HomeMy WebLinkAbout95-07365
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IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY
PENNSYLVANIA
HEALTHSOUTH OF MECHANICSBURG, INC. I
175 Lancaster Blvd. I
Mechanicsburg, PA, 17055 I
plaintiff, I
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CIVIL ACTION . LAW
vs.
DOCKET NOI
1~'} 7j{~ I( ( I( ~ L Jlul"""
AETNA LIFE INSURANCE COMPANY
AETNA HEALTH PLANS.23
3541 Winchester Road
Allentown, PA, 18195.0503
tdba
and
JURY TRIAL DEMANDED
ITT HARTFORD INSURANCE GROUP
1000 Colonial village Lane
Lancaster, PA, 17605
Defendants.
NOTICE
You have been sued in Court. If you wish to defend against
the claims set forth in the following pages, you must take action
within twenty (20) days after this Complaint and Notice are served,
by entering a written appearance personally or by an attorney and
filing in writing with the Court your defenses or objections to the
claims set forth against you, You are warned that if you fail to
do so, the case may proceed without you and a judgment may be
entered against you by the Court without further notice for any
money claimed in the Complaint or for any other claim or relief
requested by the plaintiff. You may lose money or property or
other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ON!':, GO '1'0 OR TELEPHONE 'l'HE
OFFICE BET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELPI
cumberland County Courthouse
Court Administrator
One Courthouse Squaro
Carlisle, PA, 17013
(717) 240'6200
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IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY
PENNSYLVANIA
IlEALTHSOUTH OF MECHANICSBURG, INC.
175 Lancaster Blvd.
Mechanicsburg, PA, 17055
plaintiff,
CIVIL ACTION . LAW
DOCKET NOI
vs.
AETNA LIFE INSURANCE COMPANY tdba
AETNA HEALTH PLANS-23
3541 Winchester Road I
Allentown, PA. 18195-0503 I
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and I
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ITT HARTFORD INSURANCE GROUP I
1808 Colonial Village Lane I
Lancaster, PA. 17605 I
Defendants. I
JURY TRIAL DEMANDED
NOTICIA
Le han demandado a usted enla corte. si usted quiere
defenderse de estas demandas expuestas en las paginas siguientes,
usted tiene viente (20) dias de plazo al partir de la fecha de 1a
demanda y 1a notificacion. usted debe presentar una apariencia
escrita 0 en persona 0 por abogado Y archivar en la corte en forma
escrita sus defensas 0 sus objeciones alas demandas encontra de su
persona. Sea avisado que si usted no se defiende, la corte tomara
medidas Y puede entrar una orden contra usted sin previa aviso 0
notificacion y por cualquier queja 0 alivio que es pedido en 1a
peticion de demanda. usted puede perder dinero 0 sus propiedades
o otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABODAGO 1MMED1ATAMENTE. SI NO TIENE
ABOGADO 0 S1 NO TIENE EL E1NERO SUFIC1ENTE DE PAGAR TAL SERVICIO,
VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE
ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUE~E CONBEQUIR
ASISTENCIA LEGAL.
cumbsrland County Courthouse
Court Administrator
One Courthouse Square
CarliSle, PA, 17013
(717) 240.6200
IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY
PENNSYINAN1A
HEALTHSOUTH OF MECHANICSBURG, INC.
175 Lancaster Blvd.
Mechanicsburg, PA. 17055
Plaintiff,
CIVIL ACTION . LAW
DOCKET NOI
vs. I
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AETNA LIFE INSURANCE COMPANY tdba I
AETNA HEALTH PLANS-23 I
3541 Winchester Road I
Allentown, PA. 18195-0503 I
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and I
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ITT HARTFORD INSURANCE GROUP I
1808 Colonial Village Lane I
Lancaster, PA. 17605 I
Defendants. I
JURY TRIAL DEMANDED
COMPLAINT IN ACTION FOR DECLARATORY JUDGMENT
Pa, R.C.P. Rule 1601(e)
1. PLAINTIFF, Healthsouth of Mechanicsburg, Inc., formerly
Mechanicsburg Rehabilitation Systems, is a medical treatment
facility located in the City of Mechanicsburg, County of
Cumberland, in the Commonwealth of Pennsylvania.
2. DEFENDANT, ITT Hartford Insurance Group, is a corporation
organized and existing under the laws of the State of New York,
engaged in the business of insurance, and having substantial
business contacts in the Commonwealth of Pennsylvania, with its
principle place of business in the commonwealth of Pennsylvania
located at 1808 Colonial Village Lane, Lancaster, PA. 17605.
1
3. DEFENDANT, Aetna l,iCe Insurance company tdba Aetna Health
Plans'23, is a corporation organized and existing under the lawa of
the State of Connecticut, engaged in the business of insurance, and
having substantial business contacts in the commonwealth of
Pennsylvania, with its principle place of business in the
Commonweslth of Pennsylvania located at 3541 Winchester Road,
Allentown, PA, 18195.0501.
4. This is an action for Declaratory Judgment pursuant to 42
Pa, C.S. 5 7531 et seq., for the purpose of determining a question
of actual controversy between the parties as hereinafter more fully
appears. The purpose of this action pursuant to 42 Pa, C.S. 5 7541
is to afford relief from uncertainty as to the status and legal
relations of the parties.
5. Jurisdiction of this Court is based on subject matter
juriSdiction according to 42 pa CS 55 7532, the patient's treatment
was provided by the provider, plaintiff, in Cumberland County.
COUNT I
Allegations of Faot
6. On May 29, 1992, Christopher Fallon was driving a company
car when he experienced blurry vision, lost control of the vehicle
and orashed into a construction barrier. Mr. Fallon was immediately
transported to the Fick Community Health Center in Mt. Pleasant,
PA,
7. Mr. Fallon was then transferred to the Hershey Medical
Center. Mr. Fallon was treated for cardiac contusions,
gastrointestinal bleeds and a confused and very aggressive medical
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state.
8. Mr. Fallon was transferred to the Plaintif f' s facili ty on
June 16, 1992. Mr. Fallon was treated at Mechanicsburg
Rehabilitation System ("MRS") for serious confusions and for
threats of suicide, for which he received one-on'one supervision.
9. Mr. Fallon was discharged from MRS on July 6, 1992 and
transferred to The Woods, a managed care facility. He died there on
August 2, 1992.
10. Defendant Hartford Group ("Ilartford") is the carrier for
Mr. Fallon's worker's compensation and his auto insurance pOlicies.
Defendant Aetna Insurance ("Aetna") is the carrier for Mr. Fallon's
commercial health insurance policy.
11. Employees oC MRS made mUltiple phone calls to all three
insurance carriers over the course of Mr. Fallon's treatment at
MRS. MRS sought to determine which insurance carrier would be
covering the expense of Mr. Fallon's medical services at MRS.
12. MRS' s "payor Interaction Sheet" indicates that most of
the phone calls made to the Defendants were unreturned.
13. On June 12, 1992, in a phone conversation with a MRS
employee, Hartford, acting as the worker's compensation carrier,
stated that they were denying coverage of Mr. Fallon's medical
expenses because of prior dizzy spells that suggested that Mr.
Fallon suffered a stroke immediately prior to his auto accident on
May 29, 1992.
14. There is no conclusion in Mr. Fallon's medical records
that he suffered from a stroke at the time of the accident.
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15. On June 12, 1992, Aetna informed an MRS employee in a
phone conversation that MRS was a qualiCying hospital under their
pOlicy and that they would certify MRS for ten days of care for Mr.
Fallon.
16. On June 18, 1992, a letter was received by MRS from Aetna
which stated that Aetna would provide nine more days of
certification for treatment under their plan.
17. As of November, 20, 1995, there are more than $29,000. in
outstanding medical bills for the treatment of Mr. Fallon.
18. Agents of the estate of Mr. Fallon have tried to
ascertain which of the two Defendants should be responsible for the
coverage and payment of Mr. Fallon's medical treatment. Neither of
the Defendants have responded to said agents phone calls and
correspondence.
COUNT II
Allegation of Actual Controversy and Harm
19. paragraphs 1 through 18 are incorporated herein by
reference as though set forth in full.
20. plaintiff expended large amounts of medical expertise,
personnel and resources to provide care for the Defendants'
insured, Christopher Fallon.
21. plaintiff has not received any payment by the Defendants
for the care of their insured, Christopher Fallon.
22. plaintiff has Buffered economically because each of the
Defendants refuse to address questions and claims as to their legal
status as to the primary insurance carrier with respect to the
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claims arising out of Christopher Fallon's automobile accident and
subsequent treatment by Plaintiff's medical facilities.
WHEREFORE, plaintiff Healthsouth of Mechanicsburg, Inc. prays
thatl
1. The Court enter a Declaratory Judgment that determines
whether Defendant Hartford's worker's compensation or auto
insurance, or Defendant Aetna' s commercial health insurance policy
has primary coverage with respect to claims arising out Christopher
Fallon's automobile accident and his subsequent medical treatment
by the plaintiff I and
2. The Court grant such other and further relief as may be
proper.
DATED I December 7, 1995
ARE, Esquire
for plaintiff
1776 B. Queen Street
York, Pennsylvania 17403
(717) 846 -3000
I.D. No. 18631
\clc\llllcn\dlcjudq.c.-
5
12.12. Be; 1012BAM ..RICHARD OAR.. ..101
P02
YJlI.tr:J:CATION
I verifY that the statements made in the foregoinq complaint
are true and correct to the best of ~ knowledqe, information and
b81ief. I undentand that false statements herein are made subject
to the penalties of 18 Pa. C. S. 4904 relating to unllworn
falllification to authorities.
Date, /2 ~/~-J?r
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SHERIFF'S RETURU - OUT OF COUNTY
CASE NOI 1995-07365 P
COMMONWEALTH OF PENNSYLVANIA I
COUNTY OF CUMDERLAllb
HEALTSOUTH OF MECHANICSDURG
VS.
AETNA LIFE INSURANCE CO ETC
~J1Qmas Kline , Sheriff, who being duly sworn according
to law, says, that he made a diligent search and inquiry for the within
named defendant. to will ITT HARTFORD INSURANCE GROUP
but was unable to locate
Them
in his bailiwick. He therefore
~ County, Pennsylvania.
deputized the sheriff of LANCASTER
to serve the within COMPLAINT
On ~_Jan\.larL. 19th, 19~6
the attached return from
Sheriff's Costs I
. this office was in receipt of
LANCASTER
County, Pennsylvania.
50 answers I
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rr.~!~~:<~1~';'~, /Sher Hf
6.00
9.00
2.00
32.00
.~~, RICHARD DARE
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5worll alld subscr-ibetJ l-o before me
this _J/~ day Of(~.'r ~_
19--&___ A. D.
Docke-Ung
Out of County
Surcharge
LANCASTER COOUNTY
Ch~' ...L1ilf.:/
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CASE NOI lY~5'07JG5 P
c0l1110NWEALTlt OF PENNSYLVANIA'
COUNTY OF CUM"ER1,AN~
IlEALTSQlITH ~!L.!!~CltfillJfEIJU!ill_,..
VS.
~ETNA LlEli_Jl!SUI1!lNCE CO ETC
JL__TI1~~~lillll~ ' Sheriff. vho being duly svorn according
to lav, says. that he made a diligent search and inquiry for the vithin
named defendant, to vitI _lTT Il^RTfQRP--D!RURANC~ GROUP
but vas \Jnable to locate ,_'____Ih~!!!_..- 1n his bailivicl~. He therefore
deputized the sheriff of _......-hMI!;;~~TER.____.._-- County. Pennsylvania.
to ANV,? the vithin ,j;:.Ql1t1AlRL..----.-. -.----
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On )~n\lj!u._...J9111J._!.99.!L--__.__._.' this office vas in receipt of
the attached P?turn from LA!ic;l1J5Tt.IL County, Pennsylvania.
Shenff's Costal
poclleting
out of County
Surcharge
LANCASTER COOUNTY
50 auaversl
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R:''I'llomns-l\nne'-1n,'er iff
6.00
9.00
2,00
32.00
G49:"0~ RIClIARD DARE
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~;Ilr.1i IFF'::; IlETIIHIl
CASE NOI 1995-07Jb5 r
COMMONWEALTH OF PENNSYLVANIAI
COUNTY OF CUMBERLAND
OllT OF cuUNTY
tlEALTSOUTH OF" MECliA.IiH;SIlUfiq.___
VS.
MH!J!I--.hl FE INSURANCE eo Ere
.JL...Jllomas Kline . Sheriff. who being duly sworn according
to law, Baye. that h~ made a diligent search and inquiry for the within
named df.'fendant. to wit I AETIlA I.IrE ItlIDJ.lJ.A..tli;E COMPA.liL_ __
TDIlA AETHA HEALTH PLANS-2~
but waa unable lo locale Them 1n his bailiwick. He therefore
depulized lhp sheriff of LEHIGIL
to serve lhe within _CO.tlJ:WUliI
Counly, Pennsylvania.
---------,---------_._-~~--_.~-,._._--------------~------_.~
On,Il'!n.!1.i!r_y._....1.'2~h,__..u19G_______., this office was in
rec...ipt of
Penney 1 vani '1.
Lhe attached reLurn from
LE1li.!ill._____.......__ Counly,
Sh~ri1i'G Coetsl
Docketing
Out 01 County
Surchar\1e
LEH 1G11 COUNTY
So anewel'V I
18.00
9.00
2.00
29. 15
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Rf.rfii'n;:i'.:Rrrn~~il~r if f
~DS:'IS RICIlARD OARE
01/1911995
Sworn and oubecribed to before me
t h 113 __J!. ,..t _ day (1 f 4!&!.H!~ ___._...
19.._'l.1!_ A. D.
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CASEI 95-NC-QQ10
EXPIRI 2B-Jan-199G
!:it:POSl T I 2''''. 1 ':;
HEAL THSOUTH DF MEeHAN J LUElUr,G, I NC .
VS
AENA LI FE I t~SUn,)NCE CDMF'AllY 11 P I lil A
AElNA HEI\!. TIi PLAI~G -I~,.
95-7365 C 1 V I L TERM (CUMBEr,L At~[1 CrJI.lI~lY)
WRIT I NOTICE OF COMPLAINT IN m:TIoN FOR
PECLARIHORY .llJnG11EI~ r
SEIWE I AETNA LIFE IN8URI~NCE Cll.
AT I AE1NI\ HEA1_TH PLANS 23 ;.":"qj WINCHESTEr<
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hO(.\[1 ALL ENTCIl~N, PA
181 '35-(1~:1():7,
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RETURN OF SERVice
1. NAME OF I ND [V I DUAL SERVED: _.4jll.(~._BJ.11_b l<au..l':l.L._..___.__._..______
e. RELAT I ONSH I P TO DEFENDAN11_~80.^:t....-...--..---...--..--.-.-------..-
3. DATE: _L:::-!:/.. 192.k. T I t1E : _._._L~~L3S.-----..-.. HOURS 1___._._
'I. LOCATION OF SERVICE, '2.l~ 'fL_.~!t'\r...bJ'-c..lA-..nn..---......-.--..........---..-.....-..
....lJILtd..1-u-I^."-1.nn... ....... ..__ ..___n_....__..._
5. UNABLE TO LOCATEI
( ) NUMBER OF A TTEI1F'TS TlJ LOCATE: [IEFnWI\NT AT LAST "'N[)WI~ AU[lREl,S I
1. DATE f., TINE
e. [JA1 [ \'. 11I1E
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3. [IIHE ", TI~lE
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[ I HEREEIY CERTIFY THAI I AI1 AU1HOf1l2'1:11 lO ,:0 HO,. .
~ t11MY (1 . i'rlr:t!lJJllliL ___.....__ If~..':..~ .~. A:, _d::.w.-:.f.k...-------
I PRINTED t-IA~lE OF AUTHor~I:Eb' Al3EN1 Sll1WntRf ~lI.THIJRJ:'Eli IWiENT
! DATE, __..L=__-:i._- (Lk. r I I' IE I .nI':i...J.S... FJ/Ll___...
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t:7 l/ '11..a ./)..1. ',III r,[1f OF I.FHIGH CUllll1Y
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'5. DATE t: TIME
t,. IIA TE f., 11 ME
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ACCEPTANCE OF SEIWIFT
I HEREBY ACCEPT SERVICE OF THE LEGAL PROCESS
DOCUMENT. THIS SERVICE IS ACCEPTED IlN BEllti!.!'
1\8 Oil 1l11'ILll ON IIIE FRONT elF THE
OF THE LIb I ED DI!FENl'nNT (G) AND
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Healthsouth of Mechanlcsburq
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Actna I,He Insurance company
Atena Health I'lans-23 .
ltd. b.;t'
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:iow1
necember 29
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SHERIFF'S OFFICE
'Ill HlllIlIIIHJk.1 ~i1IU 11 I MH :^~; 1111 PI rHj~IYI VMW\ ,,'.,n,' . (11" ~1!J~J 1l;'UO
StlERIFF SERVICE
PROCESS RECEIPT, and AFFIDAVIT OF RETURN
",-p'CAiNllrr,s
IIEALTHSOUTII OF MECIIAN I csmll\G.
3- DEFENIJANlI6!
INSlIIUI liONS fun 6t1W1C( Of flROCE89 un Ihe IeVlHI. of Ih, las' (NO
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95-7365
j';1 I YI'1 t II WIl11 (JH UJMI'I ^lt~l
COMPLAINT
:J:
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AT
INSllllANCE GROllI'
,) tl^'," III ItIlIIVIIII,^1 1I1MI'Mji' {11IU'tln^11l1f~ 'If' 1I11l! :,1 IlVI II
I'r'r IIAII1'FOIlD INSURANCE GROUP
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7 INIJICAII
Now,
1000 COLONIAL VII,LA,]E (,ANE, LANCASTER, PA. 17605
Ul4\ JStlM ~;II\V!\ I t (lM'~1 IN Of I'A 1l11'1I11/1 \11 Hill
. I. SHEI1I1T OF LANCAS1Hl COUNTY, PA, do horelly deputiZe Ihe Sherill 01
Count V to oxeculo Ihls Will and moko return the real according
to law TIm; deplltatlon hUlI1U modo ot the roquosl and fisk of tho plllinllll. l;,;tliH, '!A'!i~~fEU'!i'!i~!-=_'~~_~~:_-~_~~~_"_____~".
i. SPECIAL INSTIlUCTIONS OR OTIIER INFORMATION THAT WILL AssisT IN EXPEDITING SERVICE:
III
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NOlE ONLY APPLICABLE ON WRll OF EXECUTION: N B. WAIVER OF WATCHMAN All\, tit'lllJ!)' shetlllll'vYlII1l ujlon III l1l1flChlllg till)' 111UpCt1y llIuim
wllhln WHlll1ilY liJa\i,1 ",\tilt" wlUlllul il ,^ilhtllllilll !II l:il!,!n'ly 01 ,^h(l!llt'w~1 Iii 'mUlti !Il POf;!it)b~hlll altP.ll1nl,I,lny 11l'I'illll llllev't' ut itllar/lflll'1I1 w,Ihoul Iiijblhl~ on
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~i-6IiiNATlJRE III ATTORNEY 'H 1l1l11'1 ORIGINATOR
1111\ 111I P\'''W 1,0Mmll 1" IIA1L 12-2S-95
I IKRIE"RR. 1-717-~46-3000 lKaBKl1
(thl. atellll1ull be cOltllllelod 1I1l0llce 'I 10 hI nlBlled)
CUMSERLAND CO SIIERIFF PAID ADVANCE COSTS
il SEND NOTICE OF SERVICE COP V TO HAME AND ADDRESS DELOW
1] 11ICkllllwl"dql' IHPII.11,lllil' Vi",}
(II' 'JIlII'I,I'1l1 H!i Il1dli,I\!'1I HbLlvP JUDY MORRIS 29~ 360!J
Iti I 11t'II'lit CERTIFY ,11,,1 RETURN p,.,\ I hh" Id'I""'''I'I~ ""1.,,1 .,.1:':10'1' II',!,I' I'vlh..; ,.1 '..'," I'd',
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NAME 1,1 A'IU""'/I',llCSD {JI'11111, 'I ('1,,1.
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1-26-96
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In. TMt!J Court cf C.:mmO~i ?le::s or C:.J:'..:..:~lt'l::nd (;.:H'::-;':Y, Panr:syl'lc:r:i::
Healthsouth of Mechanicsburg Inc
'IS.
1 tt Hartford Insurance ,Group
:-low, nc,",o.mhnr ")9
h=b)' d=FUC:: th: S~E of
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95-7]65 Civil
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01
ORIGINAL
II TBI COURT or COMMOI PLIAI rOR CUKBaRLAMD COUNTY
,....8YLVlUIlA
HBALTHSOUTH OF MECHANICSBURG,
INC.
CIVIL ACTION - LAW
plaintiff
v.
DOCKET NO.1 95-7365
AETNA LIFE AND CASUALTY
COMPANY AND ITT HARTFORD
INSURANCE GROUP
Defendants
HOTICI or RINOVAL TO rlDIRAL COURT
TOI The Clerk of the Court of Common Pleas of Cumberland county,
Pennsylvania
Richard oare, Esquire
1776 S. Queen Street
York, PA 17403
Please take notice that on February 5, 1996, Defendants
caused to be filed with the united states District Court for the
Middle District of Pennsylvania a Joint Notice of Removal of the
above-captioned caee to said district court pursuant to 28 U.S.
Code sections 1331, 1441, and 1446 and 29 U.S. Code section 1132.
A copy of all papers filed in the United states District court
for the Middle District of Pennsylvania are attached hereto and are
hereby filed of record with this Court.
NJlI.\
,
,....10....
-
'aT"l , ...ILlrlal
BYI
steve Moore, Esquire
2931 N. Front street
Harrisburg, PA 17110
(717) 238-7555
Attorneys for Defendant ITT
Hartford Insurance Company
CUIITII, tABARUI, 1l0RTUI..
all4 YOUIIG
A Professional corporation
Jame . Yo
Michael J.
1880 J.F.K.
Tenth Floor
Philadelphia, PA 19103
(215) 587-1600
BYI
Attorneys for Defendant, Aetna
Life Insurance company t/d/b/a
AETNA Health Plans
Mm.1
CIRTIrICATI or IIIVICI
This is to certify that the undersigned on February 9, 1996
have caused to be served Defendants' Notice of Removal to Federal
Court upon all other parties to this action by depositing a copy,
postage prepaid in the United states mail addressed as followsl
Richard Oare, Esquire
1776 S. Queen street
York, PA 17403
PITBRI , WASILlrSKI
BYI
steve Moore, Esquire
2931 N. Front street
Harrisburg, PA 17110
(717) 238-7555
Attorneys for Defendant ITT
Hartford Insurance Company
CHRISTIB, PABARUI, KORTIKIIK
and YOUNG
A Professional Corporation
BYI
James A. Young
Michael J. Bu s, Esquire
1880 J.F.K. B u1evard
Tenth Floor
Philadelphia, PA 19103
(215) 587-1600
Attorneys for Defendant, Aetna
Life Insurance Company t/d/b/a
AETNA Health Plans
94221.1
J5U
In" 01 fUll
ORIGINAL
CIVIL COVER SHEET
'to, JS" 1,.,1 10." I"'" I'>d I~' .hIO'"',I'lllI tll"II""'1 "f"'" 'If I"" 'IV'.' "0' ",1'1"""'''1 ''', 1,1'''1 ''''I ",.". ul I"......'~I ". Ill"" l'fI"'1 tI "'1'1"'<1 "1 'I" "111'1 111",,,,,''''1,, IUt "
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I"'" IllllNllflUCllONI mw IItI IUVIIUI Of tHl '0""1
I (a) PLAINTIFFS
IIEAI.TIlSOUTII OF HECIlAN1 CSIlUlll;, I NC.
DEFENDANTS .
