

B. any act of terrorism. For the purpose of this insurance, an act of terrorism means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

This insurance also excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (A) and/or (B) above.

This insurance also excludes loss, damage, cost or expense of whatsoever nature arising out of contamination due to an act of terrorism, as herein defined. For the purpose of this insurance, "contamination" means the contamination or poisoning of people by nuclear and/or chemical and/or biological substances which cause Illness and/or death.

IfUnderwriters allege that by reason ofthis exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon the Insured. , In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

2. Pre-existing Conditions -Charges for other Dependents resulting directly or indirectly from or relating to any Pre-existing Condition, defined as a medical condition (whether physical or mental, and regardless of the cause of the condition) for which medical advice, diagnosis, care, or Treatment was recommended or received, or which manifested symptoms that would have led a reasonably prudent person to seek medical attention, during the 12 month period ending on the Effective Date of Coverage, are excluded from coverage under this insurance; and

3. Mental Health Disorders- Charges for Treatment of Mental Health Disorders for Dependents are excluded from coverage under this insurance; and

4. Charges for any Treatment, services or supplies that are:

(a) Not incurred, obtained or received by an Insured Person while this insurance is in effect;

and/or

(b) Not presented to the Underwriters for payment by way of a complete Proof of Claim within 90 Days of the date such Charges are incurred; and/or

(c) Not administered or ordered by a Physician; and/or

(d) Not Medically Necessary; and/or

(e) Provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or

(t) Inexcess Usual, Reasonable, and Customary; and/or

(g) Performed or provided by a Relative of the Insured Person; and/or

(h) Not included as Eligible Medical Expenses as defined in Section H; and/or

(i) Provided by a person who resides or has resided in the Insured Person's home; and/or

G) Required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, service, supplies or conditions excluded from coverage or which are otherwise not covered under this insurance; and

5. Charges incurred for telephone consultations or due to a failure to keep a scheduled appointment; and ·

6. Charges incurred for Surgeries or Treatments, services or supplies which are:

(a) Investigational, Experimental, or for Research Purposes, and/or

(b) Related to genetic medicine or genetic testing, including without limitation, genetic screening, risk assessment, prevention and/or to determine pre-disposition, genetic counseling, and/or gene therapy; and

7. Charges incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and

8. Charges incurred for any surgery, Treatment, services or supplies relating to, arising from or in connection with, for, or as a result of:

(a) Weight modification, or for any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms of intestinal bypass Surgery; and/or

(b) Modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or

(c) Cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance; and/or

(d) Any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor non-felonious traffic violations; and/or

(e) Vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy;

(f) Orthoptics or visual eye training; and/or

(g) The feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet;

metatarsalgia or bunions; and any Treatment, services or supplies for corns, calluses or toenails;

provided, however, that claims for services, Treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the Underwriters and subject to all other Terms of this insurance when related to:

(i) an Injury to the foot arising from an Accident covered hereunder; or

(ii) an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment; and/or

(h) Hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or

(i) Any exercise program, whether or not prescribed or recommended by a Physician; and/or

G) Any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s);

(k) Any organ or tissue transplants or related services, Treatment or supplies, except Covered Transplants as defined herein and covered pursuant to the Terms of this insurance; and/or

(1) Any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant; and/or

(m) Any Covered Transplant in excess of one (1) during any twelve (12) month period of coverage under this insurance plan, except re-transplantation Charges if incurred during the initial Covered Transplant hospitalization; and

9. Charges incurred for any Treatment, service, supply or procedure that promotes or prevents or attempts to promote or prevent conception; including but not limited to: artificial insemination;

Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; charges incurred for any drug relating to these services and procedures are also excluded, except birth control pills or similar contraceptive prescriptions are covered;

10. Charges incurred for any drug, Treatment, service, supply or procedure that promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction;

11. Charges incurred for Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder; and

12. Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and Charges for any Treatment, services, supplies, examination or fitting related to these devices; and

13. Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism;

14. Charges incurred for Treatment of the temporomandibular joint; and

15. Charges incurred by the Insured Person for the care or Treatment of his/her Newborn (or for services or supplies related thereto) unless the Newborn is properly enrolled within 31 days of birth; and

