2016-2017 Enrollment Guide - Marsh Driver Benefits –...

2016-2017 Enrollment GuideSupplemental Health Insurance Options

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Homeland HealthCare

Enrollment Begins September 12, 2016

1 How to Get Started

2 Supplemental Health Insurance Options

Aflac Term Life - New for 2017 3

Nationwide Dental - New for 2017 4

Aflac Disability 5

Aflac Hospital Indemnity 6

Aflac Critical Illness 8

Aflac Accident 10

12 Value Added Services

MeMD 13

Health Advocate 13

Medical Bill Saver 13

14 Limitations & Exclusions

Table of Contents

1

How to Get Started

To ensure a successful enrollment, we need to collect important information about you, your drivers and other employees. This ensures we can communicate the benefits options available during open enrollment. Information needed is detailed in Step 3 below.

Follow the simple steps below to access a secure, online portal to register your employees for Open Enrollment.

How to register your employees:

1. Visit https://register.marshdriverbenefits.com/ You will be asked to enter your Business Entity ID for verification. This is provided on the top of the endorsement letter

included with this brochure.

2. Verify that the business information we have on file for you is correct. If not, please make any necessary changes.

3. Enter the following employee information. Please note, the employee phone number is required for enrollment. • First and Last Name • Phone number (cell # preferred)* *If cell number is unavailable, please enter another number in the required field

You may also contact a Homeland HealthCare, LLC representative to assist you with entering your employee information.

(844) 275-2721Monday - Friday 8:00 a.m. - 7:00 p.m. (Central Standard Time)

2

Supplemental HealthInsurance Options

Term Life

Dental

Disability

Hospital Indemnity

Critical Illness

Accident

3

1 Sample weekly rate based on non-smoker age 35.Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.Continental American Insurance Company| Columbia, South Carolina AGC1601597 IV (8/16)This is a brief product overview only. Products and benefits vary by state and may not be available in some states. The plan has limitations and exclusions that may affect benefits payable. Refer to the plan for complete details, limitations, and exclusions.This is a brief product overview only. The plan has limitations and exclusions that may affect benefits payable. Refer to pages 15-21 for limitations and exclusions.

Term Life Insurance (Policy Series CAI9100)

Aflac Term Life insurance helps address your loved ones immediate and future financial needs following your death. Immediate needs can include burial/funeral expenses, uninsured medical costs, and current bills and debts. Future needs could include education plans, ongoing family obligations, emergency funds, and retirement expenses. Group Term Life insurance from Aflac provides a death benefit for a specific length of time and coverage expires at the end of the term.

Features• Term life coverage available – 10-year term and 20-year term

• Coverage available for spouse (18-70) and children (15 days-24 years)

• 10-year termo $100,000 employee (Ages 18-70)o $50,000 spouse (Ages 18-70) (not to exceed employee’s coverage)o $10,000 per child (age 15 Days - 24 Years)

• 20-year termo $50,000 employee (Ages 18-65)o $25,000 spouse (Ages 18-65) (not to exceed employee’s coverage)o $10,000 per child (age 15 Days - 24 Years)

• An Accelerated Benefit for Terminal Illness is built into the plan and will pay 50% of the Death Benefit if an insured is diagnosed with a terminal illness.

• Accidental Death, Loss of Sight and Dismemberment Benefit Rider is included with the plan, and pays an additional benefit for covered losses

• A Waiver of Premium for Total Disability Benefit is built into the plan and waives all plan premiums if the insured is totally disabled for more than six consecutive months

• This plan is portable, which means you can continue coverage if you change employers (with certain stipulations).

NEW:

To review the full detailed summary of benefits, go to www.marshdriverbenefits.com.

Sample Weekly Rate1

$3.47

4

Dentaflex Group Dental Insurance Plan is a fully insured dental plan that pays for services and procedures, including Orthodontia for dependent children up to age 19, based on a Schedule of Covered Procedures. You have access to the Maximum Care Network, a nationwide network of more than 200,000 general dentistry and specialty dental access points. It’s the largest network of its kind in the nation, and will give you access to superior dental care treatments and services. You have the freedom to select any dentist, however, by using a PPO provider, out-of-pocket expenses are generally lower, because PPO providers agree to charge no more than the contracted fees established for covered procedures. And you can have confidence when using a network dentist, as they undergo a rigorous review, including a thorough quality-assurance process and routine verification of their credentials.