AETNA 1.1 FE ANU CASUA1.TY WHI'ANY AND
ITT IIAHTFOIUl I NSUHANCE I;HOUI'
(b)
ClImlw rl II lid
cov~" 01' AE510E~CE O' FlASI LISIEO PV.I~lI"
IUCEPlI~ V S PV.I~IIf' CASESI
COU~IY OF AESIOE~CE O. FlASI LiStED DEFE~OA~' ...__~th____
IIN u 6 PLAINtlH CASES ONlYI
NotE IN LAND CQNOEUNAlION CASES u&E tHE LOCAtiON OF HIE
fAAC' OF LAND INVOlVED
(e) AnOA~"SIFlAlA ~'lAE AOOAESS A~O IElEPHO~E WlAOEAI
A"ORNE VB Ilf ~NOWNI
,'. 1 ,.' . I
.JUIllCli A. Young, i'.Hllu ru
HlcllIl~1 .I. 1l1lrllH, Ehqlllr~
ChriHtie. Pnharuu, NurtullHUIl und Youll~
111110 .IFK Illvd.. 10th F1uur, I'hllll.. I'A
I..
If, II,; ,.II,
'f' 1'1.,,1 ,
IUehnrd Onre, E8qulre
1776 S. QlIeell Street
Yurk. I'A 17403
1910)
1(,00
II. BASIS OF JURISDICTION
Ifl\ll(;l'Iif,""IOItH."
III. CmZENSHIP OF PRINCIPAL PARTIES ."".,~.....",.
tFa O'f....ry c.... 0nIt'1 '0Il ~I.' WI ~ ~I'~ P",lCWffl
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IV. CAUSE OF ACTION It''.'Mlu.tMlI''fV11~.~fO.I'''''IlHI''''_'1''''''''''''I4IfIOltAUM
L:1 =1
OOfrlOl("1 ~\lXIOoIAl.I''''lIllIlN.'''(JI''''1ilIIlh'1
A8 tu Aetlln, claim for I'lIym~"1
SIOOI, et. Heq.; SlIl'l'l~lne"tary
Ill' hellllh I"H"ra"C~ h~"efltH ullder
lurlHdlclloll over Hlal~ law cJallllH
EHISA. 29 U.S.C.
IIMal1l8t ITT lIortfurd.
V. NATURE OF SUIT IPl.'CE AN . IN ONE BOX ONIl,)
CONIMCt 10111 'O"'IIfURI,""Aln '1
:~110'__, P'lIUQMAL INJun "1lONllllIJ\JftT '10~. ~~ . U AaPt..
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VI. ORIGIN
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VII. REQUESTED IN
COMPLAIN'f.
VIII. RELATED CASE(S)
IF ANY
DEMAND S
CttEC' " !IllS IS' CLASS AcnON
~l UND(nfllcp n
ChIC' t( 5 P"'~ II l1,m.'IfIf'O ./1 (jJ"'pI..n,
JURY DEMAND: 'IS XlO(NO
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107'11"1
.
For ITT Harttordl
steve Moore, Esquire
Peters , Wasiletski
2931 N. Front street
Harrisburq, PA 17110
(717) 238-7555
A'
.."
UNITBD STATBS DISTRICT COURT FOR THB
MIDDLE DISTRICT OF PENNSYLVANIA
to~r
I
IlEALTHSOU'rH OF MECIlANICSBURG, I
INC. I
Plaintiff I
CIVIL ACTION NO. 95-7365
v.
:""'1) ~ ~A f I'.~~"'(P, j.D3 FILED
: ~ liARRISBURG, PA
: ~ FEB 2 '~Qi
I
I
I
I
AETNA LIFE AND CASUALTY
COMPANY AND ITT HARTFORD
INSURANCE GROUP
~:rv a. ~R'A, QLERI<
epu 1 Olerk
Defendants
DBFBNDANTS' JOINT NOTICB OF RBMOVAL
TOI The Clerk for the United states District Court for
the Middle District of Pennsylvania
Defendants, AETNA Life Insurance company t/d/b/a AETNA Ilealth
Plans - 23 and ITT Hartford Insurance Group by and through their
respective counsel, hereby consent to and join in and give joint
notice of removal of this cause of action from the Court of Common
Pleas of cumberland county, Pennsylvania in which this action is
now pending, to the United states District Court fot the Middle
District of Pennsylvania pursuant to 28 U.S.C. S 1441, It JAg. and
in support thereof avers as fol1owsI
1. Plaintiff Hea1thsouth of Mechanicsburg, Inc. is a
corporation which upon information and belief is an organized,
existing, and/or incorporated in the commonwealth of PennsYlvania
and located at 175 Lancaster Blvd., Mechanicsburg, PA 17055.
.y
- ..
2. Defendant ITT Hartford Insurance Group ("ITT Hartford")
is a Conneoticut corporation with a prinoipa1 place of business at
1 Tower Square, Hartford, Connecticut 06183.
3. Defendant AETNA Life Insuranoe company t/d/b/a AETNA
Health Plans - 23 ("AETNA") is a connecticut oorporation with its
prinoipa1 place of business at 151 Farmington Avenue, Hartford,
conneoticut 06156.
4. Plaintiff commenced this oivil aotion by filing a
complaint in the court of Common Pleas, cumberland county,
Pennsylvania entitled Healthsouth of Hechanicsbura. Inc. v. AETNA
Life Insurance ComDanv t/d/b/a AETNA Health Plans 23 and ITT
Hartford Insurance Groue, at Docket Number 95-7365.
5. A true and correct copy of the state court record
consisting of the Complaint is attached hereto and incorporated
herein as Exhibit "A". Said document constitutes all process and
pleadings served upon defendants in the state court action as
required by 2S U.S.C. S 1446(a).
6. On Deoember 28, 1995, plaintiff filed its Complaint in
the Court of Common Pleas of cumberland county, Pennsylvania. ITT
Hartford received the Complaint on January 16, 1996.
AETNA
received the Complaint on January 4, 1996.
Accordingly, this
Notioe of Removal is timely under the provisions of 28 U.S.C. S
1446(b) in that defendants have filed this Joint Notioe of Ren,ova1
~ ...
within thirty (30) days of receipt of the service of process.
7. plaintiff's complaint is related to a claim for the
payment of medical bills by defendants for treatment rendered by
plaintiff to Christopher Fallon, as set forth more fully below.
B. Upon information and belief, at all times relevant, Mr.
Fallon was an employee of the American society of composers,
Authors and publishers ("ASCAP").
9. Plaintiff's complaint seeks recovery and payment of
medical benefits under and pursuant to a group health insuranoe
plan established by Mr. Fallon's employer ASCAP and funded by the
purohase of group health insurance from AETNA. Attached hereto and
inoorporated herein as Exhibit "B" is a true and correot copy of
ASCAP Group Life, Accident, and Health Insurance Po1ioy number GP-
392514 effective 1/1/92.
10. plaintiff'S Complaint seeks recovery against AETNA of
benefits under an "emp1oyee welfare benefit plan" as that term is
defined by the Employee Retirement Income Security Act of 1974, 29
U.S.C. S 1001 ~~. ("ERISA").
11. As to ITT Ilartford, plaintiff'S complaint seeks payment
of medical bills for treatment rendered by plaintiff to Christopher
Fallon under Mr. Fallon's worker's compensation and auto insurance
policies issued by ITT Ilartford.
..
, J).
12. This court has original subject matter jurisdiction over
the within matter pursuant to the ERISA, 29 U.S.C. 5 1132(e) and 28
U.S.C. 5 1331. Further supplemental jurisdiction is conferred over
all other parties under 28 U.S.C. 51367 and removal is proper under
28 U.S.C. 51441(C) as well.
13. There are no other named defendants whose consent/joinder
is required in order to remove the instant matter, all named
dsfendants joining in and oonsenting to the removal of the within
matter.
WHEREFORE, defendants ITT Hartford and AETNA hereby jointly
give notioe of removal of the above aotion now pending in the court
of Common Pleas of cumberland county, pennsylvania to the united
States Distriot Court for the Middle Distriot of PennsYlvania.
This action will therefore prooeed in this oourt as an action
properly removed thereto.
".......
PETBRS . WASILBF8KI
BYI st~;o~~~'~
2931 N. Front street
Harrisburg, PA 17110
(717) 238-7555
Attorneys for Defendant ITT
Hartford Insuranoe company
OHRI8TIE, PAnARUE, KORTBMSBM
an4 YOUNG
A Professional corporation
DATBDI~
BYI
Ja es A. You g, Esqu re
Miohael J. B rns, Esquire
1880 J.F.K. Boulevard
Tenth Floor
Philadelphia, PA 19103
(215) 587-1600
Attorneys for Defendant, Aetna
Life Insuranoe Company t/d/b/a
AETNA Health Plans
_~, 1.."J~
..... A
.
"
'/ ,
'.
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"l'._____Jiha1____. ~ITJ11fW
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r-e
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. .
,
Policyholder No. 392514
RIDER
ATTACHED TO AND MADE A PART OF GROUP POLICY NO. GP-392514
A CONTRACT BETWEEN MTNA LIFE INSURANCE COMPANY AND THE POLICYHOLDER
AMERICAN SOCIETY OF COMPOSERS,
AUTHORS AND PUBLISHERS
It is understood and agreed thatl
"Group Policy No. GP-392514 (originally effective February 1, 1_982) ill
restated (that is, "amended in its entirety") effective ~anuary 1, 1992."
Nothing contained in this rider shall be held to alter or affect any of
the terms of the policy other than as herein specifically stated.
IN WITNESS WHEREOF, the ~TNA LIFE INSURANCE COMPANY has signed this rider
at HARTFORD, CONNECTICUT, to become effective January 1, 1992.
Signed by the Insurance Company February 9, 1993.
;r7J/~L__/~ ..a~
~~t;a~/-"
~1i~
Legal Director
Signed by the Policyholder ~cL 2., I'" ,
GR-23-R1
Ed. 9-'57
,~... EXECIlTt AND R[JU~H THIS COPr TO
AI1'M lifE INSURANCE COMPMY
9980
.
.
.
INDEX
POLICY CONTENTS
PART I
ELIOIBLE CLASSES - CHANOES -
SPECIAL PROVISIONS
PART II
POLICYHOLDER AND INSURANCE
COMPANY HATTERS
OR-29
0040
ED. 7-73
Page 9000
F205236
. .
POLICY CONTENTS
.
This policy consists of:
The Face Page, Index, this Policy Contents page and all ths provisions
of Parts I and III and
The provisions found in the Certificate(s) listed in this section.
The words "you" or "your" in any Certificate included in the policy, will
refer to a covered Employee.
The Certificate(s) included in this policy are as followsl
A "Certificate" consists of a Certificate Base document ("Cert. Base")
and any Summary of Coverage ("SaC") or Certificate Rider r "Rider") which
may be issued to support or amend the Cert. Base.
Identification
Issue Date
Effective Date
Cert Base-1
SOC-1A
01-28-93
01-28-93
01-01-92
01-01-92
Cert Base-2
SOC-2A
01-2B-93
01-28-93
01-01-92
01-01-92
OR-29
1508
ED. 6-86
Page 9010
f'205478
PART I
.
ELIOIBLE CLASSES
. All classes of employees of a Member Employer are eligible except thole
who are:
Part-time:
Temporary:
Substitute: or
In a class for which a Certificate is not in this policy.
An employee is eligible only for the coverages shown in the Certificate
which applies to his class.
If a Member Employer is a partnership or proprietorship, each of its
natural-person partners, or the proprietor, will be deemed to be an
employee. This applies only if the person is working on a mostly full-time
basis for the Employer.
.
GR-29
0150
ED. 7-73
Page 9050
F205823
.
PART I (Continued)
CHANGE IN AMOUNTS
EMPLOYEE COVERAGE (CONTRIBUTORY)
Status Change: If, at any time, the employee's rate of earnings or status
changes so as to warrant an amount of contributory coverage other than
that for which the employee is then covered, the amount of his coverage
will be changed as follows:
A reduction will be effective:
On the date the employee requests it under Life Insurance and
Accidental Death and Dismemberment Coverage.
On the date of the status change under all other coverages.
An increase will be effective on the date of the earnings or status
change. The Active Service Rule must be met. The employee may refuse an
increase in Life Insurance or Accidental Death and Dismemberment
Coverage. This must be done within 31 days of the date it would have
taken effect. If refused, no other increase because of the earnings or
status change will be made until the date Aetna gives written consent.
Schedule or Benefit Level Change: If, at any time, any schedule or level
of benefit is changed so as to warrant an amount of contributory coverage
other than that for which the employee is then covered, the amount of
coverage will be changed to the new amount. An increase will be subject to
the Active Service Rule.
The employee may refuse an increase in Life Insurance and Accidental Death
and Dismemberment Coverage. This must be done within 31 days of the date
it would have taken effect. If the employee later elects the increase, it
will be made on the date Aetna gives written consent.
GR-29
0190
ED. 7-73
Page 9060
F205239
PART I (Continued)
CHANGE IN AMOUNTS (Continued)
~MPLOYEE COVERAGE (CONTRIBUTORY) (Continued)
All Ch8ngesl A retro8ctive ch8nge in an employee's rate of earnings or
status will not result in a retroactive change in coverage. Any change in
coverage will be effective on the date the change in earnings or status is
made.
This section will not apply to reductions due to reaching a stated age or
due to retirement.
EMPLOYEE COVERAGE (NON-CONTRIBUTORY)
Status, Schedule or Benefit Change: If, for any reason 8nd at any time,
the employee's rate of earnings or status or any schedule or level of
benefit is changed so as to warrant an amount of non-contributory coverage
other than that for which the employee is then covered, the amount of his
coverage will be changed to the new amount. An increase will be subject to
the Active Service Rule.
A retroactive change in an employee's rate of earnings or status will not
result in a retroactive change in coverage. Any change in coverage will be
effective on the date the change in earnings or status is made.
This section will not apply to any applicable reductions due to reaching a
stated age or due to retirement.
GR-29
0190
ED. 7-73
Page 9062
F205328
PART I (Continued)
CHANG! IN AHOUNTS (Continued)
BEPENDENT COVERAGE
Status, Schedule or Benefit Level Change: If, for any reason and at any
time, a dependent's status, any schedule or the level of any benefit for a
dependent ie changed so as to warrant an amount of coverage for a
dependent other than that then in force, the amount of a dependent's
coverage will be changed to the new amount. An increase will be subject to
any Non-Confinsment Rule.
GR-29
0190
ED. 7-73
Page 9069
F205240
PART I (Continued)
OTHER CHANGES
, EMPLOYEE COVERAGE
Change in Eligibility Date: An increase in any required period of eervico
will apply only to an employee who enters service on or after the
effective date of the increase. A decrease in any required period of
service will permit an employee to become eligible on the effective date
of the decrease if he then hae worked the new period of oervice.
Otherwise he ie eligible on the date he completes it.
Change in Age Reduction Rule: If an Age Reduction Rulo IS changed and nn
employee is eligible for an increase in coverage due to such change, such
increase shall be effective only if Aetna gives its written coneent.
EMPLOYEE AND DEPENDENT COVERAGE
Addition or Deletion of a Benefit: Except as set forth in tho neMt
paragraph, if any benefit becomes applicable to an employee or a dependent
who is already covered under the policy, that person will he eligible for
that benefit right away. Coverage will be effective in lino with the
Effective Date provisions. This includes the Active Work Rulo ftnd any
Non-Confinement Rule.
If any Medical EMpense Benofit becomes applicable to an employee or a
dependent already covered under the policy for Medical EKpenee nenetite,
that person will be covered for that benefit right away. The Active
Service Rule and any Non-confinement Rule will apply. The Rulee will not
apply to any Major Medical or Comprehensive Medical EKpense Benetite up to
any stated dollar Maximum Benefit for the pereon under any such prior
coverage under the policy.
If any benefit no longer applies to an employee or a dependent, coverage
for that benefit will stop right away for that pereon. Any righte under
the benefit gained by the person while the coverage wae in force will not
be affected.
GR-29
0190
ED. 7-73
Page 9070
F20524lA
PART I (Continued)
SPECIAL PROVISIONS
A'CTIVE WORK RULE
If the employee is both disabled (that is: ill or injured) and away from
work on the date any of his Employee Coverage (or any increase in such
coverage) would become effective, the effective date of the coverage (or
increase) will be held up until the date he goes beck to work for one full
day.
NON-CONFINEMENT RULE
If a person has recently been confined on the date any Medical Expense
Benefits coverage to which this Rule applies would otherwise become
effective, or be increased, it will be deferred until he has either:
Been free of all confinement (at home, in a hospital or elsewhere) for
31 days; or
Aetna has received evidence adequate to it that the person no longer has
any disease or injury.
A "recent confinement" means either that:
The person is confined anywhere on the date coverage would become
effective; or
The person has been confined in a hospital during the 31 days prior to
thet date.
Application of the Non-Confinement Rule
The Non-Confinement Rule applies to:
Any Major Medical, Comprehensive Medical and Comprehensive Dental
Expense Benefit coverages shown in the Certificate for a dependent.
Any Medical Expense Benefits coverage for a retired employee and such
employee's dependent, and for any other person if the terms of the
Certificate, which applies to that person, state that the provisions
of the Rule apply. To find whether a "recent confinement" exists for
any person in this group:
^ "hospital confinement" will also include a nursing home
confinement.
The Rule does not apply to a newborn child who becomes covered within the
31 days after he is eligible.
OR-29
0170
ED. 7-73
Page 9072
F205329A
PART II
POLICYHOLDER AND INSURANCE COMPANY MATTERS
ur;CLARATIONS
The first "policy month" starts on
Each subsequent policy month starts on the
of a calendar month
January 1. 1992
first
The first "policy year" starts on
and ends on
Each subsequent policy year starts on a
It ends on a
January 1, 1992
January 31. 1993
January 1
January 31
MEMBER EMPLOYERB
Member Employers are those employers which are included under this policy
by written agreement between the Policyholder and Aetna.
An employer may be a Member Employer if not egainst the law of the
jurisdiction in which this policy is delivered.
The Policyholder may act for all Member Employers in all policy matters.
Each such act, or agreement made between Aetna and the policyholder, or
notice given by one to the other will be binding on all the Employers.
DATA REQUIRED
The Policyholder and each Member Employer must give Aetna all data
required as to policy matters. All data which may have a bearing on
insurance or premiums will be open for Aetna to inspect while this policy
is in force. Also, they must be open until the final rights and duties
under this policy have been resolved.
CLERICAL ERROR
Any clerical error by anyone in keeping records, or a delay in making an
entry, will not alone decide if insurance is valid. A fair change in
premiums will be made when the error or delay is found.
MISSTATEMENTS
If any fact as to a person to whom the insurance relates is found to have
been misstated, a fair change in premiums will be made. If the
misstetement affects the existence or amount of insurance, the true facts
will be used to decide if insurance is 1n force and its amount.
GR-29
1150
ED. 7-73
psge 9080
F'205333
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY MATTERS (Continued)
CONTRACT
This policy and application of the Policyholder are the entire contract. A
copy of the application is attached. All statements made by the
Policyholder or an employee shall be deemed representations and not
warranties. No written statement made by an employee shall be used by
Aetna in a contest unless a copy of the statement is or has been furnished
to the employee or his beneficiary, or the person making the claim.
LIFE INSURANCE - INCONTESTABILITY
With respect to Life Insurance
The validity of this policy shall not be contested, eKcept for
non-payment of premiums, after it has been in force for 2 years from its
effective date. No statement made by any insured employee relating to
his insurability shall be used by Aetna in contesting the validity of
the insurance with respect to which such statement was made after the
insurance has been in force prior to the contest for 2 years during the
employee's lifetime nor unless such statement is contained in a written
instrument signed by him.
ACCIDENT AND HEALTH COVERAGE - STATEMENTS
With respect to Accident and Health Coverage
EKcept as to a fraudulent misstatement:
No statement made by the Policyholder or any employee shall avoid any
coverage or reduce any benefits or be used in defense of a claim unless
it is in writing.
No statement made by the Policyholder shall be used to void this policy
after it has been in force for 2 yeers from its effective date.
No statement made by any employee eligible for coverage under this
policy shall be used in defense to e claim for loss incurred or
commencing after coverage with respect to which claim is made has been
in effect for 2 years.
GR-29
1165
ED. 7-73
Page 9100
r205244
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY MATTERS (Continued)
,PREMIUM RATES
Employee Life Insurance Coverage
Age On
Birthday
Nearest
Beginning
of the
Policy Year
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
TABLE OF PREMIUM RATES
Monthly
Premium
Per
$1,000
of
Insurance
Male
Female
$ .31
.24
.19
.22
.30
.48
.80
1.38
2.37
2.44
4.21
6.81
10.00
15.07
21. 60
31. 03
56.99
$ .10
.07
.08
.12
.15
.22
.38
.61
.92
1.00
1. 76
3.19
5.28
9.04
15.08
23.43
47.87
For annual, semi-annual, or quarterly premiums multiply the above premium
by ll.B3, 5.96 or 2.99 respectively.
GR-29
1170
ED. 7-73
Page 9110
F205245
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY MATTERS (Continued)
PREMIUM RATES (Continued)
Employee Life Insurance Coverage (Continued)
In place of determining the premium rates from the Table of Premium Rates
and by agreement with the Policyholder, the premium rates are determined:
on the basis of an examination of the experience of the risk assumed,
and
on reasonable assumptions as to interest, mortality and expense.
The rate is subject to change as provided in this Part II. The premium
rate is for a period of one month.
GR-29
1170
ED. 7-73
Page 9120
F206636
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY HATTERS (Continued)
'PREMIUM RATES (Continued)
Employee Life Insurance Coverage (Continued)
The premium rate may be figured again as of any premium-due date only:
By reason of a change in factors bearing on the risk assumed. Aetna
must request this.
Once during any continuous 12 month period. The Policyholder must
request this and give 60 days notice to Aetna.
The latest premium rate will be used to figure premiums until a new one is
determined. Each premium due during the policy year will be figured by
multiplying the amount of insurance in force at the start of the
premium-paying period by the premium rate.
OR-29
1181
ED. 7-73
Page 9140
F206639
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY HATTERS (Continued)
,PREMIUM RATES (Continued)
Accident and Health Benefits: The premium rates are for a period of one
month.
The current premium rates for all of the Accident and Health Coverages
provided under this policy are on record with both Aetna snd the
P~l icyholder.
.
GR-29
1190
ED. 7-73
Page 91BO
F206484
PART II (Continued)
POLICYHOLDER AND INSURANCE COMPANY MATTERS (Continued)
PREMIUM DUE - EXPERIENCE RATING
The premium due under this policy on any premium-due date will be the sum
of the premium charges for the coverages then provided under this policy.
If premiums are payable monthly, any insurance becoming effective will be
charged for from the first day of the policy month on or right after the
date the insurance takes effect. Premium charges for ineurance which
terminates will cease as of the first day of the policy month on or right
after the date the insurance terminates. If premiums are payable less
often than monthly, premium charges or credits for a fraction of a
premium-paying period will be made on a pro rata basis for the number of
policy months between the date premium charges start or cease and the end
of the premium-paying per.iod. If this policy is changed to provide more
coverage to take effect on a date other than the first day of a
premium-paying period, a pro rata premium for the coverage will be due and
payable on that date. It will cover the period then starting and ending
right before the start of the next premium-paying period.
The premium charges will be figured at the premium rates shown before.
Aetna may change them due to experience or a change in factors bearing on
the risk assumed. Each change shall be made by written notice to the
Policyholder by Aetna.
No experience reduction or increase in premium rates shall become
effective less than 12 months after the effective date of the group
policy. As used here, "group policy" shall be deemed to include any group
policy previously issued by Aetna that has been replaced in the whole or
in part by this policy.