16. Charges incurred for any immunizations and/or Routine Physical Exams except for the eligible benefits and covered expenses provided for under WELLNESS EXPENSES; and

17. Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and

18. Any taxes, assessments, charges, fees or surcharges imposed by any governmental agency or authority:

(a) arising out of or as a result of any Treatment, services or supplies received by the Insured Person, or

(b) based upon the Underwriters' election hereunder, if any, to pay benefits directly to providers, or

(c) for any other reason; and

19. Charges or expenses incurred: for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; for IV vitamin or herbal therapy; for drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered "off-label" drug use; and for drugs or medicines not prescribed by a Physician; and

20. Charges incurred for Illness or Injury arising out of, or in the course of, employment for wage or profit when eligible for a specific program covering such events; and

21. Charges incurred for an Illness or Injury eligible for coverage under the Federal Employees Compensation Act ("FECA"), regardless of whether the Illness or Injury is filed under FECA;

22. Treatment by a chiropractor, unless ordered in advance by a Physician; and

23. Charges incurred for breast reduction Surgery.

EMERGENCY MEDICAL EVACUATION BENEFIT - Subject to the limits set forth in the Schedule of Benefits/Limits, and the other Terms of this insurance, including the Conditions and Restrictions set forth below, the Underwriters will reimburse the Insured Person for the following expenses incurred by the Insured Person arising out of or in connection with an "Emergency Medical Evacuation" occurring while this Certificate is in effect:

(a) Emergency air transportation to a suitable airport nearest to the Hospital, where the Insured Person will receive Treatment; and

(b) Emergency ground transportation necessarily preceding emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment.

Conditions and Restrictions - To be eligible for coverage for Emergency Medical Evacuation benefits the Insured Person must be in compliance with all Terms of this insurance. The Underwriters will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance.

The Underwriters will provide Emergency Medical Evacuation benefits only when all of the following conditions are met:

(i) Medically Necessary Treatment cannot be provided locally; and

(ii) Transportation by any other method would result in loss of the Insured Person's life or result in debilitation that may cause permanent and irreversible damage to a part of the body; and

(iii) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (i) and (ii), above; and

(iv) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person; and

(v) Emergency Medical Evacuation is approved in advance and all arrangements are coordinated by the Underwriters; and

(vi) The condition, Illness, Injury or occurrence giving rise to the Emergency Medical

Evacuation occurred suddenly and/or spontaneously, and without: (1) advance warning, (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions which would have caused a prudent person to seek medical attention prior to the onset of the Emergency.

The Underwriters will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment, or the United States if the closest suitable Hospital is within the US. )'he Underwriters will use their best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible. The Insured Person understands and agrees that the timeliness, duration, and outcome of an Emergency Medical Evacuation can be affected by events and/or circumstances which are not within the direct control of the Underwriters, including but not limited to: availability and performance of competent transportation equipment and staff; delays or restrictions on flights or other modes of transportation caused by mechanical problems, government officials, telecommunications problems, and/or geographical and weather conditions; and other acts of God. The Insured Person agrees to hold the Underwriters and their agents and representatives harmless from, and agrees that the Underwriters and their agents and representatives shall not be held liable for, any delays, losses, damages or other claims that arise from or are caused by the acts or omissions of such independent third-party contractors, or that arise from or are caused by any acts, omissions, events or circumstances that are not within the direct and immediate control of the Underwriters and/or its authorized agents and representatives, including without limitation the events and circumstances set forth above.

EMERGENCY REUNION - Subject to the Terms of this insurance, "Emergency Reunion" expenses will be reimbursed to the Insured Person as outlined in the Schedule of Benefits/Limits in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the Deductible and Benefit Percentage and other limits as specified in the Schedule of Benefits/Limits, expenses incurred in respect of travel by a Relative or friend of the Insured Person, will be reimbursable to the Insured Person upon the recommendation and prior approval of the Underwriters.

Certificate of Insurance Underwritten by:

Peace Corps, Office of Health Services

INSURING CLAUSE

Certain Underwriters at Peace Corps, herein referred to as "the Company" hereby insures all persons whose Application has been Approved, by Seven Corners, Inc., herein referred to as "the Administrator" on behalf of the Company and whose name is identified on the ID Card and/or recorded with the Administrator, subject to all of the Exclusions, Limitations and Provisions as set forth herein and in the Certificate of Insurance issued by the Company. Coverage is afforded only with respect to the named Insured Person(s), Coverage, amounts and limits specified herein and as identified in the Schedule of Benefits for the Insurance requested on the Application and for which the specified Premium has been paid to the Administrator.

Section 1: Certificate Definitions

The term "Accident" or "Accidental" shall mean an event, independent of Illness(es) or self-inflicted means, which is the direct cause of bodily Injury(ies) to an Insured Person(s).

The term "Administrator" shall mean Seven Corners, Inc. the organization contracted with the Company to provide underwriting, administrative and claims payment services under this Certificate.

The term "Aggregate Limit of Indemnity" shall mean the total limit of the Company's liability for all indemnities payable under the Accidental Death & Dismemberment Benefit with respect to all Class(es) of Insured Person(s) arising out of Injury(ies) sustained by two or more Insured Person(s) as the result of any one Accident.

If the total of such indemnity exceeds said Aggregate Limit, the Company shall not be liable to any one such Insured Person(s) for a greater proportion of such Insured Person(s)'s indemnity afforded by the Accidental Death & Dismemberment Benefit than their equal share as divided by the total of all indemnities afforded by this benefit to all such Insured Person(s).

The term "Alcohol" or "Drug Abuse" shall mean any pattern of pathological use of alcohol or drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

The term "Application" shall mean the official enrollment form issued by the Administrator, which must be completed, signed and dated by each applicant (or legal guardian for applicants who are minor Child(ren) and all accompanying and/or documents pertaining to underwriting information of each applicant listed on the Application.

The term "Approved" or "Approval" shall mean the final determination of the Administrator to issue Coverage with or without Exclusionary Rider(s) and/or an increase to the Premium to an Insured Person(s), after the Administrator has received and reviewed the Application and all underwriting information requested.

The term "Certificate" shall mean the summary of the terms of Coverage, which includes this document, the Insured Person(s)'s Application and any endorsements, Exclusionary Rider(s) or amendments that will attach during the Insured Person(s)'s Period of Coverage.

The term "Child(ren)" shall mean the Primary Insured Person's natural child, step-child or a Child(ren) under the Insured Person(s)'s legal guardianship, but only if such Child(ren) depends on the Primary Insured Person's support and maintenance and lives with the Primary Insured Person in a parent-child relationship.

The term “Child(ren)” does not include a foster Child(ren) who is eligible for benefits provided by a governmental program or law, unless required by the law of the State.

The term "Chiropractic" shall mean services as provided by a licensed Chiropractor for manipulation or manual modalities in Treatment(s) of the spinal column, neck, extremities or other joints other than for Treatment(s) of a fracture or Surgery(ies). The term "Class(es)" shall mean a group of Insured Person(s) defined by common characteristics selected by the Company, including but not limited to demographic group, geographic region, employer or industry classification.

The term "Coinsurance" shall mean the percentage amount of Eligible Benefits, after the Deductible, which is the responsibility of each Insured Person(s) and must be paid by each Insured Person(s), before benefits under this Certificate are payable by the Company. The Coinsurance amount is stated in the Schedule of Benefits.

The term "Co-payment" shall mean the amount of Eligible Benefits, which is the responsibility of each Insured Person(s) and must be paid by each Insured Person(s), before benefits under this Certificate are payable by the Company. The Co- payment amount is stated in the Schedule of Benefits and does not accrue towards the Insured Person(s) Deductible or Coinsurance amounts.

The term "Common Carrier" shall mean any public air conveyance operating under a valid license providing for the transportation of passengers for hire.

The term "Company" shall mean Certain Underwriters at Lloyd's, London, the organization providing the Coverage under this Certificate.

The term "Complications of Pregnancy" shall mean any or all of the following conditions which are made worse by, occur during, or are caused by Pregnancy: acute nephritis, nephrosis, cardiac decompensation, missed abortion, hyperemesis gravid arum, ectopic Pregnancy that is ended, non-elective cesarean section, pre clampsia, gestational diabetes, spontaneous end of Pregnancy which occurs when a viable birth is not possible, and other medical problems of similar severity.