The Employee Life Insurance Coverage section of this policy sets forth the
way in which the premium rate for such coverage will be figured. The
premium charges for any other coverage under this policy may be figured,
as of a premium-due date, only:
By reason of a change in factors bearing on the risk assumed. This must
be requested by Aetna.
Once during any continuous 12 month period. The Policyholder must
request this. 60 days advence notice has to be given to Aetna.
They will be refigured using:
The ageR of the employees I
The amounts of insurance in forcel
The premium ratesl and
Any other pertinent factors.
All facts will be taken as of the date of the refiguring.
GR-29
1195
ED. 7-73
page 9160
F205770
PART II (Continued)
POLICYHOLDER AND INSURANCE COHPANY HATTERS (Continued)
PREMIUMS DUE - EXPERIENCE RATING (Continued)
At the end of 8 policy ye8r, Aetn8 m8Y dec18re 8n experience credit. The
amount of each credit Aetn8 dec18res will be returned to the
Policyholder. Upon requeet by the Policyholder, p8rt or all of it will be
applied ag8inst the payment of premiums or in any other m8nner as m8Y be
agreed to by the Policyholder and Aetn8.
If the sum of employee contributions which h8ve been m8de for group
insurance exceeds the sum of premiums which h8ve been p8id for group
insurance (after giving effect to 8ny experience credits), the excess will
be applied by the Policyholder for the sole benefit of employees. Aetn8
~Iill not h8ve to see to the use of such excess.
Inste8d of figuring premiums as described above, premiums may be figured
in any way 8pproved by Aetna that comes up with about the Bame amount of
premiums.
Aetna will not have to refund any premium for a period prior to:
The first day of the policy year in which Aetna receives proof that the
refund should be made: or
The d8te 3 months before Aetna receives proof, if this produces 8 l8rger
refund.
This applies even if the premium W8S paid in error.
On termin8tion of the Life Insurance Benefit Aetn8 will figure a
Termination Premium. It will be based on the amounts of life insurance
converted under the Conversion Privilege in the 12 months which ends 90
days 8fter the termin8tion date. The Termination Premium will be due to
be paid to Aetna within 31 days from the d8te the Policyholder receives
written notice of the 8mount of the premium.
Payment of Premiums: The Policyholder will P8Y premiums in advance. They
may be paid 8t Aetn8's Home Office or to its authorized agent.
A premium is due to be p8id on the first day of each policy month.
The Policyholder may ch8nge the number of premium p8yments as of a
premium-due date. Thi8 needs Aetna'8 written consent.
Grace Periodl ^ grace period of 31 days after the due-date will be
allowed the Policyholder for the payment of each premium.
GR-29
l19B
ED. 7-81
page 9170
F205756
NY
PART 11 (Continued)
POI.ICYHOLDER AND IN8URANCE COMPANY MATTERS (Continued)
DISCONTINUANCE OF POLICY
The Policyholder may terminate this policy as to any or all coverage of
all or any class of employees of anyone or more Member Employers. A
Member Employer may terminate this policy as to any or all coverage of all
or any cless of its employees. Aetna must be given written notice. The
notice must state when such termination shall occur. It must be a date
after the notice. It shall not be effective during a period for which a
premium has been paid to Aetna as to the coverage.
Aetna has the right to terminate this policy as to all or any class of a
Member Employer at any time after the end of the grace period if the
premium for the employees' coverage has not been paid. Written notice of
the termination date must be given by Aetna. This right is subject to the
terms of any laws or regulations.
Aetna may also terminate this policy in its entirety or as to any or all
coverage of all or any class of employees of a Member Employer by giving
the Policyholder advance written notice of when it will terminate. The
date shall not be earlier than 31 days after the date of the notice unless
it is agreed to by the Policyholder and Aetna.
If:
This policy terminates as to any of the employees of a Member Employer:
and
Premiums have not been paid for the period this policy was in force for
those employees:
then the Policyholder and the Employer shall be jointly and severally
liable to Aetna for the unpaid premiums.
The Policyholder will also have to pay Aetna any Termination Premium that
Aetna may require.
GR-29
1210
ED. 7-71
Page 91BO
F205847
CA,tN
-
SUMMARY OF COVERAGE
EMPLOYER: AMERICAN SOCIETY OF COMPOSERS.
AUTHORS AND PUBLISHERS
GROUP POLICY: GP.3921514
SOC: 1A
IIIUI Oltl: JANUARY 2B. 1993
Elflctlv. oltl: JANUARY 1. 1992
The bllllfitl shown In lto Summary 01 CCMrIgI all avaiablt lor
you and your eKjpbII dtplf1denll.
The accldenl and health blntlill described In thIa Booklel.Ce"iflCate
alllnleyralld with cerain blllIfitl lor which the Employer I, liable.
AlIna I' IlabIIIor such btntfill 10 the e.ttnt thtt lhey III not lhe
IlIbiUty 01 lhe Ernpla,w. AlIna. howIYtr. wi procell II benelit
paymlllll.
1
2/93
GR.9 00>>0 120
Employ...
.
'1tlu are In an Eliglbl. Clas. If you are a regular full.nme employe. of
an emplover partlclpatlf1g In lhl, Plan.
'1tlur Eliglb~ily Dlte IS the first Illy of lhe cllendar monlh cOlf1clding
With or ne.t foloWlng the dlt. of employment. but not before the
later of the Eff.ctlve 011. of tllll Plan or the dlte you enler lhe
Eligible Clas.
'1tlu cln remain In In Eligible Clall.. . rer"ed employee If you rerir.
under your Employer'S IRS CuaHi.d Relremenl Plln and Will recelV8
I pensIOn. except a deferred vesled pension. ~ may continue your
Hellth E.pense Coverage and any coverag. you have for youl
dependenl. .
D.p.nd.nt.
'1tlu m.y cover your:
. wlf. or husband; and
· unm.nied cIvldren who are undar 19 ye.r. of 'ge.
Any olher uM\l(fled child under age 26 who gO'1 to Ichool on a
regular ball. and depend. solely on you for Support Will be covered
a. a dependent.
'1tlur childrwn mdude:
. Your bioIogic.1 children.
. Your _tld children.
· Any odIIr dIkl you support who live. With you in I perenl-child
relauOllIIip.
No p.rson m., be cOllllred both II In employee Ind dependenl:
end no pnon mlY be covered II a dependlnl of more lhan 011I
employH.
ENROLLMENT PROCEDURE
'Ibu wiI gII . larm 10 f~1 OUI. This form wiN .Iow your Employer 10
dtduct .".. .-nbutiOl1l for dependenl. cOYlreg. from your pay.
lie .... ...nd retum jt within 31 days of VOW e~gibililY.
GR.g CIIIIMl' 20
2
2/93
.......... ..I ...."\Jlu 111\1 .v:ai vi ,uur ":tHJttlhJdlll:; ~u'-iU(Jue. It
any. Will be deducted from VOAJt pay and are lub,.Clto change, The
r.te of .ny reqund conlnbubonl WI. be dllermllld by your Em-
'PIovtr See vour Employer for dll.i1I, If you .re e~glble lor lilY
cover.ge al . relllld employee, your Emplover will adVise you con-
. . cemtng the mllhod and alT1OlJ1l 01 any requwed cOnlllbuuons,
EmploY"1
'tbur coverage W1lIlIke effecl on your Eliglbjily 0.11. If you happen
10 be bolh dillbled and llWay from wor1l on the d.le your cOlllllge
would like effecl. the covellge will not like effwcl unlil you relUm
10 lull. lime WOItI lor one full d.y, Thll rule al.o .pplles 10 .n Incre..e
in your coverage,
Dependentl
Coverage for your dependenll WIll lake effecl on the dale yourslakll
effecl if. by then. vou Nve rlQUllled dependenl coverage, 'tbu lhoI*l
report any new dependenll, Thil may affecI your conlllbullonl. If
you do nOI do 10 Wllhln 31 d.ys of any dependent's eligibility dall.
proper IVldence of hll or her good hllllh Will be requll'ld,
Some coverage WIll be delayed if vour dependenlls confined al home
or elsewhere on lhe dall II would lake ellecl. The delay allo appllll
if lhe dependenl w.s confined In a hospllal within 31 days before
lhal dSle. The delay applies 10 ComprehenSive Medical ~nd Com.
prehensMl DenIal Expense Coverage, These Will be de laved unlll:
· lhe dependenl has nOI been conlined lor al leall 31 days; or
· he or she submtls proper evldanca 01 good health,
Coverage for a newborn child WIll nOI be de laved if he or she becomea
covered within 31 days alter he or she becomee e~ible,
The above ruIet allo apply to any incre..e,
EFFECTIVE DATE OF COVERAOE
Retired Employe..
Huhh Ellpenll Cowlllle wiI be de. if . perlOl1 I. confined .t
home or e'..wll... on the dete It woWd leke effect, The delay alIo
appIlel if . pIfIOI1 w.. confined In a hospital or nurling home within
31 dIylI before that date. CCMIIge W1I be de~ unlll:
· lhe peraon he. not been confined lor II leUt 31 dlVl: or
· lhe person IIDnIl proper evidence of good health.
QR.g 0030-0120
3
2193
The ibove rule applies to any new aependenl ana to any employee
Of dtptndenl becoming e~QIble on the Elfecllve Date 01 lhls Plan.
.In Iltu 01 conespendlng rul.. which Ipply to employees:
. I II any Health eKpense Benehll are paylble based on a "pened
01 dillbiily". the rule wt1tch applies to determine when a de.
pendent'1 pened 01 dlsabllily ends WIll Ilso apply to you.
. The rule wtltch ellPlies to I dependenl to determllle Illolal dll-
ability eK1111 when Heallh eKpense Coverage termlnat.. Will also
apply 10 you.
COVERAGE FOR YOU ONLY
LIFE INSURANCE
CIIIllhcallon
AM employees Insured under
the pnor individual
PIInslon Trull
Amounl
An amount equal to lIem ta) reduced
by 111m (b) but in no evenl shall the
rlllulting amounl ollnsurlllce eKceed
5700.000 or be less than 56.000:
(al 300~ 01 your basic annual eam.
Ings. rounded to lhe neKt higher
5100
lbl The value 01 contnbullons plus In.
teresl under the pnor IndIVidual pen-
sion lrusl.
AM other employees
200'16 01 your basiC annual eamlngs.
as delermlned by your Employer.
rounded to the nexl higher 5100.
MaKimum: 5700.000
Minirru11: 5 5.000
" yolI' clllsi&.tion provides an amount 01 lIle Insurance over
$500.000. you can bocomelnsured or'- your insurance Increased
to I1'1lII1OlII1tln e_sl 01 5500.000 or. rlgreater. your then eKlating
ImCllII1t. only by submitting proper evidance 01 good he.lth to Aell\l.
GR.g OO~120
4
2/93
.
. .
ACCIOEN fAL OEAfH AND DISMEMBERMENT ..
PRINCIPAL SUM
Cllltiliclllon
AM Imploye.. IIlIUlId undll
the pnor tndlVdlIl
"'nllon Trult
Amount
An ImolXlt equll to Item II' reduced
by icem Ibl but In no 8VIII1 Ihallche
mulling emount 01 InlUllnC8 exceed
5700.000 or be lell chin $5.000.
(II 300'1(, 01 your balle annual earn.
mgl. rounded to the ne.t higher
5100.
Ibl The value 01 contributionl plUI In.
IIr.lt under the pnor individual pen.
lion lrult.
All other .mploye..
200'16 01 your blllc aMUlI 'Imlngl.
II dll.nmned by '(0411 Employer.
I1)UI1d.d to th. n'.1 higher $100.
MI.mum: 5700.000
MIOlmum: 5 5,000
Ag. R.duction R~.
On the firat day 01 the month In which you reach age 65. your I.Jle
Inlurlnce and ACCIdental Death and Dismemberment Coverage
amountl each WIll b. reduced by 20'16 and Will be flJ'ther reduced
to che leller 01 60'l6 or 560.000 on the lirat day 01 the month in
which you reach age 70, If you become insured dunng or alter lhe
month in which age 65. your ute Insurance and Accidenlal Death
Ind Dilmemb.rmenl Coverage WI. be 80'16 01 the amountl shown
lbove. If you become inlured dunng or alter ch. month in which you
rllch ag. 70. your I.JI. and Accidenlal Death and Dilmemberment
Coverage wiU be 60" 01 the lmounll shown above or $60.000 if
I....
GR.8 oo3().()120
2/83
II
HEALTH EXPENSE COVERAGE
FOR YOU AND YOUR DEPENDENTS
, . 'rtlur Bookltt.C.rtrliclll IP.nl out me p.nod 10 which IIch mlKlrrAlm
applill, The.. blll.lill .pply separately to IIch cover.d person.
If . holP.I.1 or other hlllth care lacWity doel not IIparl1ety idenllfy
lhe lpaclfic .mowlle 01 ill room and board challl" .nd It I olher
chargel. Attn. WII u.. the loIowlng a.oc.tionl 01 lhelt charg..
lor the purpO"1 of the group conllact:
Room and board chargee: 40'1(,
Olh8f' ch.rg.., 60'l6
Th'l ..ocallon may be changed .t .ny IIITlI II Attn. linds lhat luch
aCllon II warranted by re..on of . change In feclorl used In lhe
allocallon
BASIC HEALTH EXPENSE COVERAGE FOR EMPLOYEES ONLY
BENEFITS AND BENEFIT MAXIMUMS
tRead the cover.ge lactlonl In your BookletoCenlficall lor. complel8
d"cnptlOn 01 the benelill avaiablel
VISION CARE BENEFITS , ",,"............., See Booklll.Cenrficate
COMPREHENSIVE MEDICAL.
COMPREHENSIVE DENTAL.
EXPENSE COVERAGE
CERTIFICATION REQUIREMENT
F YOU OR ONE OF YOUR DEPEMlENTS REQUIRE CONFINEMENT
IN A HOSPITAL
DIY' In the hoepil.1 mUll be cenified if UI ptan benefile .r. to
be .....~able.
Ae loon .. you or one 01 your dependenll know conlintmll1t
WIt be required. reed the Comprthenln.. Medical ExpenM Cov-
eragelaction of the Bookltt.cenificlle for detail I on how 10 get
the certification.
DEOUC1l8U: AMOUNTS
Calendar Year DeduCllble "".............",,....... S 200
GR-g 0030.0120
8
2/93
CerllllCallon tor HOSPIlII AOrTllSSlons
Excluded Amounl ".....".................
s
400
Common Accidenl Otducllblt umll S 200
Fam~v Deducllble umll ........ .. . . . . . S 400
" anv expense IS clMlred under one Ivpe 01 ClMIred Medical Ex.
pense. It cannol be ClMlred under anv olher lvpe.
PAVMENT PERCENTAGE
80% al to:
HOI~laI Expensel
Convalllcenl FactlilV Expenlll
Home Hlllth Care ExpenslI
HospICe Care Expenall
Olher M.dlcal Exp.nles
TYpe A D.nlal EKpenses
60% in excell of the Calendar Vear Deductible II to:
TYpe 8 Denial Expenlel
(SPECIAL MAXIMUMS FOR ALCOHOUSM.
DRUG A8USE OR MENTAL DISORDERSI
Alcoholilm or Drug Abuse
Outpatient Maximum V'Sitl
Counleling Maximum Villll
60
20
Menial Disorderl
Cri..1 Inl8rvenlion ServICIS
MaJllirrlum Visits..... "".. ,.,. ...... ..t'. ..,.' 0"" 3
MeKiroom Per Visit ...... The Illlnlmum alowed bV New 'ltlrk
Regulation 62 which II 560.00.
Oth.r Services
Maximum Vilits ......................... ........". 30
Maximum P.r Vilit .................................5 60.00
Calendar Vear MaKlmum .. Th. minimum slowed bV New 'Ibrk
R.gullllon 62 which II $1600.
pavm.nt Urnlt.
The.. limll' apply onlV to Cowrwd MtdicIl Expen"l and Cowrad
OIntal Expen... which ... PlVabIt It a ra.. greater than ~ and
not applied IQIIn.t ell'f deductible.
2/93
GA.9 003().0120
7
Plym.nl Urnn Which Appll.. 10 bpln... for . P.r.on
When . plnor", Cowrtd M.dlctl bpenH' tnd COVlred Dtnltl
. UptnH' lor YIt1ch no btntlill Ire ptld btctuH 01 the Plyrntnl
. Pltctnllge relch. $600 in . ctltndtr .." Wllh re.pecllo employft.
.trTWIlIl... IhIn 530.004 per Vllr; 5700 In I ctltndtr Vllr Wllh
r'eplCI 10 .mployen .tmII1g belWftn 530.005 .nd 580.008 per
yI.; or 5900 in I Clltndtr y..r wllh rnp,cl to .mploy.n liming
580.008 or mort p.r VI". b.n.lil. will be paylblt al 100" lor II
01 hi. or her Cowrtd Medictl EMpenll. and COYIred Dent.1 EMpen.n
10 which 11111 limit .pplle. and which art incurred In Ihe rnl 01 Ihll
ctltndar ye.r.
Plym.nl Urn It Which Appll.. to bp.n... for I F.mlly
Whtn a lamdy'. Cow red Medical EMpenlt. and COllllr.d D.nlal EN'
p.n... lor whICh no benelil' ara paid beclUH 01 lhe Peymenl PI/'
c.ntage reach: 5600 In a cal.ndar year With r.specl to employe..
liming lu. IhIn :530.004 p.r year; 5700 In a calendar Vllr wllh
rllpecl 10 employtn nmlng btlWltn 530.006 and $60,008 p.r
v"r: or $900 in I cal.nder y"r Wllh rUplcl 10 employee. liming
560.008 or mort per ye". benelill will be payable al 100" lor al
ollhetr Cowrtd M.dlctl EMP.ntt. Ind COllllred Denlll EMpentt. 10
wl1lch thi. limi' .pplill and which ar. incurred in lhe rill 01 INI
ctltndtr yeer
BENEFITS AND 8ENEFIT MAXIMUMS
(Rlld Iha COll8rtg' secllon In vour Bookltl.Canrllcale lor a compltle
dllcnpllon 01 lhe bene IiI' aVllleble I
Dental Celendar Ve.r Mumum .
... ... 5 1.000
The liral 120 dly' 01
convalescenl flcililV
confinem.nl.
MeN mum Conv.lelcenl ""nod
Home Hellm Cn Muimlm VI.il.
HoIpIc. Clre
MtMimum fbnber 01 DIY' .... ...... ...... ....... 30
PlMIt Room Umll ""........ The In.titutlon.. IImlpriv.lerlll,
Ulwtlm. Mninun Ben.fil ......................... S 2.000.000
GIl., 0030-0120
8
120
2/83
, ,
pIOYtdt bU1C 110111I11' or bUM: mldlCll IOlUllnel ., IlIdlllon. .1 pro-
vldll Iccldlnt, dlntll Ind vllion l.pll1II benthtl.
GENERAL
Thll SummllV 01 CO\IIlIgI ,..pIIc.. Iny Summary 01 Coverage ,n-
vioully In Ilfac:l und" lhe group conlrlCl. RlqulIll lot Imounll 01
CCMIIOI olhlt IhIn lho.. 10 whICh you IFI Intltled in accordanct
Wllh thl, SummllV 01 Covellge cannol be ICCIPled.
The ,nlurlnee d"cnb.d in thl, Bookl.I.c,ndlclIl WII bl providtd
unci" AlIna UII In,ullncl Company. polCV 'olm QR.29.
KElP THIS SUMMARY OF COVERAGI
WITH YOUR BOOKLET.CERTlFICATE
CII.I oo:JO.O 120
10
2113
TABLE OF CO~ENTS
Summlrv 01 Cowrl'"
f!.u
. . . IlIu.d with
Your Bookl.t
L11. In,urlne. ..........
1
Aeeldlntll Dllth Ind
Dl,m.mb.rment Cowrl'"
2
H.llth bpln.. COYlrl'" .. ."""" """""."".."""". 3
Bille VI,lon Clr.
Expen.. Cover.ge .......................................,.. 3
Compr.hln,lv. Mldlell
E.pen.. Cowrl'"
Compr.h.n,ivI Dlntll
Expen.. Cowrl".
O.n.rll E.elullonl
4
17
23
2&
EH.et 01 B.n.fitl Und.r Oth.r PI.n,
Oenlr.llnlormltlon About
Your Cowrl'" . .. . " " ..
31
Olotllry . . .. " " " " .. " " " " " . . .. . 42
lDeflntl Th. T.rml Shown In Bold 'TYP' In Th. T.xt Of Thl,
Docum.nt.1
.
GR.g
YOUR GROUP COVERAGE PLAN
Thil Plan II underwnnen by the Alina Ufe Inlurance Company. of
H.rtford. ConnecbCul (called Aetnal. The benallls and mBlI1 points of
lhe group contrlClfor perlons covered under Ihis Plan are sel forth
In lhis Booklet They ere elfecll\lll only while you are covered under
me group contrlCt.
II you become covered. Iln Bookl4ll will become your Certificate of
Coverage. It replacel end lupersedes all Cerliflcates ISsued 10 you by
Alina under Ihe \lIllUP contract.
Prllldenl
Cerl BII': t
luue 01'1 Jlnulry 28. 1993
EHlclivl Olle Jll1UIry 1. 1992
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Lltt lI~bUHAN(;t:
ThI, f'IIn WIll PlY II . Uht In.urlnee benefit the Imount olule 1n1lJ'"
~ric. 10 lore. lor you II you die Irom Iny ClIlse while InlUred. 'l'ou
,neme your benehcllry You may change Y041l chOICe II Iny lime
.
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ACC'DEN IAL Oa:ArH AND
DI$MEMBERMENT COVERAGE
. .
Thol Plln PIVI I bene tit if. while inlured, you luffer I bod'y I1jUlV In
'In Iccldent; ,nd II. WIthin 90 dlYS Iher thl Iccldlnt, you 10M, II a
direct result ollhe Inlury:
I Your hfe,
. A hind, It or above the wrtll joInl.
I A 1001. at or ebove lhe IIllkle JOinl
I An eye. IrlvolvIr1g ,rrlCOlllrlble end compllle loll 01 light lithe
eye.
WHAT ARE THE BENEFITS?
Your lull Principal Sum il peyable lor lOll ollile.
Hall yOUl prinCipal Sum II payable 101: loll 01 a hand; lOll 01 a Iooti
or 1011 01 an eye.
No more than your lutl Pri1clpal Sum II payable lor allo.... whlc:h
result from one aCCIdent.
ARE THERE ANY LIMITATIONS?
aenellls are plld lor 10.... cauled by accidenll only No benelill
are payable lor a lOll caused or contributed to by:
. Bodily or menlll inllrmllY.
I Ois..se. plomlln.. or blclenal inleclions'
. Medical or lurglcaltrealmenl.'
. Suicide or attempled auicrde.
I In\enlionally "If.,n'hclld injury.
. War or any aCI 01 WI! ldlclared or undeclared}.
'TheM do not apply illhe lOll il caused by:
I An Inl.Clion which reautll directly from Ihlllnluly.
I Surg.ry ntlded becauM 01 the InjUry.
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HEALTH EXPENSE COVERAGE
BASIC VISION CARE EXPENSE COVERAGE
. This !'lan pays . blnl'lI 01 nOI morl thin 560 01 the COll8rld VISIon
CIII bpenlll lIlCurrld by the employee only.
Covered Vllion Carl Expenle.
ThlY are lhe chlrgtl lor III lve examlllllion which is Iurrlllhed by .
legally Qualllied ophlhllmologlll or optomelrlSl
HOWlMlr. dunng .ny one period 01 12 conlecutlll8 monthl. nOl morw
thin one eye ell miNt IOn will be considered IS . cOll8red VillOll C.re
Expense.
Umltallon.
The lolowlng limitatIOns epply
No benelits WIll be pay.ble lor. charge which is:
. For a VIsion cere service or supply which is . cOll8flld expense in
whole or in PIn. under .ny other pan 01 tillS Plan; or under any
other pl.n 01 group benefits provided through your Employer.
I For a VISIon care service or supply lor which a bene'lt IS prO\lided
In whole or III parI: under any workers' compensation law; or any
other I.w 01 ..e purpose.
I For special procedures. ThiS means things such as onhoptics or
VISIon Iraflling.
I For speci.1 supplies. This means lhlngs such as nonprescnption
sunglasses and slilnormal VISion aids.
. For ant,.rellecllve co.tings.
. For tlllting or lor prescription sungl.sses or light &enSllill8 lensll.
. For an ave IXIm which:
i. requftd by an employer .1 . condlllon 01 employment: or
an emplovel is required to proyide under . lebof egreement; or
Is rwqund by .ny law 01 a government.
. For Iense. or 1rIm1l.
· For a servloe or supplV received while lhe person Is nOI cOVlred.
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COMPREHENSIVE MEDICAL EXPENSE COVERAGE
Th4I.Summlry 01 Coverlg. 0UlIinI1 the Paymenl Parc.ntlgtl thl! Ill'
. ply 10 the COl/llred M.dlcal E_pen..1 dtlcnbed below
. WHAT ARE "COVERED MEDICAL EXPENSES"7
They Ire the ekP.n... lor c.rtlln hOlplll1 Ind other medic, I "I'
vlClllnd 'Uppliel. They mUll be lor the Ir.ltment olin Injury or
dl.....
H.ra 1$ a h.t 01 Covered M.dlcal Ekpen....
HOIplll1 E.pen"l
Inpallenl HOlpllal bpen"l
Chargn mad. by a hOlplllllor giv'"9 board Ind room and
other hOlpltal servIces and .uppl". 10 a peraon who II con.
filed a. a lull.tlme Inpllianl.
NoI Included i. any charge lor dilly board and room in I
privale room over the Privale Room Umll.
Outpallent HOlpltal E.pen..1
Charges mad. by a hOlpltal lor hOlpltal servIces and IUP'
piles which are 91ven 10 a person who 15 nOI confined .. a
luIHlme Inpaltlnt.
Convalelcent FacilllY E.penlls
Charges made by a convalelclnt facility for Ihe folOWlng ..rille..
and supplies. They must be fwnIshed 10 a per.on whil. confin.d 10
c~lCe from a dil.... or injury. The confmement mull Illrt dur.
ing a "Convalescent Period".
. Board and room. Th" include. charges lor servicel, luch .. gen.
... nurSing cwe. made In COIV1ectlon with room ocaJPlOCV. NoI
Incbled is any chlrge for daily board Ind room in I private
room over lhe Privlll Room Umlt.
. U.. 01 .peclallr..tmenl room..
. X~ and lab work.
. PhyIical. occupational or .peech lherapy
, OIV9.n and Olher g" lher1py.
. Other medical serviCes ulUllly given by a convalllcent facility
. This does nOl include pnvatl or lpeelal nurllng. or phYllollnl
services.
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I M'JI~aI ::'uIlIH'U
. IIIr\Itfjll WIll be paid 101 up to the m..mum number of dlVI dunng
IIY( ant Convelelcllll Ptrlod Thl lIenl on thl lirlt dry I p.rlon II
conlined in . con,,,Ie"lnt faclUty II h. or sh..
I wal conlined In . holplta' for II lalll 3 d'YI In . raw. whll.
cover.d under thil Plan. 101 Ulllm.nt 01 a dl..... or in,ury. .nd
. tl confinld In thl fa~IY WIthin 14 dl'fl .ft.r dlacharg. from the
hDlpltaf; and
I it confined in thl faCllily 101 lerVIt.. nndld to conVlleIC. Irom
the conditIOn that caulld thl holpltal ...y. Th... includ. Ikilled
nuralng and phyllCal rellOrllMl IIrvle...
It tndI wh.n chi perlOll hll nO( be.n confined in . holpltal. con.
valeaclnt facility. 01 olher plac. givlflg nurllng care 101 90 d'VSIn
a row.
Umltatlon. to Convlle.clnt Facility bplnl..
TlIII IICtlOO dOls noc cover Chargll m.dI for trlltmlllt of:
. 0Ng Iddlction.
I CI1ronic br.in syndrome
I Alcoholill1l
I Senibty.
I Mlnlal r.tardallon.
I Any olher m.ne.1 dllorder.
Hornl Hlalth Car. bplnl..
HomI he.lth c.re 'Ipenael arl CCMIred if:
I the charge il made by a home hlllth carl aglncy; .nd
. thel*l II giWIn lJ\dar a homl hlllth care plan; and
I thel*l il given 10 a p.rlon In his home.
HomI health care 'llpllf1Iel all charg.. for:
I l'Irt-time or Inten11l1Ulnt care given or lupervllld by .n R.N.
. l'Irt-limI OIlnt.mwtllnl home hlalth aide lIIVicn for petltnt
l*I.
I Physical. ocCUpllionll .nd speech lher.py from . hornl hi 11th
CIIfl aglncy.
I The folowing to the extent they would haw been ClMIred under
tWI Plan if thl ptrIOI1 h.d belli In a hospltll or I Ildlled nurling
fIciIily II d.fened in Tille XVI of tile Social Secwity Act:
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. -..... ......... '." - ...~.J "I,U "L"U".Jl.UlI:>> lJ'Utn.IlUthJ O~ d
phYllciln
lib l.rvlC.1 proyldtd by 01' 101 . home hlllth CI,. 11I.ncy
, 'Thef. II . maximum to the number 01 VIII" covered In I celendar
V-Ir, Any Villi aft.r the tnl 40 III lhal V-.r Will be cover.d only If,
A home h.allh CII. progrllT1 WII leI up Ind Ipproved by th.
.tt.nding phYIlcitn, Thll mull be 0011I wllhin 7 OI'(l Iftlr 011'
chtrgl lrom hospltlllnp.lI.nl cn, Thil program mull bl lor lhe
clltndtr V-Ir in whtch any VIIl1I .ft.r the tnl 40 Ir. Includ.d,
Home h.alth cn Ilertl dunng luch 7 deya, II mUll be lor Iho
IImt or r.lat.d condlllon II the holpll.1 clre.
The an.ndlng phyllclln certlfiel that the proper Il'tllment would
require conlinued holpltl' inptll.1ll Cllll in lhe ablenc. 01 lhe
horn. helllh cn program.
One home health CIrt VISil shill be:
I Etch Villi by I nurlt or IhtrtpllllO I perlon'l horn.,
I Elch 4 hours ot home h..lth tide Itrvietl, IAh.r lhe fnl 40 VII"
ill In . calend.r v-ar. e.ch Vlllil 01 up 10 4 hours will be deem.d
10 be one Villi I
This seCllon ooes nOI cover charges msde lor
o ServicII or IUppIiI. nOI a pari olllle home helllh cn plln,
o Servlctl 01 I penon who ulually lives with you or i. I m.mber 01
your 0( your WIle" or husband'l Ilmlly
Cullodial Clre,
lianspon'llon,
Servicel or IUppliel given whele 100 person is not under Ihe care
ot I phytlclln,
HOlplc. elr. Expen"l
ChIrg.. mad. lor the lolowlng Iwnished 10 8 perlon 101' HOlple.
elr. when given II a pari 01 I HOlplel elr. Prollrlm ere in.
c:UlId II Covered Medical Expentll.
FlelDly Exp.nltl
1'ht ehtrgll made In Itl own beIItlI by I:
· '-PIc. flclllty;
· '-PIt.I;
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o convelucent feclllty.
which. e,. Ie)/'
I' Boerd end room and other aarvlCes snd supp/les h.ntslled to a
pellon willie a lull. lime Inpsllent lor
p"n control: end
other Kute end chronic symptom management
I Not Included II any charge lor dally board end room In a pnvate
room IMr the Priv.le Room lImll. Also not Included is the charge
lor .ny day 01 conhnement In e.ClII 0' Ihe M....num Numbel 01
Oay. IOf aN conlinements for Ho.plce C.le.
o ServICes and supp/..s lurnlshed to a person while not conllned ..
e hAl.lIma Inpallent.
Other ElIpenses
Charges made by a Hospice Care Agency lor
o Part-tma or Internultllnl nursing care by a R.N. or L,P.N. IOf up
to 8 hours In any one day.
I MedlCll loelll aerval under the direcllon 01 a phYllclln. The..
include:
......ment 01 the person's sooal. emollonal and medical
needs, and Ihe home and family sltuallon;
ldenllficallon 01 the community resources which are aVI~able to
the perlon;
..sisling the plllOll to obllln those resources naeded 10 meet
the person's .......d needs
I Psychologicsl and diellfy counseling
I Consult.ttion or ca.. manag.ment services by a physlclln.
I PhyIICII and occupetionll therapy.
I Part-time or intenninent home health aide services 101 up to 8
hours in anyone dly. These conllSI mainly 0' canng 'Of the
=
I . supplies. drugs. end medicines presClibed by I
phYllclln.
Chary.. made by the providers below. bUI only If the provider i. not
an employe. 0' a Hotplcl elll Agency. and such egency retlln.
,..ponlibity lor the care 01 the pel1Ol1.
I A phyelclen for consultanl or clle management selVlCI.
I A phytic.lor occupltionallherepist.
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pbYIICII or OCCupIIlCIIIIllherlPY,
plrl'lIml or Inllrmlllanl home h.lllh .Ide IINIC.I for up 10 8
houri In lilY on. dey; lhel. conllll mllnlv 01 clnng lor lhe
p.rlon;
medlcll lupphea. drugl Ind medlClnel prncnbed bV a
phYllclln.
pIychologlCl1 and di'l"" counselong.
Ben,'lls Will nO! be paYlbIe lor more Ihln 180 dlVl 01 HOlpIC. Car.
given whll. lhe p.llon II nol con lined II . lull'lime Inplli.nl in a
hoepic. Ilc~IlV, hOlplll1 or convalesc.nl fldllY and while lhe plrlon
II cOVlr.d under lhil S,clion
AIIO Included are chlrges incurred lor lhelwsl 6 viii IS lor bereaw.
menl counllhng which II provld.d 10 memberl 01 lhe perlon's Ilmily
end il Olr.cllv rellted 10 the person's deelh,
Not included are chlrges mede:
o For luneral arrangemenls.
o For pallorll counsehng,
o For I,nanc,al or legal counseling. These include ellale planning or
lhI drahlng 01 a Will.
o For homemaker or carelaker services. These are services whICh
.. nOI loIelv rellted 10 clI'e ollhe perlon. Thele include: liner
or complmon servIces for eilher lhe person who is ill or olher
memberl 01 lhe family. IranspOrlallOn; housecleaning; and ma'nte.
RIllC. 01 the hous..
o For r,splle care. ThiS jl car. furnished dunng a period olliml
when lhe perlon's lamily or usual carelaker cannol. or will nOI.
In.nd to the p.rlon'l needs.
Routin. PhYllcl1 EXlml
ThI chlrges below .re includ.d 81 Cowred Medical Expenses IMn
though lhey Ire nor incurred in conn.ction wllh an injUry or di......
ThIv .. cowred al 100" Ind Included oriy lor a dependenl cIiId
under 3 velrs 01 age
IncbMd Ir.:
o A I'I\IIIW and won.n record ollhe child's comp!ell m.dical
hislory.
o PhyliC11 ElIIminelion.
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I DeWlOpnlental dlUJ llehavlllral a55U5511lUllt.
. Anlqlllory Guid.nee.
. .' "ppropnIlIlmmlnllllOl1S
. IIborllory T"I.
All of Ihllbow In keeping wllh prevelling medlcll Ilendardl
Other Medlcll hp.n...
. Chlrgll made by I phy.lcl.n
. Chergll made by In R.N. ()( L.P.N. or I nUlling 1gency for
lkilled nUlIlIlg cn,
A. used herl, "Ikilled nurling clre" mllnl lhell l.rVICII,
Vilillng nUlIlI1g calli by In R.N, or L.P.N. V,lillng nUlling
c-. Olein. I VillI of nol more lhan 2 hour. for lhe purpolI
of performing Ipllcific skilled nUlling IIlkl,
Privlte dUly nUlling by 111 R.N, or L.P.N. if IhI perlon'. con.
dillOn requinl Ikilled nurling ..rVICII Ind Vlliling nurling care
,. nol edequell,
NoI included II "lkiNed nurling CIIlI" I.:
IhIt pan or II of Iny nurling clre Ihal doel nol IlIquire lhe
skll of In R,N.; and
t/I'f nUlling clre. given while the pellon II en Inplllenl In I
helhh cere fac~iIY. lhal could ..Iely Ind Idequllely be fur.
nilhed by the fldily'l generll nurllng Iliff If it WIll fully
,""ed,
. Chargel for the tolowlng'
Onlg. and medicinll which by law need a phYllclln'.
preaaiplion.
OlIgnoIUc lab work Ind .-fI'(8,
X-f-V. rld,um Ind radioactive ilotope IherIPY.
Anellhetlcl and oxygen.
Renlll of durlble medical ()( l~iCII equipment.
Anificiallirnbl end eyel, These ere not included: . e.lm. end
eyegIel..l; hI.ring lidl; orthopedic .hoe. or other devlcll 10
IUppOft the 'eet,
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Profuslonal ambulance SlIVlce 10 lIensport I person from Ihe
pllee where he II IIllured or IIndlen by dlMlse to the flrSl hOI'
, Illtl' where tr.llment II IIIvto,
EXPLANATION OF SOME IMPORTANT PLAN PROVISIONS
C.lend.r VII' Deductible
Thll II the Imounl of Covel'ld Medicll E~Pln"l you PlY IIch cllen.
der Yllr blfore beneflll ere pltd. There IS e c.lendlr 'Wlr Deductible
lhat Ippl"l 10 IIch perlon
Common Accident Deduotlble Umlt
An Idded benefil may be paid il for inJurill arilf1g out 01 the lame
Iccldent:
I Covtl'ld Medical Expenses are IncUlTed by 2 or more pellonl In
your flmily; and
. the.. expan..1 Ire applied aglinll the llparl" Calendlr 'Wlr De.
ducllblel: and
I in the yelr 01 the .ccldenl and the next yelr. they exceed the
Common Accidlnt Deducllble Umll.
The Idded blnefil is 80'16 of the exc"l
Family Deductible limit
If Covered Medical hpenses incurred in a calendar year by you and
your dependenll Ind applied agamll the separl" Calendar 'Wlr De.
ductlblll equlll the Family Deductible Limit, you and your depen.
denll will bI considered 10 have mel lhe llparate Calendar Year
Deductlblel for the rest ollhal calendar year.
M.xlmum Benefit
Thil II the mOlt tNt Will be payable for any perlOn In 11I1 or her
lifetime:
. It will bI rlllored IIch January 1 by the IITICUIt thin charged
againlt it. Not 1110I1I than 51.000 WIll be~.
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I h may be re,"Slaled In full when $1.000 or mole IS CN'lled
191101111. Proper evidence of good health must be pnMded II
yOur exptnlt.
Netther 01 the ebove WlM provide benellls lor Covered MediC. h.
. penses Incurred before the dlle the maximum" reslored or
rell1ltated.
Routine Mlmmogrlm
Even though not Incurred in connectIOn wllh e dllt..e or injury. Cov.
ered M.dtcaI Exp.nsll Includ. chargtl Incurred lor routine screening
by mammography lor the pretence 01 OCCUll brelll cancer 111 I
lemale.
Routine Pip Smear Ind Routine Proltrete EllIm
Even though notlncurr.d In connection wllh a dllllle or tnjUlY. Cov.
ered MediC. Expenses include 100'16 01 the charg.s Incurred for on.
routine gynecological villi Including routine Pap sm'lI and one rou.
tll. male g.nnalla exam Including prollrate exam each calendar year.
Mouth. JIWS Ind Teeth
Expenses for th. trlltment of the moulh, jaws. and teeth .re Cov.
er.d M.dicll Expenses, bUI only those lor:
I servIces rendered. and
. supplies needed,
!of the loIowlng trlltment 01 or relllld to conditions 01 the:
I tilth. mouth, j.ws. jaw ,oints; or
I supportllg tlllues (this Includ.s bon... muscles, and nIMII,
For the.. .xpenses, phYllcl.n includes a dentllt.
Surg.ry I1IIded to
. Trllt 1 fracture. dialocation. or wound.
. Cut out:
Teeth partly or completely impacted in the bone of the jIW.
Teelh thai WIll not erupt tlvough the gum.
Other tlllh thlt cannot be rema.'ld without cunng into bone.
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The rootl 01 d 100lh without relllO\/f19 the entire tooth
. .Cy,'" tumorl, or other di....1d li.lUes
. Cut Into gUITII .nd U'1U1I of the mouth. I OI, I. only cOYlred
when not done In connection wllh lhe remOl/.I. replacemenl or
repair of leelh.
I Aller the ,aw. ,aw jOints. or bile relatIOnship, by II cutting proce.
dure when .ppll.nce Iherapy II10ne clll1not result In functional
Improvement
NonsurglclIl trlltmenl of infection. or dlstllSIl Th. doe. not Include
tholl 01 or related to the lelth.
Dentel work, surgery and orthodonlic tllllment needed to remove.
repair. replace, reltoll or repoSItion:
I nalural IlIth damaged. 1011. or rllmoved; or
I other bOdy tlSlUII 01 the mouth fractured or CUI;
due to InJury. The treatment mu'l be done In th. celendar yeer of the
ICcid.nt or Ihe next one
Any such IlIth mull have been: fru from decay; or in good IIplllr;
II1d firmlv 1I11lChed to the jllw bone III the ume of the InjUry
Excepl as provided for InJurv. nOI Included are charges:
. for In-mouth appliances. crown.. bndgeworil. denture.. looth rll'
torlluons. or any relaled filtlng or adju.tment IIIVal, whether or
not lhe PUrpostl 01 .uch lelVlCes or IUpplies il to lI~eve p8ln;
. for rOOI cnlherllpy,
. for routine looth remOl/ellnot needing CUltrng 01 bonel
Not Included .re chargel:
. to remove. repair. r.place. rlltoll or llpolitlon IHlh 1t'lt or dam.
aged in the courle of biling or CheWing;
. to rep.ir. replace. or rlltore f~lingl. crowns. dentlnl or
bridgeworil;
. for non lurgical perlodonl.1 tll.lment;
. for in.mouth lcaling. dental clearing. pIarong or ac:repll'1g;
. for myofunctionaltherllpy; tti. il:
muscle trllining therllpy; or
Irllining 10 COIrtCI or conlrol harmful habill,
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\.III/tIC.1I01l tor HOlplI.1 Admllllolll
": .
, .
.. · perlon becomel conllned In I hOlplt., 81 I lutHlme Inpelien!:
IOd
I It hel nOI bIen clllifild lhel such confinement (or ellY day 01
.uch confinement) II "'C'"IIY.
Covered Medlcll E.penltl incurred on Iny d.... nOI clllilted dunng
lhe confinement WIll be plid II fGlowI:
· AI 10 HOIPilll E.penlts IIlcurred dunng the confinemenl'
" cendlcelion hel been requelled end del1led:
No benelilS WIN be paid for HOlpilel E.penses incurred for bOlrd
IIld room
IItntfil. lor II olher Ho.pilel E.penl8. Will be peid et the Pay.
menl Perclnt..
" ctndiclllon he. nOI bttn requellld end the confinement (or
IllY day of luch confinement) il nOI nec'"IIY:
No bene fill Will be paid for HospllIl E.penses Incurred for bOlrd
IIld room.
AI to all other HOlp111l Expen..s:
Expensll. up to the E.cluded Amount. Will nOI be deemed to
be Covered Medical E.penses.
Beneflll 101' such e.penlll In excess of lhe Excluded Amount
will be paid II the Paymenl Percentage.
If cendicallon he. not been requested end the confinement (or
any day 01 .uch confinement) i. neCtlllIY:
Hoapit.1 E.pen.... up to the E.cluded Amount. will nOI be
detmed to be eo..red Medical Expen....
IItntfill lor II other Hoapitll E.pen..1 Will be payable II the
'"-Yment Percentage.
· A, to olher COIIIIedMedtcal E.penl8.:
IItnefill Will be P4id II the P....m.nt Percentage.
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'illVlIhll VI IIVI d \ldy Ul .vuIII,emVIII lij ~vlllheLl, no uenelll wllIlle
Plid lor eMpenlel ncllTlld on lilY dlV of confinement II I lull.ume
~'lInll' 'MCIudtd by IIIYV other terml 0111111 PIIn. 'McePllhll, "
C,M'lCIllon has bien gi\/ll1 lor I dlV of confinement. lhe .llClullon
ofl8rvlCeI Ind IUPp.... beceull lhey are nOI n.c....'y WIll nOI be
. applied 10 'Mpennl lor holplc.1 room and bolrd,
CarltflClllon 01 days 01 conllnemenl can be obtaIned as lollows:
Illhe admlsllon II . non.urg.nt admllsion, you mUll gal Ihe daYI
c.nrllld by clllrIQ lhe number shown on your ID clrd, Thll mUll
be don. al '.all 14 days b.fore Ihe dale lhe perlon II schaduled
to be confined II I IUHII118 Inpallent Illhe adnlllslon II an emer.
g.ncy or an urgenlldmllllon, you. Ihe perlon'l phYllclln. or
the holpltll mUll get lhe days cerlllled by calling lhe number
shown on your D card, ThIS mUll be done:
I before Iha Slart 01 I confinement 81 a 1ul1'llme Inpalienl whIch
requwes an urgenlldll1lllion; or
. nollll81 Ihln 48 hours foIowlng Ihe Slllt 01 a confinl:menl as a
fuI.,ime Inpallenl v.t1ich reqUires an emergancy admilllon; un.
It.. II is nOI possible lor lhe phYllclln 10 reQUasl centficallon
within thaI II/llt. ., Ihlt clle. it mUlt be done al sooo as raa.
aonably possible. ., lhe 8I/llnt the conlinemenl Ilarls on a Fri.
day or Saturday. lhe 48 hour reqUllement will be eMlended to 72
hours.
"Emergency admiSSion": One where Ihe phYliclan admllS Ihe per.
son 10 lhe hOlpltal dUI 10 a sudden and uneMpected change in the
perlOrt's phYSical or menIal condlllon which is severe enough 10 reo
quire immedIate confinemenl as an inpallent in a hOlpltll.
"Urgent admission": One where the phYllclln admits the person 10
the holpltl' due to:
. the onsel 01 or change in a disease; or
. lhe diagnosis 01 a disease; or
. an Injury caused by an accident;
whlch. while not needing an amergency edmillion. IS I_Ie enough
to recP't confinemenl al an inpatrenl in a ho,ph.l wilhin 2 weekl
from the dale the need for the confinemenl becomel apparenl,
"Non'iJlgenl admission"; One which is not an emergency edmillion
or an urglnt admission,
If, in the opinion of the person', phy,lcl.n, il ia nec8l11rV for lhe
perlOrt 10 be confined lor I longer time Ihln Ilreldy clnifMld. you,
GR.g
14
lhe pi ,IIClln, or Ihu hOlplll1 may requu~1 Ihll more oaVI be cerll'
fied bV CIIll1g lhe numbe, Ihown on your 10 <*d, Thll mUll be
donl.no 1111' Ihln on lhe 1111 illY Ihll hll IlnIIdV beln CI"~lId
Wonln noltcl 01 lhl number of daya cerllfled will be IInl promptly
'10 lhe hospilll, A copy Will be IInl 10 you and 10 lhe phYllclln,
Conlln""lnll For Trellmlnt Of Alcoholllm Or Drug Abu..
Certlln expensel for the ueltment Ihown below Ire Covered Mldlcll
Expenlls,
If I pilson Is I full-tlml Inpllllnt enhlr'
. In I ho.pltll: or
I In I ITlllment flclllly;
lhen the coverlge II 81 shown below,
HOlpita!