The term "Consultation(s)" shall mean either a visit or a session with a Physician(s) or Service Provider.

The term "Convalescent" shall mean Treatment(s), services and supplies provided to aid in the recovery of a patient to reach a degree of body functioning to permit self-care in essential daily living activities.

The term "Convalescent Care Facility" shall mean an institution, or a distinct part of an institution meeting all of the following; a.) It is licensed to provide and is engaged in providing, on an Inpatient basis, for persons Convalescing from Injury(ies) or Disease(s), professional nursing services rendered by a Registered Nurse or by a licensed practical nurse under the supervision of a Registered Nurse, physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities, b.) Its services are provided for compensation from its patients and which patients are under 24 hour full-time supervision of a Physician(s) or Registered Nurse, c.) It maintains a complete medical record on each patient and has effective utilization review plans. Convalescent Care Facility does not include a facility primarily for rest, the aged, drug abuse, Custodial Care, nursing care, or for care of Mental or Nervous disorders or the mentally incompetent.

The term "Coverage" shall mean the Eligible Benefits described in this Certificate, to which the Insured Person(s) is eligible for reimbursement from the Company or payment for the Treatment(s) and services paid directly to the Service Provider by the Company.

The term "Coverage Period" or "Period of Coverage" shall mean the period between the Individual Effective Date of Coverage and the Individual Termination Date of Coverage for this Certificate, which is stated on the Insured Person(s)'s ID Card.

The term "Covered Event(s)" shall mean the Covered Expense(s) for an Illness(es) or an Accidental bodily Injury(ies) necessitating medical Treatment(s) by a Service Provider as defined in this Certificate.

The term "Covered Expense(s)" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment(s); due to Illness(es) or Injury(ies), as described in the Certificate; prescribed, performed or ordered by a licensed Physician(s) and/or Service Provider; Reasonable and Customary charges; incurred by the Insured Person(s) during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits.

The term "Custodial Care" shall mean care primarily for the purpose of assisting a person in the activities of daily living or in meeting personal rather than medical needs, and which is not specific Treatment(s) for an Illness(es) or Injury(ies). It is care, which cannot be expected to substantially improve a medical condition, and has minimal therapeutic value, whether or not totally disabled, in the activities of daily living.

The term "Cytological Screening" shall mean a pap test to detect cervical cancer through the simple microscopic examination of cells scraped from the surface of the cervix.

The term "Deductible" shall mean the amount of Eligible Benefits which are the responsibility of each Insured Person(s) and must be paid by each Insured Person(s), before benefits under this Certificate are payable by the Company. The Deductible amount is stated on the ID Card and/or in the Schedule of Benefits.

The term "Disease(s)" shall mean any condition or Disease(s) listed in the most recent edition of the International Classification of Disease(s) ICD-9-CM or a condition accepted and recognized as a known Illness(es) or Injury(ies) by the American Medical Association.

The term "Dentist" shall mean a legally licensed doctor of dental surgery, dental medicine or dental science. A dental hygienist who works within the scope of his/her license, under the supervision of a Dentist, is a covered practitioner.

The term "Dependent" shall mean the spouse who is legally married to the Primary Insured Person; the Primary Insured Person's natural or legally adopted unmarried Child(ren) from fourteen (14) days old until his/her nineteenth (19th) birthday and the Primary Insured Person's Child(ren) from nineteen (19) years old to twenty-six (26) years old.

The term "Educational" or "Rehabilitative Care" shall mean the care for restoration (by education or training) of the Insured Person's ability to function in a normal or near normal manner following an Illness(es) or Injury(ies). This type of care includes, but is not limited to, physical therapy or occupational therapy.

The term "Effective Date" shall mean the date Coverage under this Certificate begins. After review and Approval of each Applicant by the Administrator, Coverage will become effective on the later of the following dates: (1.) The date requested on the Application, (2.) The date the appropriate Premium and Application are received by the Administrator, or (3) The date the Applicant is Approved by the Administrator. The Insured's ID Card will state the official Effective Date of Coverage, as issued by the Administrator.