Expenlls for the followmg III covered:
I Trllunlnt of thl medicll compliCllions of lIIcohollsm or drug
lbull, Thll melns things luch II clrrho.il of the liver. delirium
lramenl or hepllllll,
I EHecllve treltment of IlcohoUlm or drug IbuII, Thil is cov.
ered only If there II nOI I sepI'lte trnlment flclllty seclion
Treatment Flclllty
CIIlllO expenses for the eHective trellment of Ilcoholllm or
druglbu.e are cOVllred, They are cOVllred If they are Incurred in Ihe
frat 45 days of full.llme confinement In a calendar yelr, The ex.
penll. DlMlred are lhose for:
. Board and room, NOl covered il Iny cherge for dilly bOlrd Ind
room In I pnvlte room over the Pnvlle Room Umn.
. Other necellery IINice Ind supplies,
Thl 45 d8yt will be relb:ed by Iny days of hospltll confinement
for Iffec1Ive trellment of IIlcoholllm or drull abu.e that Ire cov.
Ifed IbcMlln the lIme celendlr yelr,
OUtpltlent Expenle. For Alcoholllm Or Drug Abu'l
Chlrgel incurrwd by I plrton for the IHective tflltment of Ilco.
hoIl.m Of drug Ibule while not confined a. I fUHime Inpetient in
I:
GR.g
15
. hOlpltll: or
, . I tr"ltment flclllty:
It. COVIt.d M.d,cII E Kpensel, Ben.f,ll will not be p....abl. for more
(Nn the Speclll Outpatient MamlUm VIIIII each cllendar vear Such
M.xlmum Vialll wdl b. recb:ed by each Counleltng Maximum Villi
which II Included II I Ccwerad Medical Expensl dunng Ihe &lme ell.
endar Vllr, Expenl.. which are Incurred in a It.ltment facility are
IIlcluded to lhe 11m. .KllI1t II If lhey we" IncUfTlld Ir'I a hOlpltal,
Allo Included II Coveted Medical EKpenl" are counseling .KpenHl
lncumtd by a family member covered under thl P\In, They mull be
directly related to the pereon's alcoholiem or drug abuse, Benefill Will
not b. payable lor more then Ihe Counseling MaKIlTUTl VISits In .ach
cal.ndar year,
M.ntal Ollord.rl
I For crrses II1terventlon services:
bpenses for Ihe treatmenl of a menial dISorder lie COVIred Medical
bpenl.. to the eKlenl lhown below
If a person is 8 fulHlme Inpatient in a hoepllal Theil 'Kpens.. 1/1
covered In the same WlY II those for Iny other disease,
If I perlon IS not a full.tlrne Inpatlenl in a hOlpltal: Thele expenlll
Ira cOVlred as followa:
Btnefill will not b. paylble for more lhan the Maunum Vilita
In any one cal.ndar year,
Not mora lhen lhe Mlximum Per Vilil Will be peYlble for eny
one vilit for criles Intervention serviees,
Crisel Int'rventlon servicel are lervie.. rendered 111 connectiOn
WIth .n unfoIeseen clinical condolion which raQUl''' prompt action
slnce without prompt actlon
the pereon may be alrilk of injuring him or her"" or otherl; or
the perIGO II at rilk of subllantlsNy daterlorating in abUity 10
perform,
The crisil Intervention serviees should stan within:
24 hours of iniUII palient contact wilh the provider of the III'
vie..: or
GR.g
18
old hours 011011111 pallent comacl WIth the provider of Ihe ser.
vaa, If the pI1l\Ilder makel an aHorl 10 lafaly Itllbllll8 tha pa.
. UtIlI until IhI achIduled Vlllt.
~ . For any olher HfVicea:
Benaflll WIll noc be payable for mora then the Maxmum V,lita
III anyone calendar year
NoI more lhen the Maxmum Per Vllil will be paYlble for any
one ViSit.
The mosl lhet WIll be paid for Iny ona person In Iny one calan.
dll year I' lhe Calendar '1Ilar MaXimum.
COMPREHENSIVE DENTAL EXPENSE COVERAGE
Thll Plan pays beneflls for cherges for dental services and supplies
incurred lor treatment of a denial disease or Injury These benefit a
epply I8parately to each cOIle red person.
Advlnce Clllm Review
Be SIn to reld thil leclion clI1fully.
Before slartlng a cour.e of lreltment for which dentl'II' cherges are
..pected 10 be S 150 or more. delalls 01 lhe proposed course 01
trellmem and cherge. 10 be mede should be filed In eccepteble lorm
With Alina. Your Employer h.. lhe proper forms Aelna wlIllhen es.
limite lhe benefit I. 'lbu and lhe dentllt will be laid whet they are
before treatmenl starts
Some services may be given before Advance Claim Review is made.
The.. Ire: emergency treetments; oral eums, including prophylaXIS;
Ind X"'IVS.
A cour.. of treltment i. a plamed progrlll1 of one or more services
Of supplie. to trelt I denIal condllion. The condition mUll be dilg'
nOMd by the wending dlntl.t " I result of In oral eXlm. The
lrutmant may be gillen by one Of more dentl.t.. The cour.e of
lrutmenl Ilartl on IhI date I dentlat fnt give I a IIfvice 10 correct
or t,.,1 such denIal condllion.
Notl
AI I part of Advance Claim Review and .. part of proof of Iny
claim:
GR.g
17
. Aetna hal Ihe nghl to requre an oral eum 01 Ihe perllll1 al 'II
own e.pense
. . I VOIl mUll g've Altna el dilgnol\lc II1d eveluauYll """OIl whICh It
. m.y requll'e. The.. include: li'1yI; modell. ctlarlllOd wnllen
, reports.
The benef,ls for a cour.. of treatment may be for a lesler amount
lhan would Otherwtll be paid: d Advance Clllm RevIeW IS not made;
or rf loy required VlnlyW!g matlrllll. nOI furnllhed. In Iln .....nl.
benefnl Will be recilctd by lhe emoll1l of COYllred Denlll bpenses
thai Alina ClnnOI verily.
Benefitl
This Plan pays a benefll for Covered Denlll E.plnses equal 10 Ihl
Paymenl Perclnllgt:
. of Type A e.penles; and
I of Type B e.plnl..
COVERED DENTAL EXPENSES
Cerllln dentll e.pen... ere clJIIIred. These are Ihe dentlltl'
charges for Ihe serval and supplies lillld below which. for lhe con.
dition b.ing trell.d. ere:
I nlcenllY; and
I CUltomanly uI.d nllionwlde: and
I deem.d by Ihe profeSSion 10 be appropnall. They mUll meet
broadly acceplld na\lonal II.,dards of dentll praCtlcl.
Alterna" Trlltment
If alllrnall eerv,ces or supplies rT1IY be used to treat a denIal condl'
lion. Covered Denlll bpenses WIll bl limiled 10 those services Ind
suppllll which:
. are cUllomlrily used nationwide for lreltmenl; Ind
. are deemed by the profusion 10 be Ippropnall for IrllIIT1enl.
They mUll mHt bloIdly accepltd nllionll IlInderdl of dlnlll
prlClice. TIll person's 10lel ronsnt orll condllion will be IIkln
inlo ICcounl.
The Umllltlonl section h.. some e.amples of how 1111 worIIl.
'lYPI A EJlpln..s
I Or.1 ..Iml onc. lIVIIV 6 monthl. This Includes: prophyIIxll; leal.
109; .nd cleeni09 of leelh
I Toptell Ipplicalion of sodium or Itennoul fUonde fO( penon. un.
der 16 velrs of Igt.
GR.g
18
I Spatc malnlil1nCll
I )I,.ray. for dlagno".. AIIO other X-fayl nOf to .xceed: one IuIt
mouth 1fIlll. In a 38 month p.nod; and ' "' lit 01 blteWWl91 In a
,6 month ptnod
,; Non'lurglCII elllactlOl1l,
'I fU~ngl
I General anesthetIC I gIVen In connecllon with cO~llled dental
Ger~lCtI.
I Non'lurglCII treatment 01 diltlled ptllodonlllllructurtl,
I Non'lurglCal endodontIC treetment. Thil Indudel rool clllII
therapy,
I InJeclion 01 anllblotlC drugs,
I Rep.lr or recementlng of crown.. inlayl. bndgework or denturel.
I Re~ning 01 denturtl.
I Firlt Inltallallon 01 removable denlUl1l1 to replace one or more
natural teeth eXlIlCted while the perlOn II ClMred, Thll includtl
adJU'tm.ntl lor the 6 monlh penod 10UowIIlQ the date they WIre
inlllUed.
I Replacement 01 an exiltlllg removable dennn or lixed bridgework
by a new denture. or lhe Idding 01 teeth to I plnlll removable
denture, But. the "Prosthelis Replacement RUe" below mUlt be
met,
'lYP' B Exp.n"l
I InlaYI. gold lillings. or crowns. This includes precision anachmentl
lor denturel.
I firlt InlteUalion 01 fixed bridgework to replace one or more natural
leeth extracled while the person is covered. Th'I Includel inlaYI
and crownl al abutments.
I Replacement 01 an elll\lOg removable denture or lixed bridgework
by MW fixed bndglWOrk. or the adding of leeth to eXlStong fixed
bridg.worit. Bul. lhe "ProsthesIS Replacemenl Rule" below must
be met.
Pro.thlll. R.pllc.mlnt Rul.
Certain r.pIacemenls or additions to exilllng denlUrtl or bridgework
wi be covered under thil Plan. Bul prool IItisfactory to Altna mUll
bI givIn thet:
I The replacement or Idditlon 01 teeth il required to replace leeth
extracted aher the prllIfll denlUre or bndgework WI' iOllaled.
The ptrlOll mull '- bee., covered when the tooth wel
extracted
I The prllenl denhn or bridgeworll CIOnOI bI made slllVicllble.
AIIO, it mult bllIlIIlI 6 Villi, old.
.
.
GR.g
1e
I The presem oemure II an ImmeOlato lemporarv one 10 replace
one or more nalurll leeth ellrlCled whle lhe perlon II cOYIred
. Md cannol b. mad. pennanenl R.pe.r..mem bv a p.rmanent
. demure II n'lded. hI... pIK. Wllhin 12 morllhl Irom lhe dale
. lhe 1m media Ie IemporlrV 0IlI WI' 111I1 Inslllled
EXPLANATION OF SOME IMPORTANT PLAN PROVISIONS
Cllendlr Vllr Deductible
ThlllS Ihe Imounl 01 ClMIred Dent.l E.penl88 you PIV 88ch calen.
dlr vesr before blnelil. Ire paylble. There II e loparale Calendar
"',r DeduCllble lor elch perlOll
The Calendlr Yelr Deductible 15 applied 10 Coverad Dental and Medl'
cll E.pens88 combVled.
Femllv Deductible Umlt
II COYIred Denial E.pen..s Incurred In I calendar year bV you and
your dlpendlnlllnd applied agl1051 the IIplrlle Calendar Yelr De.
ducllblll equels lhe Famllv Deducllble Umll. you and your depen.
denl. Will be con.ldered 10 hevl met lhe IIplrale Calendar Year
Deducllbl88 lor the rOIl ollhel calendar year.
The Famllv Deducllble Umil IS applied 10 Covlred DenIal and Medical
hpcnles combined.
Celender Vllr Mulmum Senlfit
Thi. Plan h~. a Calendar "'ar Ma.lmum Benellt. thaI is Ihe mOil
lhells pevable for aU dent" e.penses Incurred bV a person In a cal.
ender velr. II appl 85 even if lhere 15 a break In cOYlrage.
Maximum Senlflt
Thi. Is lhe mo'l lhal wil be pavable lor any person In hil or her
IifIlime. h applies even if there II a bre8k In cOYlr'ge.
There i. on. MI.1mum Benefit for I perlOn's COYIred Dental and
Medical E.pen.e. combilld. h Ippliel 10 II luch ellpenS88 during
his or her lifelme.
Anv benefilllhellre payeble under Ihis secllon WIll be cherged
IQIlIlIt lhe MaIllTlJlT1 Benefit under lhe Comprehenlive M.dicel E..
pen.. Benllit. .lCllon of the per.on inwlved. Benelill for ClIYII8d
Dentel hpen... which .. cIwg.d Iglll1.t Ihe Ma.inum Benefit win
be IIIIl.d " " Ihty Mil CCMlred Medlcll E.p.n....
GR.g
20
WhIn lhe Aller""" Trellment pan at thll Plan epplle.. beneht. WIll
b,,'lIIl11l1d Some exemple. 01 how IhI. worlls follow
R..tollllve
Gold. Baked Porc.laln. Crown.. and J.ck.I.. Cov.r.d O.ntel b.
pen... w,lI b. lunlted to the cherg.. for the procedure ullng emlll.
gem or like metenel. ,Ill would re.,or. a loolh Th" IImll epphes
.....n " you end lhe d.nt/II choose .ome oth.r typ. 01 reelor.lion
Recon.tructlon. COVIlred OIntel Expen.e. Will be IImlled 10 lhe
cherge. for the proc.dur. need.d to .lIminel8 orel dl.elle end re-
place lTlIlllng teeth, Apphancee or re.loreliona needed to Incr....
VIlrucal dlm.n"on or restor. th. occluelon er. de.m.d to be op-
lionel, They are nOI covered.
Proedledontlce
Plrllll dentulII. Covered Dental Expen.es Will b. Irmlled to lhe
chergea lor a call chrome or acrylic denture II ttlll would .aliafactor-
Ily II110re an erch, Th" IImn.ppllee .VIln " you and the dentlll
choose a more elaborate or pr.clllon appliance.
Compl"e d.nturll, Covered Dental expense. Will be limned to the
cherges lor a lIendard procedure. TIll' limit .ppllee even If you and
tho denllll chooso por.onakred or specl8llzed !reatment
Repllc.ment of ..I,ling d.nturll. ThiS Will be cOVllred only If th.
eXllmg dentur. ~not b. ueed or r.pall.d " it can b. ueed or re-
paired. Covered Dent'l exp.nses WIll be limited to the chergee for
lhe IIIr\IICII needed to make the de~ture useble
The 'oIowlng ..cullan. .pply
COVIlIed Dent.1 Expen.es do not ,nclude and no bene',t. er. payable
for cherg.. IOf
. Any denlel .lIVlCee end auppli.. which Ite covered In whole or in
1*1:
under eny other p.rt of thll Plan. or
under any olller plen a' group b.ne',1I prOVided by your
Emp!oY'r,
GR.g
21
I Tre.tmlllt lly olhor Ihan d dlnllll Ilut lhe Plan will covor SOllie
Hell men" by . lICensed denial hygienist Ihal are supervised by a
dentin The.. .re .cahng 011l8lh. cle.llng 01 Ilelh and loplcal
appllcaUon 01 lluonde
. Personahallon or characllHIl.uon 01 dentures
~ The replacemelll 01 a prOSlh8llc device Ihll IS losl. missing or
stolen.
I AnV IIrvIC.. or supplies which .re for onhodonuc lIealmenl, ex
cepl as speclllcallV provided.
I Services or SUppll" 10 Incre..e verUc.1 dimenSion. These are
denlUrIB, crowns. inl.vs end onlavs, bndgework or any olher ap.
pllanca or service.
Benelltl After Tllmlnlllon 01 Covlrege
This secllon apphes 10 a persOll whose coverage cesses while not
"lolallv dlubled". ThiS IIrm IS delined In the Gener81lnlormauon
secuon
expens.. IIlCurred lor lhe 10Nawing aher Ihe pellon's covellge
ceall' under IhI. beneln secUon will be deemed to be Incurred
when ordered
I Denlures
I FiMed bridgework.
I Crowns.
ThiS applie. onlv illhe Item IS I,nallv Installed or delivered no more
Ihan 30 days aher cover.ge ends
"Ordered" me.ns,
. impressions h.ve been t.ken Irom which lhe denlures, crown.. or
lixed bridgework will be mada. and
. as to li..d bndgework and crowns:
The IHth muSI have been fully prepared II,
they Will lllve a. retalnere or .upport; or
they lIa beng rellored.
.
GR.9
22
GEN'I!RAL ElCCLUSIONS APPLICABLE TO HEALTH
ElCPENSE COVERAGE
Covvrage IS nOI provided lor the loIawlng charges
I Those lor lervlC4lS and supplies.
Not nlclI..ry. I' determined by Altne. lor the dllgnolll. clre
or treatment 01 the phYllcal or menl.1 condition involved ThiS
applies even If lhey are prelCnbed. recommended or Ipproved
by the a!lendlng phYllclln Of dlntllt.
Which any school syllem IS r~irId to provide under Iny law,
o Those lor care. treltment. servlC4ll or supplies that are not pre.
SCribed. recommended and approved by the person'. attending
phYllclln or dlntlst.
I Those lor procedures. services. drugs .nd other lupplies Ihal are.
as determlr1ed by Aetna experimental or Itln under cllOlcallOvestl'
galion by health prolesllonals,
o Those lor servlCls 01 a relldenl phYllclln or Intern rendered In
lhat clpaclty
I Those 10 the extent they are not rlllonlbll chargll. es deter.
mined by Aetna
o Those that are made only because there IS health coverage
o Those that a ClMlred perlon IS nOI legally obliged to pay
I ThOle. as determined by Aetna. to be for custodlll care.
o To the extent a.0W8d by the law 01 the Jurrsd,ctlon where the
group contract IS delivered. those lor services and suppllel:
Furnished. paid lor. or lor which benellts are prOVided or reo
quired by rll.on 01 the pasl or present service 01 any person in
the armed lorcII of a government
FUrnllhed. paid lor or lor which benefits are prO\llded or required
under any law 01 I glMlrnment. (ThiS does nOI Include a plan
eltablilhed by I government lor 115 own employees or their de.
pendentl or Medtcaid I
o Thole lor or relaled to Iny eye IWllery mllnly to correct relractlve
errors,
o Those lor education. special education or job traiOlng, wI1elher or
not given," a lac.ity that alia provldel medical Of psyctllltrlC
Ireltment,
I Those lor plastic surgery. recOl1strucuve surgery. cOlmetlc surgery
or ocher services and suppll8S wNch imprlMl. Iller or enhance ap.
palranee. whether or noc lor psychological Of emotlonalllason..
excapl to the extent ne.ded to: .
.
GR.g
23
Improvo lho funCllOO 01 a pari ollha bod V lhal
II nOI a looth or IIrUClure Ihll support I IhI IlIlh:
II mlllormed
bV re..on of e congeMl1 abnomlalllV, 01
al a dll.cl flSU11 01
dilea.., or
lurgery p.rformed 10 tr.1l I dI..... or II1JUlY
Repair an Injury Survery mUll be Plrlormed 10 the cllllldlr Vllr
of Ihe accld.nl which C'U"I lhl InjUry or In lhl n'.1 cMllldlr
year
o Tho.. Ihal are tor IherlPY or. lor luppli.. or for coun..llI1g lor
"Iual dylfuncllonl or inldaquaclIl.
o Those for or rellted 10 I" change IUlg.ry or 10 any .re.lmenl 01
g.nder Idenuty dllon.1
I ThOle lor or r.llted 10 .rllllclIl 1O"lT1IOallon, 10 In vllrO ',"'llIllOn
or 10 embryo Ir.nlt.r procedurll
o Those tor Ihe reverlal 01 a IlerdllBlIoo procedure.
I ThOll for routine phV'lcel e.ernl, roullne Vlllon ..ami, rOUlln.
denial e.ams, rOUllne hearing e..ms, ImmUOIZlIlOOI or olhar pre.
venllve servlCII and Iupplles
I Those tor or in connecllon With marriage. family. child, ener. 10'
clal adJUslmenl. pasloral or IInanclII coun..llng
I Those for acupuncture therapy NoI elcluded II acupuncture when
il is.
performed bV a physlcl.n, and
.. a torm 01 anlllhella In connecllon wllh IUIlJery lhal il cov.
.red under Iln PI.n.
o Tho.. lor or in conneclion With lpeech lherapv Thll 'Ick/lion
doel 1'01 apply 10 chllg.. for lpeech lherapy lhalll elPlcled 10
r.llor. spllch 10 . parson who halloll elistlng Ipeach funcllon
(Ihe abllily 10 IIpr... thoughll, lpeak wordl, and form Hfl-
lences) .. lhe IlIull of e dise..e or injury
Any elcluSlon above WI. not apply 10 the ellent lhal'
coverage II specifically provided by name In your lloo.d81-Cerlill.
Clle, or
GR.g
24
coveragu 01 the chargus IS requ~cd under any law that applies to
the coverage.
11- ekcluded charges will not be uled wh.n ligln1g benellll.
. The a.w 01 the ~Idlcllon where a parsOll lives when a cl8lm occurs
I1\rf prohlbu some benefus " so. ,hI!\' WIll nOI be p8ld.
DO BENEFITS UNDER OTHER PLANS AFFECT
THESE BENEFITS?
Oth... Plans Not Including M.dlcar.
Some persons haYll medical or denial coverage In addition to cover.
ege under this Plan. When thiS is the cas.. lhe bene fill Irom "other
plans" will be laken Into account ThiS may mlln . reducllon in
benefits under IIU Plan. The combined benefuI Will not be mora
than the ekpenses recognIZed under these plsns.
... a ~endar yew. thiS Plan Will pay
. ill regular benefits In full: or
. e ntduced amount of benefus To "gure IhlS amount. lubtract B.
from A. below:
A. 100% of "Allowable E.penses" Incurred bv the person lor
whom cl8lm is made.
B. The benefits payable by the "other plans". (Some plans may
proVide benefits In the lorm of servICes rather lhan clsh pay.
menll. If this is the else. the cash value Will be used.l
"Alowable Ekpenses" melns any necessary and r"lonable medl.
~ end dental tllpInse. parl or all of which IS cOl/8red under 1I1ll.0f
the plans COl/8rilg Ihe person for whom claim IS made. Not Included
Is any ekpense listed in General Ekcluslons.
iI rlld 001 whether the regular benefits under thiS Plan Will be reo
duced. the order in which the various plans Will pay benefill musl be
1Igured. ThiS wiI be done as fotows:
1. A plan with no rules lor coordlnallOll With other benellls will be
deemed to pay us benefits belore a plan which conlelns such
rules.
2. iii plan which covers a person other than as a dependent Will
be dltme<l 10 pay ils benefits belore a plan which C0I/811 the
pelson II . dependenl.
GR.g
26
J. Excepl In the 14se 01 a Qependenl child whose parenls are d"
vorced l)( lePIJIled' lhe plan which Covell the perlOl1 II ,
depend.nt of . pellOll who.. blrlhd.V comel flfllln . c.len.
dll \IlI1I WllI be pnm.ry 10 the pi." which cowrs lhe person II
, dependent 01 . person whose bUlhdav comes l'ler In thaI
cllendar VWIt': however.
.. ,f bOlh perlnlS hIVe the lime bUlhdav. Ihe benelll' of Ihe
plan which covered the parenl longer are d81ermll18d before
loose of the plan whICh covered lhe other parenl for a
shorter penod of lime.
b. If Ihe olher plan does not have lhe rule descnbed .bove. but
Instlld hll . rule baHd on lhe gender of lhe pl/enl. end If.
as a r8llull, the plans do nOI eglle on Ihe order of benelill.
lhe rule In lhe olher plan Will determne Ihe order of
benefits.
4. In the Casl of . dependenl child whose parenlS are divorced or
separated:
I. If Ihere is a courl decree which makes one parenl fll1anciallv
relponlible for the hlllth care expensll with respect to Ihe
child end the enlltv obligated 10 pavor provide lhe benefits
of that parenl has eClual knowledge of Ihose lerml. the
benefits 01 e plan which covers the child as a dependent of
such parenl llhall be determined before Ihe bene III 01 any
olher plan which covers lhe chIld as a dependent child.
b. If there il nOI such a court decree:
If Ihe parenl WIth cuslodv 01 the child has not remamed. the
benelils 01 a plan which covers the child as a dependenl of
auch pallnl WIll be delermlned belore the benellls 01 a plan
which covers Ihe child as a dependenl 01 Ihe parenl wilhout
CUllodV.