The term "Eligible Benefits" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment(s); due to Illness(es) or Injury(ies); prescribed, performed or ordered by a licensed Physician(s) and/or Service Provider; Reasonable and Customary charges; incurred by the Insured Person(s) during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits.

The term "Emergency" shall mean a medical condition Manifesting itself by acute signs or symptoms, which could reasonably result in placing the Insured Person(s)'s life or limb in danger, if medical attention is not provided within 24 hours.

The term "Emergency Medical Evacuation I Repatriation" shall mean: a) the Insured Person(s)'s medical condition warrants immediate transportation from the place where the Insured Person(s) is Ill or Injured to the nearest adequate medical facility where medical Treatment(s) can be obtained ; or b) after being treated at a local medical facility as a result of an Emergency Medical Evacuation, the Insured Person(s)'s medical condition warrants transportation with a qualified medical attendant to his/her current Home Country to obtain further medical Treatment(s) or to recover; or c) both a) and b) above.

The term "Exclusionary Rider(s)" shall mean that the Applicant will be Approved for Coverage, but otherwise Covered Expense(s) for certain medical conditions or Treatment(s) will be excluded from Coverage in written form from the Administrator.

The term "Experimental/Investigational and/or for Research" shall mean a Treatment(s), drug, device procedure, supply or service and related services (or a portion thereof, including the form, administration or dosage) for a particular diagnosis or condition when any one of the following exists:

1. The Treatment(s), drug, device, procedure, supply or service is in any clinical trial or a Phase I, II or III trial.

2. The Treatment(s), drug, device, procedure, supply or service is not yet fully approved or recognized by a pertinent governmental agency or professional organization such as the National Cancer Institute or Food & Drug Administration.

3. The results are not proven through controlled clinical trials with results published in peer-reviewed English language medical journals to be of greater safety and efficacy than conventional Treatment(s), in both the short and long term.

4. The Treatment(s), drug, device, procedure, supply or service is not generally accepted medical practice in the state or Country where the Insured Person(s) resides or as generally accepted throughout the relevant medical community by reference to any one or more of the following: peer-reviewed English-language medical literature, Consultation(s) with Physician(s), authoritative medical compendia, the American Medical Association, or other pertinent professional organization or governmental agency.

5. The Treatment(s), drug, device, procedure, supply or service is described as Investigational, Experimental, a study, or for Research or the like in any consent, release, or authorization which the Insured Person(s) or someone acting on their behalf may be required to sign.

The fact that a procedure, service, supply, Treatment(s), drug, or device may be the only hope for survival will not change the fact that it is otherwise Investigational, Experimental, or for Research.

The term "Home Country" shall mean the country where an Insured Person(s) has his or her true, fixed and Permanent Residence.

The term "Home Health Care Agency" shall mean a public or private agency or one of its subdivisions, Which operates pursuant to law; is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment(s) by a Physician(s), in accordance with existing standards of medical practice.

The term "Home Health Care" shall mean services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient; provided always that such care is in lieu of Medically Necessary Inpatient care in a Hospital.

The term "Hospice" shall mean a coordinated plan of home; Inpatient and Outpatient care which provides palliative and supportive medical and other health services to terminally ill patients. An interdisciplinary team provides a program of planned and continuous care, of which the medical components are under the direction of a Physician(s).

Care will be available 24 hours a day, seven days a week. The Hospice must meet the licensing requirements of the locality in which it operates.

The term "Hospital" shall mean a place that 1.) Is legally operated for the purpose of providing medical care and Treatment(s) to Sick or Injured persons for which a charge is made that the Insured Person(s) is legally obligated to pay in the absence of insurance 2.) Provides such care and Treatment(s) in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) Provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) Operates under the supervision of a staff of one or more Physician(s). Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

Hospital does not mean:

-A Convalescent, nursing, or rest home or facility, or a home for the aged;

-A place mainly providing Custodial, Educational, or Rehabilitative Care; or -A facility mainly used for the Treatment(s) of drug addicts or alcoholics.