If lhe pallnl with CUllodV ollhe child has remamed. lhe
bIn.,ill 01 . plan which coverl lhe child as a dependent 01
auch parenl IhelI be delermined before Ihe benefill of a plan
which covers WI child II a dependent of lhe spouse of the
parent with CUltedV. The benefils of a plan which covell
thet child II I dependtnl of the spouse of Ihe parenl wilh
CUltedV WIN be dt18rmlled before lhe benefits of a plan
which covers thai child II a dependenl of the parenl wlthoul
culledV. .
15.11 1, 2. 3 and 4 above do not eSlablish an order of paymenl.
the pi", under which the person bel been covered for lhe long.
lit wiN be deemed 10 pay Its benefits fWlt; except thel:
GR.g
26
The benefits of a plan which covers lhe person on whose
expenses cIIm II blled al a.
I IaId.olf 01 retired employee; or
I lhe dependent 01 such porson:
shall be delarmned aher Ihe bene Ills 01 any other plln
which CO\llltl IUCh person 85:
I In employee who is nOlllld.olf or relwed; or
· a dependenl 01 such perlon.
" lhe other plan does nOI have a provision:
I regarding IIId-olf or relired emplovees; and
I as a result. each plan delermlnea liS benefits aher lhe
other;
then Ihe above paragraph will not apply-
"Olher plan" meanl anv other plan 01 medical or denial expense
coverage under:
I Group Insurance.
I Uninsured arrangements 01 group coverage.
I Group cCMlrage ttvough Health MaIntenance OrgaOlzations and
Dlher prepayment. group practice and Individual practice plans.
I No-laull IUtO Insurance required by law and prOVided on other
than a group bailS Only lhe level 01 benellls required by Ihe law
wi. be counled.
If it is necessary in Older 10 admiOlster Ihis provision. Aelna hes the
nght to:
I release 01 oblalll any data; and
I make 01 recover any pavments.
EFFECT OF A HEALTH MAINTENANCE
ORGANIZATION PLAN (HMO PLANt ON COVERAGE
If vou are III an Eligoble Class and have chosen coverage uncler an
HMO Plan offered by your Employer. you and your eligible depen.
dents W1I be excluded from Heallh Expenle Coverage (excepl Dental
and Vision Cere. if any) on the date 01 your cOVIllage under such
HMO plan.
.
GR.g
27
II yOU aro III an Hy'olO Class anll are COIIorol1 unllor an HMO Plan.
yOU can choose to change 10 cOllerage lor yoursell and your cowred
. dapell\1enls under thll Plan II You'
~ live 10 an HMO plan ervoUmenl area and choose to change cover.
age dunng an open ervolmenl perIOd. coveraga will take effect on
the group policy anl1lversary dlle alter the open enrollment penod
You WIll nOI have to gIVe eVidence 01 Insurablllly There Will be no
ruin for waiting penods or preaxllllng condlllons.
I live In an HMO plan ervoRment area and choole to change cover.
age wl1en tl1ere " not an open ervollment perIOd. covellge WIll
lake effecl only II and when Aetna gives III Wlllten consent.
I Move from en HMO pIIn enrollment area. or If the HMO dlscontln.
uel. no evidence 01 ,nsurabllity II needed " you choole to change
covellge Wlth,n 31 days of the move Dr the dlsconllnuance. There
will be no reslncllonl lor wailing periods or lIfeexisllng condltlOnl.
" you choose to change coverage elter 31 dayl. covellge will
take effect Dnly If and wilen Ihe Aetna give I III WllIIen con..nt
Any eKlenllDns Df bene"ts under tin Plan IDr dlubllity Dr pregnancy
Will not always apply on and alter lhe data DI a change tD an HMO
plan They will apply only il Ihe person" not covered II once under
the HMO plan because he or Ihe " In a hOlplll1 nDt affiliated WIth
the HMO II you give evidence that the HMO plan lIfovldea an eKlln.
slon DI benellts lor Disability or pregnancy. coverage under thll Plan
WIll be eKtended The extension Will be lor the same lenglh 01 lime
and IDr the sarno condlllDns 81 the HMO plan prDvldes It Will not be
IDnger than the "r51 to occur 01:
I lhe end DI a 90 day period; or
. the dale tho persDn IS nDt con "nod
No benelils Will be paid lor any charges lor IINic.. rendered or ,up'
plies lurl1lshed under an HMO plan
EFFECT OF MEDICARE
Heallh Expense Coverage W1Il be changed IDr any parlDn whlle ,hgl-
bIa for Madicare.
A persDn is "eligible lor Medicare" ,I hI or Ihe:
I is covered under It;
. il not covered under it becausI 01:
haVl1g refused u;
GR.g
28
, "IVlI1gl...d 10 mike pfoper requell for II
H14I18 Ire lhe ch.ng..
o All helllh e"penl" covered under IhI. Plan will be reduced by
.ny Medlc.1 benellll 1II1.lble fOf Iho.e upen... Th,. will be
done before lhe hullh benelll. of Ihl. Plan Ire Ilgured.
o Chargll uHd 10 .'lI.ly I perlon'. P.II B deduclible under Medi-
care will be Ipphed under Ihl. PIen In Ihe order fllCelVed by Allnl.
If 2 or more chlrg.. Ire reclIVld II Ihe lime lime Ihey WIll be
.ppllld I1lI1l11g with the lerge.1 11IIt.
I Medlclre beneht. will be IIkln Inlo .ccounl for Iny per.on while
he or .he i. eligible lor Med,c.re, Th,. Will be done whether or
nOI he or aile I. enlllled 10 Medlcere benehls
I Any rule fOf coordln.llng "other plan" beneht. Wllh Ihose under
Ihll PI.n WIll be .pplied .hlr thl. PI.n's benefits h.ve been figured
under Ihe .bove rul... Allowable hpen". Will be reduced by any
Medlc.re benefll. .v.lI.ble for those upen....
Coveraga will nOI be changed at any lime when your Employer's
complllnca With federall.w require. thl. PI.n's benefits for I person
10 be figured belore bene lit. .re figured under Medicere.
EFFECT OF PRIOR COVERAGE
If 100 cover.ge 01 any person under Iny pall of Ihls Plan repl.ces
any pnor coverage of Ihe person, the rules below .pply to that p'lI.
"Plior coverege" is .ny plan 01 group coverage lhat has been reo
placed by coverlge under pili or .1 of this Plan II muSI have been
aponlored by your Employer. The replacemenl can be complela or In
plft for lhe Eligible Class to which you belong Any such plln il pnor
COIIIrage if provided by:
o Group inaurance plan I .
. Holptlel SllViee or e"pense indemnity orglmlltions.
. MedicelSIIVic8 or e"pense indemnilY orglmlllOOs.
. Any olher preplymenl plans.
A perlon'l Ule Inlurance under IlllS Plan replaces .nd supersedes
IIfV pnor life insurance. II will be In e"change for everylhlng under lhe
prior life Insurance. If you Of your beneliciary become enlllled 10
claim under the poor life Inuance, your life In.urance under It 111 Plan
wiN be canceled. This will be done as of II. efteclive date. Any pre-
mluml plid for your life Inuance under Ihil Plan W1I be relurned 10
your Employer.
GR-g
29
Th. mode 01 I.lttemenl you ChoM and the beneficllry you n.med
undel. . pnor Altna Id. inaur.nee pIen W1lI epply to tin Plln Thla
~ be chlnged ICcordlng 10 lhe ttrml 01 thll fltan
'Cover.g. under any other IICUon of thll Plln WIN b. In exchange lor
II pnvtleg.. and benellll prll'llded und.r any Ilk. pnor coverag.. Any
ben"11I provided und.r auch pnor coverage may r.duce b.nellts PIV'
eble undel thll PIIn.
Th. b.nellCiary you nam.d under a pnor Aatna ACCidental Death and
Otlm.mbermanl Cll'I.r.g. plan will apply to lhil Plan. Thil can b.
chang.d according 10 the IIrml 01 11111 Plan.
Th. rul. b.1ow apphea to a pre.xilllng condition of a p.rlon who
had pnor coverage on the day before h. or she b.comea cover.d lor
Compr.henSlve M.dlcal exp.nll Cll'I.rag.. It II in lieu 01 any lik. rUe
under luch cover.ge
Any limitation under Comprehanlive M.dlcal exp.nse Coverage for
a preexlIUng condition will apply only up 10 any IpeClfied dollar
maximum b.n.hl sllowed und.r the pnor coverag..
A pr"xlltlll9 condition I. an Injury or dl..... lor which. dunng tha 3
monthl before h. or she last becama covered, lhe per.on:
. rec8lved troatmenl or services; or
. took pr.scllbed drugs or medicines.
GR.g
30
GENERAL INFORMATION ABOUT YOUR
. . CQ\(ERAGE
WHEN DOES COVERAGE TERMINATE?
.
Coverage under Ihls Plan lermlnales allhe f~SIIO occur of:
. When employment ceues
I When the group conlrllCt lermlnates as to the coverage.
I When you are no longer In an Eligible Class. !ThiS may apply to all
or pan 01 your coverage)
. When you lall 10 make any requwed conlributlon.
Celslng aclive work will be deemed to be cessation 01 employment.
II you are nOI al work due 10 one ollhe following. employment may
be deemed to conunue up to the Iimlls shown below.
I! you are not at work due 10 diseale or injUry. your employment may
be conllnued until slopped by your Employer. bUI nOI beyond:
. 30 months from the start of the absence. lor Heallh bpense
Benellll Coverage;
I 12 months Irom lhe Itart ot the absence. lor aU other coverage
I! you are not at work due 10 temporary lay.off or leave of absence.
your employmenl may continue untllllopped by your Employer. bUI
not beyond Ihe end of the policy month aher the policy month In
which the absence SIll led The term "policy monlh" is defined else.
where In lhe group contract See your Employer for this delinllion
The Summary of Coverage may show an Eligible Class of retired em.
ployees. II you are In thet class. your employmenl may be deemed to
conlinue:
. for any coverage shown 10 Ihe Relremenl Eligibility seclion; and
. subjecl 10 any limits Ihown in lhal section
I! no Eligible Class of nured employees Is shown. Ihere IS no cover.
age tOI relired employees.
In flQlKlng when employment Will SlOp lor Ihe purposes ot leonina.
lion ot any cOVllrage. Aelna will rely upon your Employer 10 noufy
Aelna. This can ba done by tellng Alina or by sloppng prlmUn
payments. '!bur employmenl may be deemed 10 conllnue beyond any
limlls shown above It Aelna and your Employer so agree In WQling.
GR.g
31
" ~ cease tcllve work. .Ik ~r Employtr If I "
conllnued
. .
Depend.nll Cowr.g. Only
. A d.p.ndent'1 cOYlreg. WlIlelmmele II the Irr.t 10 0<;,.. "..
I Termln.lloo 01 .1 dependlnll' cover. unde' Ihe C''lll~ .. 'l'lli.
I When. depend.nl blComn covered _ .n llmploywe.
I When such peraon II no Iong.r . defined dependenl
. When vour cover.ge l.rminIlel.
CONTINUATION OF COVERAGE
'tbu mev conllflUe Hlllth E_pen.. CovertgB for ,ou end vwr depen.
dentl. II II would Olherwlll lelmNle beceule you lelmmele employ.
. menl. 'lbu mU'1 requlll IMI the cover.ge be c. ~11l1Ued. The rtqUIlI
mull be made wllhln 20 daya folowlng the du. you are notified of
lhe nghl 10 conlinue In any event. lhe rtqJesl mU'1 be made wilhln
31 day. 10Rowing lhe dill coverage wlllAd othelWlle lerml1l\l.
Coverlge WI' cel.. on lhe firal 10 occur 01:
· The end of a 6 monlh penod which ..... on the date cover.g.
would IIrll1l\lle.
· The dlle you Ire eligible for coverage IKIder another group p111l.
I The dele you could be covered under Medicare
I 'lbu la~ 10 meke any contllbullon.
· Health bpenll Coverege diaconllnues lor en Illove'l 01 your lor.
mer Emplower.
'tbu mev not conlll1Ul Health E_pense COl/erage
conlilualion of hkl COI/Illge because 01 any lec
.... .....t.
CcMfIge for I dependenl INV noc be conllnuad beyond Ihe dale il
-al OIhenWe \lrminall. pclillYl 01 1m conllnuatlOn.
DOES COVERAGE FOR MY DEPENDENTS t."NTli~UE AFTER
MY DEATlt1
. you die wI* ~ under IIlV part of \hs Pl.". .'V Helllll tk.
IJIllII ClMfIIIlIll... In foree for your dependenls will be ccnUrlllcd.
an yulI' ~r mull conllnue 10 mekl premun ",vm.nll.
'lbur 1pOIM'1 ~. \Nil Ilop when yoIJ' SPOUII remlmll. A"f
..~'IlXMfWgI. including your .pouse's. wdlllop when IIrl
one of the laIomng happens:
lit.,
32
. The end of the 36 monlh period nght aher your death
· A dependent c..... 10 be e de"ned dependent
. '. A aepend.nl b.colTlt. .hglble for hke cOllllrage under tl1ll Plan
I. btpendenl coverag. ce.... .. to the Eligible Clan of which you
. wele a member right before your dealh
· Any requll8d conlributlon. stop
If Heallh Expense COIIlIlage II being conllnued for your dependenll.
your child born ah.r your death will also be cOllllred.
WHAT HAPPENS IF MY DEPENDENT CHILD IS
HANDICAPPED1
Heallh Expense Coverage for your fully handicapped child may be
conllnued pili the maximum ege for a dependent child. ilthe child
has not been l&Sued a perlonal medical conllllrllon pokey
'!bur child is fUly handicapped I"
· he or she IS not able to earn hll or her own living because of
menial illness. developmental dISability. mental retardallon las de.
fined In the menial hygiene law). or a physical handicap which
started prior to the date he or she reaches the maximum age for
dependent chldren: and
· he or she depends chiefly on you for support and malnlenanCe,
Proof that your child IS fully handicapped must be submllled to Aelna
no later than 31 days aher the date your child reaches Ihe maximum
age
Coverage Will cease on lhe fil51 to occur of:
I Cessation of lhe handicap,
I Failure to give proof that the handicap continues
I Failure to hM any reqUired exam.
· Termination of Dependenl Coverage as to your child for any rea.
son olher IlIan reaching Ihe maximum age.
Allna will hlllll the righl to require proof of the conlllluatlOn of the
hlndicap. Aetna also has lhe nghl to examine your child as often as
needed while the hancflCap conllnues at ils own expense.
HEALTH EXPENSE BENEFITS AFTER TERMINATION
If . person is totally dillbled when hiS or her Heallh Expenle Cover.
ege ceases;
Blalc Vision Care Expense benefit. will be available to him or her
while disabled fOI up to 3 months. These benefits will be ava~able
GR.g
33
onIV I' upensea are for covered urvoce. and suppltes which have
btIn rendered n receMd. including deMred and Il1slalled. I' the.e
. ~y. pnor to the end oIlhll 3 month perIOd
Comprehensive Medicel Expense benefns will be ava~able 10 him or
'her while disabled lor up 10 '2 months
Comprehensive DenIal Eapen.e benefll' will be available to him or
her while dlubled for up 10 12 monlha. The benefll' will be avaiable
onIV If eapen.e. .e for covered IIrVlce. end suppltel which heve
been rendered end recllved, Including deMlred and Installad, If lhe..
applv. pnor 10 the end of thlt 12 month period
ComprehenSive Medical and ComprehenlNe Dental EMpense beneflls
wlII cease on lhe filiI 10 occur of Ihe fclaWlng:
I The p.rlon's muimum IS paid.
I The person becomes covered under any group plan Wllh hk.
benefits. (ThIS does nol apply" hll or her coverage ceased b..
CIUI. Ih. benefilsechon ceaud as to your Eligible ClalS.1
The words "IOlallv disabled" mean lhal due 10 injUry or dls.ase:
. You are not able 10 engage In your cuslomary occupahon end are
not working for pavor profn.
I Your dependenllS nOI able 10 engage in most of lhe normel aCllv,
ihes 01 a person of Itke age and seM In good health
If thil proVIsion appll8S 10 you or one 01 your covered dependent I,
_ lhe s.ction ConverllOll of Medlcel Expense Coverage for informa.
lion which may affecl you.
MAY GROUP UFE INSURANCE BE CONVERTED1
" any of your Ufe Insurance ceases becau.. your employment lIops.
you lit no longer in a clan ehgible for IUCh insuranc.; or because of
.. penlion or nllnm.nt; or of e reduclion In your inlurence for
fIff ocher reeson; the amounl of Inlurence which cea"l may be
CXIIIvtned to e pII'IOI1ell~e insurance poky " 1..ler amount may be
convened. if 10 desired.
'tbur converted poIcy may be any kind of personal poicy Ihen CUI"
lomanIy belllg l.-d by Atlna for tha amount beong converted and
tor your age (nensl binhdavl on lhe date II WIll be ISlued A term
policy woll nOI be lVailable eMcepI for lhe hmilld period Sll fonh be'
low. II WIll nOI have dilllbity or olher eMlra benellll.
'tbu may requesl 10 hIVe the effecllVe dlte of this form of Inaurenee
to be prOYided by the pllsonal poky defelTed for up 10 one veer. II
GR.g
34
, Ill.,t II t:tt:;J vI CIItJul:JtnJ tu UfO'w'IUC lUfft1 ntbUlancu for Iht! J,Jlmoo
01 del.rmelll. The premouml due under the perlonal policy on and
Ift.rlhe end 01 lhe I.rm IIlIUrll1Ce perIOd will be baaed on your ~e
.. (n,'rllI blrlhdlYl1I .uch dlle.
. When lI1e Inlurenee ceesee becau58 lhat pan of tho group policy
lermNle. as 10 yolK employee c1asa. lhe amount lhal ceases may
be converted to I per.onal policy. The amount will be lell any
amount 01 group IIIe Insuranee the perlon becomes eWgible lor WIthin
31 dayl 01 termlllltlOl1
In order to conven, WlllIen request must be made lor a perlonal pol.
ICY wuhin 31 days after cessallon of Insurance lor any of the above
reesonl. The lirst premium mUll be p8ld wllhln that 31 dayl.
No evidence of Inaurablllly will be reqUIred
The personal policy WIll becoma effecllve at the end of the 31 day
penod dunng which converSIon IS possible
The premIUms for the personal policy WIll be at Aelna'l usual ratel
for the same policy ISlued to any other perlon 01 the lame clan 01
risk Ind age when lhe perlonal poliCY IS to become effectlVt.
Alter a personal po'CY becomes elfecllve lor any perlon, thai po'CY
will be in eKchange for all benefus and nghls under the group con-
tract as regards the person involved and the amount that could have
been convened.
IS THERE ANY LIFE INSURANCE AFTER TERMINATION?
'llll. In most casel a person can apply for a personal policy under
the Conversion Pnv~ege wllhin 31 daYI after hiS or her group life in.
lurance ceases. If a person dies dunng this 31 days and belore the
perlonal policy goes inlO effect, lhe amount payable under the group
contract II limited to the maKlmum that could have been convened.
Th. limit applies even il he or she has not applied lor or paid the
fim premium on the personal policy.
CONVERSION OF MEDICAL EXPENSE COVERAGE
Th. PlIn permits canaln personl whose Medical Expense Coverage
has ceased to conven to a personal medical policy. Thil C8n be done
without e medical eKam '1tJu end your lamily members may conven
when all coverage ceases becaule:
· you cease employment: or
. you cease 10 be 111 an e'glble class.
GR.g
35
..u "lid ..dll "."hUI I ,I ~UWld\le CedSUS llu~dU~e Ihe ~rOUII conlfacl
hll Ollcontlnued as 10 your medtcal coverage
. .'
Th, per.ooal policy mey cover
,. you only; or
. you and al of your family members who sre covered under lhlS
Plan when your CCMIrsge c.ales, or
. II you dl' al your flR\lly memberl, or your spouse only, who are
covered under thi. PlIn when your coverage cellel
Even If your own CCMIrage conllnuel, your dependents cen conven II
they CIIII to be e defined dependent due 10 di\lOlce, annulmenl, or
eny Olher reason.
The per.onal policy mull be applted lor WIthin 45 daYI after cover-
age ce..... The 45 dlyl It.rt on the date coverage cealll. Thll
applicallon penod WlI be extended lor 45 days from the dlte your
Employer glvel you Wflllen nOllce 01 lhls converslOl1 pnvilege, lire'
qUlred by law. but not beyond 90 d.ys Irom the dall cove rag.
cealll. This epplies even II the person IS s11H ehglble for benefits
bec,ule tha person II totally disabled
A8Ina may decline to ISSU. the personal policy If'
. It II applied for In a lurildiCllon In which Aetna cannot Issue or
deMr the poliCY
. On the dale of conversion, a person 15 covered, eligible or has
benelitl available under one of the follOWing:
any other hOlplll1 or surgical expense insurance policy;
env holpllal service or medical expense Indemnity corporatlon
uscriber contrlCt:
env other group coolract:
eny IlItute. welfare plan or program;
and thlt with the converted polley. would resuh In overlnlurance
or match benefits.
No one hi. the right to conven If you have ~ Inlured under this
Plan lor lell than 3 monthl. Also. no person has the nght to convert
If:
. he or she has uled up the maximum benefit; or
. he or lhe becomes e~gible for any other MedocaI Expense Cover.
age under thil PW1
GR.g
36
Tho perlonal policy form, and 115 lerms. Will bo of a typo, for group
converllon purpOIIl.
.. ..
~' 15 reqund by law or regulation, or
· al then olfered by Aelna under your Employer'1 converllon plan
II will nol provide coverage which 11 lhe same al cover eye under this
Plan Th. level 01 coverage may be leu end an overall Llfellm. MaMI
mum Benefit will apply.
lithe plan doel nOI Include MaJor Medical hpenle Benelltl, cover.
age may be eltclld under on. 01 'he to.owlng plans:
Plen I: HOlpllal room and board upenlu benefits 01 $ 70 per
day. The mtKimum duratIOn II 21 days. Milce..neous hOlpttal 'M-
p.nle benelill to a maKlmum of 5700 Surgical operation eK'
penle benelill according 10 a 5760 maximum benehll Ichedute
Plan II: Hospllal room and board upense benelits of 5125 p.r
day. The mnlmum durallon IS 30 days. Milc.Uaneoul hOlpttal .x-
pen.. benelllllo a mlMimum 01 51.200. Surgical operallon p-
penle benefit I according to a $ 1.250 maMimum bene lit I
Ichedule .
Plan. III: HOlpllal room and board upenle benefits 01 $ 1 BO per
day The maKlmum duration IS 70 daYI. MilceHaneoul hOlpltal ex.
penle beneflls 10 a maKlmum of S 1,800 Surgical operation eK'
pen.. benellll according 10 a S 1,900 mnimum benellts
schadule
If the Plan includll only Major Med,cal hpenle Benefits, coverage
mey be eleclld under the fOllowmg plan only If the Plan Include I
Comprehenslve Medical EKpense Benellls. coverage may be aleclad
under the folowlng plan.
Plan IV: A maJor medICal eMpense benefitl JlfOVlding: iiI a $ 180
per day hospilll room .nd board benefit: (iillUl'glcal expen..
b8nelits ICcording 10 a $2,500 maximum benefitl sch.duhe; fliil .
S 1 00,000 maximum henelit for" slcknUI'1 and inJurill: (iv) .n
80" benefit perc.ntage, WIth. coI1lUl'.nce limit of $2,000.