The term "Ill" or "Illness(es)" shall mean Sickness or Disease(s) of any kind listed in the most recent edition of the International Classification of Disease(s) ICD-9-CM, which is the required reporting tool for all diagnoses and Disease(s) to all U.S. Public Health Service and Health Care Financing Administration programs.

The term "Incident" shall mean all Illness(es) that exist simultaneously and which are due to the same or related causes are considered to be one Incident. Further, if an Illness(es) is due to causes, which are the same and are related to the causes of a prior Illness(es), the Illness(es) will be deemed to be a continuation of the prior Illness(es) and not a separate Incident. All Injury(ies) due to the same Accident shall be deemed to be one Incident.

The term "Injury(ies)" shall mean bodily Injury(ies) listed in the most recent edition of the International Classification of Disease(s) ICD-9-CM, which is the required reporting tool for all diagnoses and Disease(s) to all U.S. Public Health Service and Health Care Financing Administration programs and caused solely and directly by Accidental , external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event(s) under this Certificate.

The term "Inpatient" shall mean a person who is confined in an institution for a period of 24 hours or more and is charged for room and board.

The term "Insurance" shall mean the Coverage described and provided under this Certificate.

The term "Insured Person(s)" shall mean a person eligible for Coverage under the Certificate as stated on the ID Card, who has applied for Coverage and is named on the Application and for whom the Company has Approved for Coverage and accepted the corresponding Premium. This may be the Primary Insured Person or Dependent(s).

The term "Intensive Care" or "Coronary Unit" shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

The term "Loss(es)" shall mean, in reference to quadriplegia, paraplegia, hemiplegia and uniplegia, the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through or above the wrist or ankle joints, and, with regard to eyes, entire irrecoverable loss of sight.

The term "Manifest(ed)" or "Manifesting" shall mean the demonstration of the presence of a sign, symptom, or alteration, especially one that is associated with a Disease(s) process.

The term "Medically Necessary" or "Medical Necessity" shall mean services, Treatment(s) or supplies received by the Insured Person(s) that are determined by the Company to be: 1.) Appropriate and necessary for the symptoms , diagnosis, or direct care and Treatment(s) of the Insured Person(s)'s medical conditions; 2.) Within the standards the organized medical community deems good medical practice for the Insured Person(s)'s condition; 3.) Not provided solely for educational purposes or primarily for the convenience of the Insured Person(s), the Insured Person(s)'s Physician(s) or another Service Provider or person; 4.) Not Experimental/Investigational and/or for Research; and 5.)

Not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment(s).

For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person(s) is receiving or the severity of the Insured Person(s)'s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting.

The fact that any particular Physician(s) may prescribe, order, recommend, or approve a service, Treatment(s), supply or level of care, does not of itself, make such Treatment(s) Medically Necessary or make the charge a Covered Expense(s) under this Certificate.

The term "Medicine" or "Medications" shall mean the drugs and/or anesthetics prescribed by a Physician(s) and dispensed to the Insured Person(s) by a licensed pharmacist, as a result of a Covered Expense(s). Medicine or Medication shall mean the generic equivalent of a drug, or if the generic equivalent is not available, the brand name drug. Medicine or Medication shall mean only prescription drugs.

The term "Mental Illness" shall mean mental, emotional, and psychiatric disorders, Illness(es) or conditions (whether organic or non-organic, whether biological, non-biological, genetic, chemical or non-chemical in origin). Mental and nervous disorders include, but are not limited to psychoses; neurotic disorders; bipolar disorders; affective disorders;

personality disorders; psychological or behavioral abnormalities, associated with transient or permanent dysfunction of the brain or related neurohormonal systems; and disorders, conditions, and Illness(es) listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders IV-R or the most recent edition of the International Classification of Disease(s) ICD-9-CM , which is the required reporting tool for all diagnoses and Disease(s) to all U.S.

Public Health Service and Health Care Financing Administration programs on the date the medical care or Treatment(s) is rendered to an Insured Person(s).

The term "Newborn" shall mean a Child(ren) born from an Eligible Pregnancy who is aged 14 to 31 days.

The term "Occupational Disease" shall mean a Disease(s) arising out of employment that is caused by a hazard recognized as peculiar to a particular trade, process, occupation or employment as a direct result of continuous exposure to the normal working conditions of such employment.