If the Plan incfudel MajOr M.dlcal E.pense Benefits combined with
other coverlge, coverage may be elected under Plan IV or Plan IV
coftlbined with loy one 01 Planl I, I. .nd III.
Tilt p.rlooal po~cy may conllln either or both 01:
GR.g
37
. A .talemel1l thai benehtl under II will be cuI baCk by any like
baneful pay.ble under tIn Plan after your cCMlrage COlltl
. I . I. .lIl1ment thM AltAI "1IV Ilk lor dlla about your coverege
. \.Ind.r any other plan. Thl, may be ..k.d for on any pr.mlum due
dale of lhe person.1 pokey II you do not give lhe dlla, eKpenl1l
. cover.d under tllil pereooel policy nney be reduced by expenl8l
which are covered or provld.d under thole planl
TIliI perlon.1 polccy Will 1111. lhat AltAI hll the nght to relul' reo
new.1 under .ome condition I Thll. WIll be Ihown In lhat pohcy
If you or your dependent w.nt 10 convert.
· Your Employer should be asked lor a copy 01 the "Notice 01 Con
verllon Priv~ege .nd Requelt" lorm.
. Send the completed lorm 10 the address Ihown
If a perlon il eligible to convert, InformatNln WIll be lent about the
perlonal pohcy lor which he or .he may apply.
Th. Int premium for the p.rsonal policy mUll be paid at the tlltll
the per.on apphe. lor that policy The premium due WIll be A.tAl's
normal rill lor the perlon'l cia.. and ~e, and the form and lmount
01 coverage
The perlonal policy will lake effect on the day after coverage lerml-
netes under chis Plan
TVPE OF COVERAGE
Coverage under lhil Plan lor ber,elus eKcept Ufe Inlurance and Acci.
d.nt" Death and o.lmemberment Coverage is non.occupatlonal.
Only non.occupatlon"lccld.ntallnjurln and non.occupatlonal
d11.1l1.. are cover.d. Any coverage lor charges lor lerVICII and
eupplin is provided only il they are fumjlhed 10 a person while
covered.
Conditions that 111I related to pregnancy may be cCMIred und.r thll
PlIn The Summary 01 Coverage wtII say if they are.
PHYSICAL EXAMINATIONS
Aetna wtll have the nght and opponunity 10 eKamine any p.raoo who
il the basil 01 any clam at II reasoAlble tlm.1 while that claim il
pending. Th. WIll be don. at Aetna's eXRense.
GR.g
38
LEGAL ACTION (DOES NOT APPLV TO LIFE INSURANCEI
. . No lllg.1 actlOl1 can be brought to recCMIr under arry benefit after 3
~'r. from this dlldlin. for filing clllml
. ADDITIONAL PROVISIONS
The follOWing addttlonal provlllons apply to your coverago
. You cannot recti...., multiple coverage under tin Plan becaule you
are comacttd with more than one Employer
. In the event of a mlsstttement 01 arry fact affecllng your cover.ge
under thll Plan, this true facti Will be uled to determine the cover.
age In force,
This document delcnbel the main featurel of tin Plan. AdditiOnal
provillons are dllcnbed elsewhere In lhis group contract. II you have
any questlonl about the term. of this Plan or about the proper pay'
ment of benellll, you may obtall1 more II1formation from your Em.
ployer or, If you preler, Irom the Home Office 01 Alina.
'ltJur Employer hopes to continue thl. Plan indefini181y but. as with al
group planl. this Plan may be changed or disconllnued With relptCt
to .11 or any class of employees.
CAN MY INSURANCE BE ASSIGNED?
life Insurance may not be asSigned. All other coverage may be as.
SIgned only With this written consenl of Aetna.
CLAIMS OF CREDITORS
If alowed by law, Ute Insurance and Accidental Death and Dismem
blrment Coverage benefits are exempt from legal or eqUlllblA pro-
cell for your debll. ThIS allO applies 10 the debts of your
btntliclary
BENEFICIARIES
'lbu may name or change your beneflcilry by f~ing Wlltten request at
your Employer'l h.adquarter. or at Alina's Home OffICe. Ask your
Emp1ov-r lor this lonn.. The naming or arry change will take effect IS
of the date you execute the request. Altna wdl b. "'y dilcharged of
it. duties a. to any payment made by it belore yolK request II re-
ceived at III Home Office.
Any amount payable to a ~ficlary will b. paid 10 lhole you name.
UnIt.s you Itlle to the contrary, if more than one beneficiary is
named. they will shere on equal term..
GR.9
39
II . named benehcllry dlel b.lore you, hi' or her lhare WI' be pay.
. .ble, I" .qual Ih... 10 any 01'* nemed benehcllrltl who II6Vlve
you.
II no nemed benehcllry lurvlvel you or II no b.nl'lcllry hll been
named, paym.nt Will be mad. al foMowl 10 lhol. who 1Ul'Vlve you
· 'ltJur Ipoule. II any.
. II there IS no Spoul., In .quaI eharll 10 your chlldr.n.
. II there II no lpoule or child. to your par.ntl, equally or to Ihe
lurvlvor.
. If there II no spoule. child or parenl, In equal Ihlll1l1 to your
brother. end Slllerl
. II none 01 the above lurvlVel. to your ex.cutorl or admini.tratorl.
HOW AND WHEN SHOULD CLAIMS BE REPORTED1
A cllim mUll be lubml1ed to Altna In Wlnt'"9. It mull give prool 01
the n.1Ure and eKlenl of the 1011. 'lbur Employer hal clllm form..
All cllml should be reported promptly. The deadlln. lor ling a cllim
for .ny benelitl II 90 daYI aftlr the dale of the 1011 caueing th.
clllm Th. deadline doel not apply to We Insurance.
If. ttvough no lauh 01 your own, you arl unable 10 meel lhe deadline
for '.109 claim. your claim will 111M be acceptod If you file al loon .1
poealble. Otherwlle, lale clelml WIll not be covered
HOW WILL BENEFITS BE PAID?
Benelill wdl be paid II soon al lhe necessary wr'ttpn proal to IUP-
porI the clllm il reclMld. Any death benellt lor your 1011 01 life will
be paid In accordlnce Wllh lhe benellcl8ry deSlgnallon Paymenl WIll
be mille In one 11m unlell you have elected an Inltallment method
wtlk:h hat b..n egr.ed to by Allne II you do nOl do 10 pnor to
VOUf death. yolK benefic18ry WII have lhll right b.fore any paym.nt is
made. The methods 01 I.ttlement alowed wdl b. lhole off.red by
"tne und.r this Ildividualljfe inlllJrance pollclts Astlll II 'Isulng
when the election II made.
AI othisr b.nefits are Pliable to you. Howwver, Aetna hal the nght
10 pay .ny h.ahh benellll to this servlCI provider. This WtII be done
unhll. you have told Alina olherwtse by the tim. you '.1 the cllim.
If you or your benehciary is . minor or, In Aetne'l opinion. Ieg.lly
unable to 9IV8 . wild rolelle for paymenl of aoy lIf. ,"lInne. b.ne-
fit. "toe mey .Iect to pay .1 loIatvl:
GR.g
40
Monlhly peymenll of noc over 5100 lhe flrlt mooth and 550 .
mclnlh lhertaft.r to the lIldividull who, In Alina'. Optl1lon. II c.-
, 1119 for and .upponl1g you or your blneflCilry.
'A.tna m.y pey up to 51,000 of .ny other benelll 10 .ny of your
r.lltlVlS whom It b.~_s fartv enllll.d to II. Thl, can be done rlthe
b.nelll II p.yable to you end you are I mIf1Qr or not able to give a
va.d relell', It can .Iso be don. II a b.nehl ie p.yabl. to your
IIt.te,
MUST RECORDS OF EXPENSES BE KEPT?
'llls. Keep complete record. of th. eKpen... 01 each person. They
wIN be required when cllim il mede.
Very important .re:
Namel 01 phy.lcllns, d.ntlsU and others who furnlsh servicll
Datil eKpens.s Ire incumed.
Coptes 01 aI bills Ind rec'lpts
GR.g
41
GLOSSARY
., ..
the lolowlng d"IO!\lOns 01 c.n8ln words and phralea Will help you
. underltand the benefits 10 whICh lhe deliO!\lOI1s apply Some dellm.
tlon. whICh apply only to a IPICIIIC benelll appear In the ben.IIl .ac.
tlon, II a delinl1lon appears In a benellt lacuon and also appears In
the Glollary. lhe d.linltion In the benelit sacuon will apply in lieu of
the delimllon In lhe Glollary.
ALCOHOLISM OR DRUG ABUSE TREATMENT
ALCOHOLISM OR DRUG ABUSE TREATMENT FACILlTV
Thll is an Institution that meelS the 10Howrng teats:
. If Iocsled In the State 01 New 'lbrk. It:
M.i1/y provide. a progrann lor dIagnosis, evaluation, and effec.
Iivllreetmenl 01 alcoholilm and drug abule.
Mik.. charg'l.
Meetl licensing It.ndards let forth by the State of New 'lbrk.
. H Iocaled In any other IUflldlctlon, Ii
Mainlv provides a progrann for dlagnolll. evaluation, and effec.
tivltreetment 01 .Icoholilm or drug abuse.
Mak.. charges.
M.etl licenSing standardl.
Preparel and mainleins a Wflnen plan of treatment for each pi-
hili!. The plan must be based on medical, Plvchologlcal and 10'
ciII needs.
Provldea, 00 the premise.. 24 hourr a day:
Deloxilicalion services needed with lis effective treelment
program.
hoflmary.llvel medICal services. Also. it provide., or arrange.
with a haapilel in the are. for. any other medical servlCII that
mIV be rtIJlnd.
GR.g
42
. .
Supervlllon by a slaff 01 phYllclans.
. Skilled nurllll9 care by licensed /lUrl.. wI10 .re dlrlcted by e
full.tlme R N
'EFFECTIVE TREATMENT OF ALCOHOLISM OR DRUG ABUSE,
ThiS means lrealmtnt of alcohohlm or orug abuae In accord wl1h a
lr.atmen1 plan given to Attna by:
. a phyllcl8n,
. a hospital; or
· a trealment lac*ty.
The plan mult be approved by Aetna.
These arl not effecllve lrealment:
· DetoKlficallon. This mean I mainly treating the aftereffects 011
speeilic IpllOde 01 drinking or drug ebuse,
· Maintenance carl. ThiS means prOViding an enVIronment Irl8 01
Ilcohol or drugs.
MENTAL DISORDERS OR CONDITIONS
Th,s doel not include anything thaI relates to or that results Irom
alcohohlm or drug abule.
HOME HEALTH CARE
HDME HEALTH CARE AGENCY
. For New York Rllidents:
ThiS is a hOlpltal. or a non-profit or public home heallh carl
larva or agency. It mu.t oper." under a valid New York Public
Health law hc.nl'. ThiS IIC.nlt must anow the inltltutlon to
provide lhe home heallh care services Involved.
. For Non-New '1brk Rllid.nll:
This la en egency that:
mainly provides skilled nursing and other therapeutic IIrvic..:
and
IS IIloclated With a prolelllonlll group which maltll policy;
this group must hive at hsllt one physician and one R.N.; end
GR.g
43
.
has full'lIIne supervIsIon by a physlclln or an R.N., and
kettp. complete medical reCOldl on each perlon; Ind
hll a lull-lime admtnllUltOl; and
meet I Iicenllng Itandards
HOME HEALTH CARE PLAN
Th'I II I plan that provldel lor continued care Ind treetment after
discharge from a hiolpnal. Th. cere and tre81ment mUlt be:
. tor the lime or related cond,"on lhal required the hospltll Itay;
and
. pr8lcnbed In wntrlg by the I"ending phYliciln within 7 daye from
the hiospnal dilcharge, Ind
. an alt.mauve to Itayln9 In the holpital.
HOSPICE CARE
HOSPICE CARE
Thll i. ~e given 10 e lerminllly WI perlon by or under arrengementl
with a HOlplce Care Agency Th. care mUlt be part 01 a Hospice
Care Program.
HOSPICE CARE AGENCY
Thll II an ~ency or organization whICh:
. Has Helpice Cart ava.able 24 houri a day.
. M.1I1 any Iicanllng or cerulicsuon alandards 181 fonh by the ju.
nldictioo where it II
. Provides:
skied nurllng services; and
medicll aocial lervicel; and
plychologicaland dietary cOUflleling: and
bere.vennent counseling lor the Immediate family
. Provide I or arrang'l lor cIlher servlCtl which WllIlncJude:
..rvicea 01 e phyllclln: and
QfI.g
44
.
ptl~ .leal or occupational ther.py, and
, f1art-llme home he.lth llde orval which mIII1Iy consISt of CIr.
Ing lor IIrmll1.lIy III perlon.: and
Inpatltnt care In a lac~lty when needed lor plln control and
acule and chrontc Iymptom management.
· Has personnel WhiCh Include at leas\:
one phVSlCl8n; and
one R.N., and
one IIcenl8d or cenifltd loclal worker employed by the Agency;
and
one P8ltoral or ocher counselor.
. Ell8bWshtl PO~Cles governing the provillon of Hospice Care,
. Alle..es the pallent's medical and loclal needs.
. Develop. a Holplct Care Program to meet thol8 needl.
. Provides an ongoing qua~ty alluranee program. This Includll reo
VItWS by physlCl8ns. other than thole who own or direct the
Ag.ncy.
. Permits aI ar" medicel personnel 10 utilize III lerYlCts for their
pllltnCs.
. Keeps a medical record on each patl8n1.
. Utilizes voUlleers Ir8lned In providing services for nonmedical
needs.
. Has a lull-time adminillratOr.
HOSPICE CARE PROGRAM
ThIS il e wnUen plan of Hospice Care. which:
· I. eltablished by and reviewed from time to lIOne by:
. phYlicl8n ettending the perlon: and
appropriate personnel 01 a HOlpice Care Agency.
. II dlligned 10 provide:
palliative and IUPPonive cara to terminally ill persons: .nd
lupponive care to thisir families.
. Includes:
en assessment of the persoo. medical and lodal needa: .nd
GR.g
46
a allcnptlon of the care 10 be given 10 meet thOle needs.
. HOSPICE FACILITY
This II a lac~lty. or dlStllct pari of one, wl1ich'
· Mainly provide. Inpllltnt HOlplce Care 10 terminally III persons
· Chargta III palllntl.
· Melli any hcenllng or certification lIandards let fonh by the ~.
nadlcl10n where It II.
· keepl. medICal rlcord on IIch patient.
. Provldel an ongoing qualtly IIsurance program: UlII Includes reo
views by physiCl8nl other lhan lOOse who own or dir.ct Ihe
facillly
· II run by a ltaff of phYllcllnl; atle8lt one luch phySlCl8n mUll
be on call at al times
· PrOVldel. 24 houri a day, nursing lervlCta under the direction 01 I
R.N.
. Hal a full.tlme admiOlltralor.
TERMINALLV ILL
Thil is a medical prognolil of 6 monthl ()( les. to tive.
GENERAL
BOARD AND ROOM CHARGES
ChIrg.1 mid. by an Inltitulion lor board and room and other nee...
ury ..rvlcel and suppliel. They mUlt be regularly made al a dally or
-'tly rate.
CONVALESCENT FACILITY
Thil il an InlUtutlon lhat:
. II licensed to prOVide, and does provide. the following on an Inpa-
blnl balll for perlonl eoovalelcilg from dilelle or InJUry:
profellionelnuralng care by a R.N.. ()( by a L.PN. directed by a
full.time R.N.. or L.PN.; and
physical relt()(atlon lervicel to help pll1ents to meet a goal 01
..If.care in daily living.aclivitiu
. Providea 24 hour a dey nursing care by Iicenled nurl.. dlrlCtad
by a fuIl.time R.N. .
. II supervised U1.time by a physician or R.N,
GR-g
46
. K"pl a COfllplell medICal record on each pallent
. Ht.. ut~llallOl1 revllW plan
. . II DOt mllnly . piece lor r'll. for the aged, for drug eddiclI. for
ak:ohollcl, lor m.ntll r.lard.tll. lor cullodlal or 8Ib:Itlonal ~,
. or for clre 01 mental dllorderl
. M.kll chargll.
CUSTODIAL CARE
Thil mean I liMen and luppliel furllllhed 10 a person m8lnly to
help hm or her In lhe actlVltlll of dilly Iile. ThiS IOcludll board .nd
room and other InShtullonal care. The person doel not have to b.
di8llbled. Such lervicel and IUppl18S are cUllodlal care without reo
gird to;
. by whom they are prelcnbed; or
. by whom they are recommended; or
. by whom or by which lhey Ire performed.
DENTIST
This mean I a leg.lly Qua~lied den liSt. Also. I physician who I. Ii-
c.n8lld to do the dental work he or she perform..
HOSPITAL
TIllS IS a placo that:
. M.lnly provides IOpllien! facilit181 for the surglcel and medlcll dl
~nolil, trlltment, and care of injured and sick perlon..
. I. lupervlsed by I Itllf 01 phYllclans.
. Provide. 24 hour a day R.N. lervlce.
. It not m8lnly I place for relt, for the eged. lor drug eddie,.. for
lIc:oholics, or a nurling home.
. M.ke. charges.
L.P.N.
11111 means a licenled practlcll nur...
NECESSARY
This means a lerva or IUPply which I. necellary for the:
. diagnosis; or
. care; or
. tr..tment;
GR.g
47
""I Ute p/l~)''-..il Ul ....Ihtl l:.Om,IIIIUIlIlWOlvthl I1Ill~sl be widely 11'.
cepled profOSSlonally In lhe Unltod Slatel as'
. . .~.ctlVt, and
.. appropflale; and
. lIaenlial.
based upon recognized Itandards of the health care specialty
Involved .
In no event wllllhe foIowlng be conlldered to be nece...y:
· tho.. service I rendered by a provider that do nOl re~e the
technical Ikllll 01 such a provider;
. thole ItrvICel and aupphes furOllhed:
mainly lor the personal comlon or cCll1Venienc. 01:
the person; or
II1\' perlon who cares lor hllTl or her: or
any person who II pan 01 hll or her faRllly;
to a person lolefy because he or she il en Inpatient on any day
on which lhe perlon's phYSical or mental condition could lafely
and aooquatoly be dl8gnoled or treatod whllo not confinod:
. that part 01 the COlt which exceeds that 01 any other aervlce or
supply lhat would have been suff,cient to safely and adequately
diagnose or treat the persoo's phYSical or mental condition
NON.OCCUPATlONAL DISEASE
A non.occupallonal dlleale ia a dllease thaI dOli not:
· arise out of (or in the courae 01) any work for payor profit: or
· r.lllltln any way from a dilease lhat does.
A diseele Will ba deemed to be noo.occupatlonal regantell of ceuse
If proof is I1J'nished thllthe person:
· ia covered under any tvpo 01 workera' compensation law; and
. il not cCMIOld lor that disease under such law
NON.OCCUPATlONAL INJURY
A non-occupatlonellnjuly is an accidental bod~y injUry thll doe. not:
.
GR.g
48
. , -. ~ , .J"f 1~\.Ii" lUI .JLJr ..... .JIUIIl.
· relull In any way 'rom an Injury which does
ORTHODONTIC TREATMENT
Thll IS any:
· medlcsllerVlce or supply, or
· dentalltrVlCe or IUPply,
furnllhed to prevenl or to diagnose or ro correct a misalignment:
· of lhe teelh: or
· 01 this bite; or
· of this jawl or Jaw joint relatlonlhip;
whether or not lor the purpose 01 relieVing pain.
Not Included is:
· the inltallatlon of a space maint8lner: or
· a surgical procedure to correct malocclu.loo.
PHYSICIAN
Thl& means a legally quahflld physician.
REASONABLE CHARGE
Only thet pan of a charge which is reasonable I. covered. The rea-
lonable charge for a service or supply is the lower of:
· the provider's usual charge for furnishing It; and
· this charge Aetna detenmlnes to be the prevding charge level
made for It in the geographic area where It II furnished.
In dllermnng the realonable charge for a service or supply lhat II:
· unullU8l; or
· not oh.n provided In this area; or
· provided by only a ameli number of providere in this area;
Alina may like Into account factors, such 81:
· the complexity:
. the degree 01 skill needed:
· the type of sptclalty of the provider;
· the range 01 sarYlCea or suppllea provided by a facHlty; end
GR-9
49
. the prev8lhng charge In olher areas.
. R.N,\
Th.. mean. a registered nurle.
SEMIPRIVATE RATE
Thts il the cherge lor board .nd room whICh an InlliMion Ipphea to
the mOil bed. In Itl I8mlpRVIII rooml WIth 2 or men bedl. lither.
.. no luch room., Attna WIll fl\lur. lhe rill. It wiI be the 1111 most
commonly cherged by .imilar In.tltutlonl 111 the lime geogllphlc
erea.
(11.9
80
PRIVACY NOTICE
. The hformallon In till. Notice il not . part 01 'lIher the group con-
Iriel. your CerufiCl1I 01 Cover.lIt or the Bookl.t It II Imponlnt to
,you 81 a covered perlon under the group contract We hive bound II
IntO lhil document only 81 an lid to you In keeping Inlurance relaled
mltenal together
A.lna hll adOpl8d I comprehenlMl Inluranee pnvacy pokcy baled
on the recommendltlOnl of lhe Federal Pnvacy PrOl8ctlOn Sludy
Commllllon Thll Notice dllcnbel certlln alpectl 01 that policy
whICh apply 10 you 81 a covered perlon in a plan of group Inlurlnce
inaured by Aelna The poliCY doel not apply where a different IP'
proach II reqUIred by law
Information Which M.y b. Collected
Alina, In providing Insurance lervlC8S to you, rellll mainly on the
Inlormallon you glV8 on your group enrollment form and when you
I~. claim I
Alina may also colect IOIormallOl1 about you 'rom other lourcel
Thll II Informallon neclllary lor Aetna to perform II. funcl10n wllh
regard to the Inlurance transaction in queltion. For examphs, 11 lhe
amount or type of coverage you are entitled to depends on your
81mlngl or lob clau, Aetna would obtain thaI mformallon from your
Employer
Dlsclolur. of Informltlon To Oth.rs
All 01 thil InformatlOl1 will be trelled II conlidentlll It WIll not be
discloled to olherl Without your IUthonzation, eKcept In loone In.
Itancea where luch dllclolure II necellary lor the conduct 01 Aet-
n.'. bu.lnen. Dllclolure cannot be contrary to any law which
eppliel
This IolIowlng lell lorth the typel 01 dilclolure that may be made:
. hnlormatlOn may be made avllilble to your Employer or hil or her
repreaentallve in COMtCIlOO with the claim and financlll edmnil"
tratlon 01 lhe Plan. Thi. includel pokcyholder euditl.
. hnlormallOn may b. dllcloled 10 olher insurerl If there may be
dupltc.te coverage or a need to prllen18 the conllnuity 01 your
CO\/Irege.
. hnfoomation may be dilclosed to Peer RlIVIIW Organllation. and
olMr agenciel 10 det.rmne whiltMr health aervlC81 were neces.
wy Ind rellonably pnced.
In aodlllon, Informallon may bll given 10 regula lor I of Aelna I buslo
nUl and 10 olhers al may be reqund by ~ II mey .Iso be given
.. 10' law enforcemenl authontl8a when needed to pravent or prolecule
,fraud or othier IlItgII acllVlIl8S
. Your Right of Acc... and Correction
In generel. you have a nghl to learn the nature and substance of any
informalloo Aetn. h.1 111 ilS Iilu abeut you. '1bu may also have a
nght 01 acC8I1 10 luch '"1, except Information which relates 10 a
claim or a civil or criminal proceeding. and to ask lor correction.
amendment. or deletion 01 persooallnformatlon. ThIS CII1 be done in
states which provide such nghll and which grant Immunity to Inlur.
ers providing luch access. If you requelt any health Information,
Aetna may elect to diaclole dSlail1 01 the Information vou request 10
your (,"ending) phYSician. If you wilh to exercISe thil righl or II you
wllh to have more dlllld on our inlormalion practlcel, please
contact:
Alina llle Inlurance Company
Benelit ContrlCtl legal, MB5S
151 Farmington Avenue
Hartford, Connecticut 06156
.
.
~UI'14 111"\J,",IIUI~ " I \...UlJ tU""ut UI~UtN ttLJt.t\"'L L/WV
In .ccordence wllh lederaflaw (Pl99.2721 as amend.d, your Em.
. ~ II providing covered perlOfll with It.. nghtto conUrQ lhelr
",.lth e.penle coverage und.r cen.n Clrcumllancll.
. 'tbu or your dependentl may contrUI any h..llh up.nse coverage
lhen In elfecl, without havl1g 10 IlOnit eVidence 01 good heallh. If
coverage would IIrmlllte for lhe rlllonl IPeclfitd 10 lacUonl A. B
or C below. You and your dependlllll may be required to pay up 10
102% 01 the lull COlt to the Plan oIlhi. cOOlinued cover.ge, or. as
to an Indtvldual whOI' coverage II being continued for 29 monlhl In
accordance with Itcllon A, up to 150'll. of the lull COlt to the Plan
of Ihls conllnued coverage lor any month after lhe 18th monlh.
Sub/ect to the payment 01 any re~ contnbullOn, hl8lth 'Kpenll
coverage may allo be provided fOl any dependent. you acqun while
lhe coverage IS belllg conltnued Cover.ge for thelt dependenll Will
be subject 10 the terml 01 thll PI.wl reg.rdlng the edditlon of new
d.pendenll.
COntlnuallOn shall be ava~able as loIows:
A. Continuation of Cov.rlg. on T.rmln.tlon of Employm.nt or
Lo.. of Eligibility
" your coverage would termlnale due to:
. termll18l1on of your employment for eny reelon other than
glOss misconduct; or
. your loss 01 elgibility under 1hi1 Plan due to a reduction In the
number of hours you work;
you may elect to conunue coverage for yourself and your depen.
denIS, or your dependenll may each elect to continue his or her
own coverage. Thl election mull Include .n agreement to pay
any reqUired contribulion. 'tbu 01 your dependenll mU'1 elect to
continue coverage wilhin 60 dIya of lhe later to occur of lhe
dl1e coverage would terminall and the dale your Employer In.
forms you or your eMglble dependenl& of any nghts under lhil
Itction.
Coverage will lerminale on whchever of lhe foHowing II lhe .arll-
tit to occur:
. The end of an 18.moOlh penod after the dale of lhe event
which would havI ClUled cCMlfage 10 lermina18.
. The end 01 a 29-month penod after the date of the event
which would havI ClUSed CCMlrege 10 termna18. but only If
prior to the end of the above 18.month period, you or your
d.pendent providee notice 10 your Employar. In acCotdanc. with
section E below, that you 01 your dependenl hal bHfl deler.
mined to have been dillbled under Title' or XVI 01 the Socill
Security Act on the date of the event which would have CIUSed
coverage to termNlI. CCMlreg. may only be coolinued lor 1M
individual determined to be cisabled.
. The date lMI the group contract dlaconllnutS 111 III enurety as
10 hellth e.pense cover.ge HOMVtr, contlRJed coverage will
. 'b. .......bIt to you under enother plan IponIOl'Id by yout
Employer
. The dlle any reqund conlnbutlons are not made.
. The fnt day after the date 01 the election lhlt the indIVidual IS
covered under another group heahh plan. However, continued
cover.ge WIN not ttrmNte unli1auch lime that the IndIVidual IS
no longer .ffected by . preexiltlng condition exclUSion or Iimlla.
tloo oodtr such other lJIOUP heallh plan
. The lUte the IndivlllJal become I entitled to benefits under
M.dtcere. Tho. wi not apply if contrary 10 the provlllonS 01 the
Medlcere Secondaly Plyer Rulli or olher federal law
. The month tMt beglnl more lhan 30 days after the date 01 the
final det.rminatlOl1 under Title U or XVI 01 the SoCial Secunty
Act that the Individual whose CCMlrage IS bei1g continued for a
29-month pened is no longer disabled.
B. Contlnuetion of Cov.r.g. on . R.tlr..'1 LOll of Cov.r.ge
Th. PIen Admlnlltr.tor is Illqulrtd to notrlv a retnd employee If
his or her former Employer commencel a benklUptcy proceeding
under title 11. United StallS Code. If your covtrlIge as a retired
employs. would termNle or be 11tIsllntlally ~lnated due 10
tin proceeding. you may elect to cootinue clMlrage for yourself
and your dependenll or your dependents may each elecl to con-
tinue hiS or her OWlO coverage. You or your dependents must
elect 10 continue coverage within 60 days 01 the later to occur of
the date the bankruptcy proceedings beg" and the date the Plan
Admnillralor Informl you or your eligible dependents 01 aoy
rights under this saction. The election mull incble an agreemenl
to pay any reqUired contribulion.
Coversge under 11101 section wlllterlTWl81e on the fllst to occur
of:
. The dlte thltthe IPOUP contract diacontinues in its enlirety as
to health eKpenll coverage. HOWlMr, continued coverage will
be .......ble to you under another plan Iponsored by your
Employer.
. The dlte env required COI1tributionl .e not made.
. The rnt day aher the date of the election that the individual I.
covered under another group health plan. HOMVtr. continued
coverage will not terminate until such tme thlt lhe individual is
no longer effected by a preexisting condltioo exclullon or kmita.
tion under luch other group health plan.
.
C. Continuation of Cov.r.g. Und.r Oth.r Clrcumltanc.1
",poverag. lor. depend.nt would IIrmllllle due 10.
.. your d.ath:
. . your divorce:
· your ceiling to pay any required conmbullons lor cowrage as
10 a oependent IpOUH from whom you are legdlly separ31ed.
· the oependent's coaslng 10 bo a depondenl child al dellnod un.
d.r Ihll Plan, or
· the oependen1's loll of eligibililY under 11111 Plan because you
become enlltled 10 benellll under Medicare,
lhe d.pendenl may elecl to conllnue hiS or her own coverage.
The .lectlon to COOllnUll COYIrage mUll be made Wllhin 60 days
01 the Ialer 10 occur of the date coverage would lerminate and
lhe dl1e your Employer Informs your dependenll. lubjecI 10 any
notice reqUlremenll In IlCtlOl1 E below, 0lth8lr conllnualion
nghts under thll section The election mull IOclude an agreemenl
to pay any reqUIred contnbutlOn.
Coverage lor a dependenl Wllllermlnale on lhe hrltlo occur of:
. The end 01 a 36.monm penod aher the date 01 the evenl
wtllch would have C8Uled coverage to IermlOale.
. This dale that the group contract dlsconlinulI in ill entir.ty al
10 heallh eKpen.. Covtragt. However, conllnued covtrage wrI
be ava~eble to your dependenll under lNlOther plan lponsored
by your Employer.
. This oale any reqUIred conlribulions are not made.
. The first day aft"r the date 01 Ihe election lhat the dependenl
II covered under another group heallh plan. However, conlinued
coverage WIll not terminll. unlll such tme lhat the dependent
II no longer aHected by a preexisting condition exclusion or .m.
It.lion under such olher group heallh plan.
. This dale the dependenl become entl1led to benellls under
MedICare .
D. Muhlple Qualifying Eventl
If coverage for you or your dependents is being continued in ac.
cordance With the lerms 01 the above lactions A or 8, the fol.
lowing Ihall apply:
. If cCMlrage II being cOnllnued for up to 18 monlhs undftr Itc.
tion A, end dunng thil 18-monm period one of this qua~IYJlg
_nil under the above MClion C OCClJ"l. thil 1 a.month period
may be Increased In no event will the 10lal perIOd of continua.
tion provided under 11111 proviSIon for eny dependent be more
than 36 monlhl.
. If cCMIr.ge is being continued under sectIOn 8, and if your
del1h occur. dunng thi. conllnuation, ~r dependents may
elecl to COOllnut their CCMrIIge lor up to 36 moothl ahe, the
dlte of your death.
Such . qUI~Iy'"9 .vent ho_r, w,lI not ICI to ut.nd cov.r.ge
botyond the ongNl 18.monlh perIOd under IlCuon A, or the dlte
of your d.lth under 'ICtlOl1 8. lor any d.pendtnr. who w.ns
added aft.r lhe dll' conunued coverage began
E, Notlc. R.qulrtm.nll
II cover.ge lor you or your dependenll
· il btrlll contKlUld lor 18 month, In accordance WIth .ectlon
A;1Od
· it i. determned under Titl. . or XVI 01 the SoclIl Securuy Act
lhM you or your dependenl WII dlubled on the dal' of Ihe
~11r1 .1C11OI1 A whICh would hive clUl.d coverage 10
temllltte.
you or your d.pendent mUll noufy your Employsr of luch deter.
nWIItion wlthm 60 daYI after 1M dala 01 the determlllluon. .nd
wilNo 30 d.ys .h.r lhe dll' 01 any 110.1 d.lermlnallon thai you
or your dlpendlnt II no longer dlubled
II coverag. for a dependent would Isrmlnal. due to
· vour divorc.,
· vour ceiling to pay any requud conlributlon. lor cover.ge as
10 . dependent lpoule from whom you are leg.lly separlted;
or
· lilt dependenl'l ceiling 10 be a dspendent child II dtllned un-
del' th. Plen.
you or your d.pendtnt mUlt provide nOllce 10 your Employer 01
lhe occurrence 01 lhe evenl ThiS nOl'ce mUlt be g'vsn Wllhln 60
dlYS after the liter 01 Ihe occurrence 01 the event and the date
cOVtrage would termllllle due to the occurrence ollhe evenl.
If notic. II nOI provld.d within thl .bovt Ip.cifl.d Ilmt
periodl. contlnu.tlon und.r thl. IIctlon will not bt 111111.
able to you or your d.p.ndenll.
F, Othtr Conllnultlon Provl.lon. Under 'fhll Plln
If tha Plan contains 'OY other COOllnuatlon provlllons which Ipply
wt1tn health eKpen.e coverage would olherwlSe lermnate, con.
tact your Employer for a dtacription of how Ihe led.ral and other
oontinultion provilionl Inreract under Ihll PlIn.
0, Conwrlion
If any cover.g. being cootlnued under thll s.ctlon t.rmlNte. be-
eau.. the .nd 01 the maximum period of continuauon has been
reached, .ny CllnIIWrllon PrivMege Will be aveMable at lhe .nd 01
IUCh period on the lime term. .1 are apphceble upon termina.
lion of .mployment or upon c..lII1g 10 b. in In .ligible cle...
Complete OItalll of the lederal oonunuallon proviSIon. may be ob.
tllrlld from your Empl~r.
...... .
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...~~~
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,
._._H
\
IN THE COURT 01" COMMON I.'LEAS POll. COMBElU.AND COUNTY
pENNSYLVANIA
H!ALTHSOtml OF M!c:HANICSBURG, INC. I
175 Lancaster !lvd.
Mechanicsburq. Pl.. 17055
Plaintiff,
CIVIL ACTION . UAW
.
.
DOCKET NO:
VC.
q.5'- 73fAj- ~~
J,r.'!'NA. Ln'E INStlJL\NCB COMPANY td,Pa
"I A!:'l'NA HEALTH PLANS' n
~. 3541 Winchea~er Road
"( Allantown, PAt 18195.0503
/lnd
JURY 'l'1lIAL DEMANDED
IT'l' HARTPORD mSUIMlCB G1l.00i'
1808 colonial villa;- Lanll
Lancaster, Pl.. 17605
Dllrendanta.
NOTICE
Yo~ llAve been SUlld in COurt. U yeu wilb to defend aqainat
the claims set torth in the following paqes, you ~t take action
within twenty (20) days attar this complaint and Notic. ara served.
by entering II written appaarance perlonallY or by an attornQY and
rilinq in wrieinq with the CO\Irt your dllfcaQI or objectiol1l to tll.
claims s.t fo~ aqail1lt you. You are w&med that if you fail to
do 10, the case II1&Y procllId without you and a judqmant may be
entend against. you by tha t:ourt without further notice for any
monllY claimed in the Complaint or for any O~8r claim or relief
rllCl\l.etlld by the Plaintiff. You may 10" tIIOl1l1Y or pl;"Opllrtv or
otner rights ~ortant to you.
YOO SHOULD 'rAP: THIS PAlID 'IQ YQIIa L>>f1D A't CIICJI. It YOU CO
IIIO'r RAW . wna oa CU .., ...,'OJU') -, GO " .. "...,.....
COOIl'l
.~ V1 VNl3V
;eco CL~ co~~ g;:OI gO/EI,IO
.
.
too 11'I
opr:CIl SIT FORTH BILOW TO rIND OllT WHEIU: YOU CAN OM' LJSGAL HELP,
cumberland County CourthOU'.
Court A......1niatrator
011. c.curthouae square
CArlille, PA. 1701J
(7171 ,40-5200
..V1 ytU3V
lItO tLI t011l LIIOI lelllllO
gOO III
IN THE COuaT OF COMMON PLEAS FOR ctlMB!ll.I.ANtl COUNTY
PENNSnVi\NI1l
HEAL'l'HSOUTH OF H!CHANICSBtmG I INC. , CIVIL ACTION . LAW
175 Lancaster Blvd. ,
Hachanicsburq. PA. 170!S ,
Plaintil:' , POCKET NO'
.
.
VI. .
.
,
AI'!m ..In INsUIWICZ' CDHPANT tdba :
AETNA HEALTH pLANS-23
3541 winchester ROad I
Allentown, PI.. 16195 - 0!503 I
:
and JURY TRIAL pEKAmJIO
!'rT HAJlTPOBD rNSUMNC! GROt1l'
1808 colonial villAqe Lane I
LlAOalter. PA. 1760'
Dllhndantli .
~LI.DI'l' Ilf ACTIOJl 5'011. DB~TOll.'l .wD~
Pa, J.e-p- Kul. 1 t.) .
1. PLAIm'Il'F, Healthr;O\Ith of HBchanicllbur9, !D.C., fOXl1lerly
MechanieSburq aebBbilitation sYlltem!, 1D a medical tr.A~ant
facility locaud in the City of Machanicllburq, county of
CUIllberland, in the l"'nmmnJ1wealth of pannsylVWio.
2. D8~U71', I'l"r HArtford Inlunnce GrOUP, is a corporation
orqaniud and exi.tinq under the law. of tha Stat. of New York,
enqaqad 1n the business of 1nllurance, and bAvinq lSubStalltial
bulin." contacts in the CC\mlOnwealth 0' PeJmlylvania, with its
princiPle place of bUBinau in the comotlWulth of PlUU1iylvarJ.a
locata" at 1008 COlonial V111aqll Lan., ~aDC&.tar, PA, 17605.
1
.l\V1 YtU3V
geco CLZ COZ~ Lg:OI GO/ZIlla
, .
SOOll'J
3. OBP!NOAN'I', Aetna Life Insurance c:ompany tdba Aet:l14 Health
Planll-23, 18 '" cOlllorat.ion o('tJanized and e.x.1l1tinq un411r the laws of
the State 01: connecticut, engaged in the busine.. Of uusurance. and
havinq substantial budnesll contacts in the comroonwulth of
Pennsylva.o111, with its principle plllce of tluainell 1n the
Cc;mIIlOnweal.th of pennsylvania located at 3541 W!llc.nalter Read,
Allentown, PA. 18195'0501-
4. 'l'b.h is an action I:or DeclaratOry J\1dqmant pur5uant to 4:1
Pa. C.S. S 7531 et seQ.. tor the purpose of determininq a question
of actual controversy batneD. the pattiell a. hereinaft.lU' mora tully
appear.. ~ purpo.e of chill action pUI$uant to 42 Pa. c.S. , 7541
is to afford relief I:rcm uncertainty III to the status and legal
relatione of the partial.
5. wuri5d1ction of this COUrt 11 baleo OA subject mattar
:lurilldiction aceord1nq to n pa CS II 7532, tba pat1ant'Q treatment
wu pxovidad by the provider. pla.intiff. in Cumberland County.
COtllT :I:
All.,a~~~ Ge Page
Ii. 011 Kay 211. 11l92, Chri~~ophU' .allon ~ll Qr1viJlq a C~GY
car When h8 experienced blurry vision, 10lc contrOl of the VehiClll
and cra.bad into a oonltructlon barrier. l'Clr. 1'allon...as 1mnattlataly
tran.po~ed to the pick community Heelth Center in Mt. Pleasant,
PA,
7. Mr. Fallon WIl. then transferred to the Hersl1lW Mer11eal
center. air. FaJ.lon wal trl.tIIll l:or CUlUac COZI~u.1Cl11a,
q..tro1nteetina1 bl.elSl aII4 a ccmfU.IG U4 "'In' a,,,,alll1v. J\III&Io..:I.
2
llV1 YN.L3Y
SICO CLZ COZ~ LS:OI SelZl/lO
state.
8. V.r. Fallon was transferred to the plaintiff' 8 facility on
June 16, 1992. Hr. palloD wall treated at )doehan!c,bur9
Rebabilitation &l(ltUl (.NRS" I tor eerloulI confusions 4110 for
threat' of auicide, for which ho recalvad one-on-on. luparvilion.
9. Hr. ralloD was diecbarqad from MRS on July 6, 1992 &nd
transferred to ':'bo Woods, a manaqad can facility. He died there on
Auqust 2, 1992.
10. Defendant Hartford Group ('Hartford.) is the carrier for
Mr. 'allon' IS worker' , compensation and hi. auto lnlurance polLe!",
.
tlllfandant Aetna :tJ1suraneQ (. Aet.n.a. I is the carrier for Mr. pallon' ,
CCIl1ItlQrcia.1 health inllurance policy.
11. !mployaa. of MKS mAde mult1ple phonll calli to all three
insurance carriers over tbe COUflle of Mr. pallon' Ii treatment at
~S. MRS sought to dettUItlin, wl\1~ imi1~rance CIlO'j,e~ would be
coveril1q t.he expanse of Mr. Pallqn' I Mdical ..;viee. at MRS.
12. MRS'I .payor :tntaraction Gha~t. indicates thAt moat ot
the phone ca1111 made to the tl.f~tl wera ~~eturna4.
13. On June 12. 199~, in a phqne convarlation with a ~a
.
employee, Hartford, aetioq .. t,1I.1 ~r~er' I c.oIDP~.tiol1 cArrier,
.tated tluI.t they were dlll1yino coveraoe or Hr. Fallon's medical
~~I.I beCAU'" ot prior dizzy IIp,,~lll that lIul19'ellt~4 that Mr.
'allon iuffared a stroke immed1le~lv prior to his auto accident on
May :n. 1992.
14_ Tbera ill no ~nn~]U8ion in Kr. ..110n'l ma41cal r8cordl
that ne suffered from a ,trok. at the time of the acc1dtnt.
J
LOOIl!l
1\ V1 YNJ.3Y
~gtO tLZ COz,g.
g;:OI D8/Z11l0
.oo~
a, on JW1. 12. un. Aat.nl Wormed an MRS 8IIIPlayetl ~ ..
Elhon. eonv...llt1on that HRIl Will I qualify1n'J hOllpital undlSr their
pol.1CY aneS that they would eartHY MRS for ten dlya of care tor Mr.
r.Uon.
111. On Jun. U, nu, .. latter WIll rIIcdved by MRS from AattlA
which .tltod that Altna would provide IlinCl tI10re day.'! ot
~.rt1t1cation tor traatmant uneSer tneir plan.
17. 11 of Novlllllblr, ;lO, 199!l, thlre are mora than '2,,000. ion
outlunl1inq medical hllla tor tha trcaatmant of Mr. 1'101100.
18. ^r,llntD of t.hl IIIItatl of M:r. nllon bave tried to
..cutl.1U whlah of thl tWO Detandantl Ihould ba nlponaible for tha
covaralla and paymaot of Mr. vallon'. ~edlcal trQa~t. Neither of
t..be D.undanU have rupondlld to uid "'ilentll pIlOn. oil111 and
oorr..poodance.
COtlIIlT It
Alle,ltion of Aotual eontro.-rr.r ~4 I&Ca
19. flaraqrapha 1 throuqh 18 arl incoxPorated herein by
referane. III thouqb aet forth I~ full.
20. Plaintiff expended larve amount. of ~e4ioal experti'.,
"lrI0W111 entS relourc.1 to provide ca.r. for the Defend.nu'
in.uratS, Ch:riltophlt Fallon.
21. 'laintiff h.. not rac.iveeS any payment by the Defendant'
tor the car. of their insured. Chrilltaph~ Pallon.
22. Plaintiff he. .utflrld aconam1CAllY bleaul' lach of tha
oeteneS&nU reru.. to addr... quudollS an4 c1aima at to t:,ba1r l~al
lutUI II to thl pr1JlarY lnaurmO' Clrder 1f1th f"PlCt to tbl
4
.~V1 VN.L3Y
UtO tLE coZA
":01 'e/zIIlO
.
, ,
" .
800~
claims arlainq out of Christopber Fallon' a automobile accidant and
subsequent treatment by Plaintiff' I medical facilities.
WHEREFOIt2. Pla.!nt1ff Realt.htouth of Machan.1cllburq. Inc. prays
that.
1, The court anter a Declaratory Ju~t that detamUnn
whether Defendant Hartford's worker's cOltilansation or a 1.1 1.0
insurance. or Dehndant AlItna' s cammaro1al health inlll.lro.nc;:a policy
bas pri.aMu'y covaraqe with respect to claims adlling out Christopher
Pallon' II automobila accident and nis llubllSquent medical tnat;mes:n:
by the Plaintiff, and
2. The CCurt qrant such othu and turther relief as may be
proper.
DAT!D: Daclllllbar 7. 1995
. ......
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.... .... -.........
.' ~
F_~'COPv' F..oM "ECORD
..In.T1ItiniDI!Y wIIIrIaI. I ,.. unlD lit mr hind
, ~ crI CIIUslI. fIJ.___
'1~
.
RJ:CHAIW , !llquir.
Attorna tor Plaintiff
1776 S, Queen street
fork, Pennsylvania 17403
(717) BU .~OOO
I.D. No, 18631
'cfc\ta11fll'..".......
I
II V1 YN.l3Y
Uto CLI COlA
88101 U8/H1l0
.
.
0101PJ
'.
TD.IPJIID.IfT...
x v.dlr ~t ~ .tatllltZl.t. ada .in tJIe toreqoiJlq CcIalPlainc
an tn. UI4 aornoe to the hit 01 lIft'la!Gwleq_, Ul.famatian And.
l3eUef. t WIll.n1:&D4 that tal.. ata"-ta harein U1l m&da .\ab:lect
t;d t.h. 51..11;;1.... of U lIa. C. I. &906 1'1&1;1Dq t:Cl ~
'alaitlaa~OG ta authar1tia..
Dat... /2 -/~-I!'r
~_./
.II V1 YN.L3V
veto tLZ tOZ~ 8V:OI 98/ZI/TO
.
.
CERTIrICATE or SERVICE
This is to oertify that the undersigned on February 1, 1996
have oaused to be served Defendants' Joint Notice of Removal upon
all other parties to this aotion by depositing a copy, postage
prepaid in the United states mail addressed as followSI
Riohard oare, Esquire
1776 s. Queen street
York, PA 17403
and
steve Moore, Esquire
2931 N. Front street
Harrisburg, PA 17110
CHRISTIE, PABARUE, KORTIK81M
anc! YOUNG
A Professional corporation
BYI
James A. You
Miohael J. B rns, Esquire
1880 J.F.K. Boulevard
Tenth Floor
Philadelphia, PA 19103
(215) 587-1600
Attorneys for Defendant, Aetna
Life Insurance company t/d/b/a
AETNA Health Plans
'4n1.l
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