Calendar Year Deductible

Applied to Basic and Major servicesWaived on Preventive services $50 Individual / $150 Family

Annual MaximumApplied to Preventative, Basic, and Major services $1,000

Preventative ServicesOral ExaminationsFull Mouth X-Rays (once every 5 years)Bitewing X-Rays (1 set per calendar year)Periapicals and Other X-RaysCleaningsTopical Fluoride TreatmentsSealantsSpace Maintainers

No Waiting Period100%

No Deductible

Basic ServicesFillingsRoutine ExtractionsEmergency Care for Pain ReliefNon-Surgical Periodontics

No Waiting Period80% After Deductible

Major ServicesEndodontics (Root Canal)Surgical Periodontics (Gum Therapy)Oral SurgeryInlays or OnlaysPrefabricated Stainless Steel CrownsOther CrownsDentures (Complete and Partial)Denture Repair and AdjustmentsBridgeworkDenture Relines and Rebases

12-month Waiting Period50% After Deductible

OrthodontiaCovers Child Orthodontia 12-month Waiting Period

$1,000 Lifetime Maximum50%

No DeductibleCalendar Year Maximum Does Not Apply

Find a dentist in the Maximum Care Network at: www.mbaadmin.com

Group Dental InsuranceNEW:


1 Sample weekly rate based on employee only coverage. $3.00 monthly administration fee may apply.

Sample Weekly Rate1

$6.62

5

What is Short Term Disability Insurance?Short Term Disability is an income replacement plan that pays a percentage of your income if you become temporarily disabled, meaning that you are not able to work for a short period of time due to a covered injury or sickness. The insurance plan provides a payment for monthly disability benefit when a covered employee is disabled and unable to work due to a covered injury or sickness.

Why Do You Need Disability Advantage Insurance?The Aflac Disability Advantage insurance is like insurance for your paycheck. The plan insures a portion of your monthly salary in the event you become disabled or are unable to work due to a covered injury or sickness. Benefit payments begin after any applicable elimination period is satisfied and continue during disability, up to the disability benefit period.

Disability BenefitThe Disability Advantage plan includes a Total Disability Benefit (pays the monthly benefit when a covered Employee is totally disabled and unable to work due to sickness or injury) and Partial Disability Benefit (pays 50% of the monthly benefit when a covered Employee is partially disabled and returns to work earning less than 80% of base income due to sickness or injury). Benefits begin following the expiration of an applicable elimination period.

Issue Ages: 18-74 (Employee only)

Waiting Period: Accident Elimination Period: 7 Days Sickness Elimination Period: 7 days

Pre-Existing Conditions: There will be a 12 month waiting for a Disability caused by a Pre-Existing Condition and will not be covered unless it begins more than 12 months after the Effective Date of coverage.

Benefit Duration: Maximum Benefit Period: 6 Months

Guaranteed-Issue Amount: The Guaranteed-Issue Amount is $1,500

Features• Guaranteed-Issue - No health questions or Medical Exam; up to $1,500 is guaranteed-issue during Open

Enrollment. Health questions required for amount over $1,500.

• Coverage is Nonoccupational, which means the plan covers disability due to off-the-job injuries and sicknesses.

• Partial Disability Benefit allowing for a transition period before returning to full-time employment.

• Minimum monthly benefit $300 up to maximum monthly benefit of $3,000.

• Premium payments are waived after 90 days of total disability.

• Maximum income replacement is 50% of the Employee’s salary in most states.*

Disability Advantage (Policy Series C50000)

*State Statutory Disability Insurance BenefitsThe maximum income replacement is 50% of salary. The maximum income replacement for employees who reside in states with state disability ( NJ, HI, CA, and RI) benefits is 40%.


1 Sample weekly rate based on annual salary range of $33,600-$35,999, age 18-49, monthly benefit amount of $1,400.This is a brief product overview only. The plan has limitations and exclusions that may affect benefits payable. Refer to pages 15-21 for limitations and exclusions.

Sample Weekly Rate1

$13.21

6

1 Sample weekly rate is based on plan level II for employee only.

Hospital Indemnity (Policy Series 8500)

Features• Guaranteed-Issue – No Health Questions or Exam!*• The plan pays regardless of any other insurance programs.• Out-Of-Hospital Prescription Drug Benefit is included.• Well Baby Care Benefit is included.• Surgery and Anesthesia Benefit is included.• The plan is portable (with certain stipulations).

Why Hospital Indemnity Insurance is ImportantNo matter how good your major medical insurance is, when you’re hospitalized for an injury or illness there will probably be medical expenses and out-of-pocket costs that aren’t covered. Without a financial plan in place, you could have difficulty paying for high out-of-pocket costs resulting from an accident or illness as well as everyday expenses such as mortgage, rent or car payments, transportation, groceries and child care.

A hospital indemnity insurance plan from Aflac provides cash benefits paid to you (unless otherwise assigned) to use as you see fit. The benefits are predetermined and paid regardless of any other insurance you may have.

How It Works

$50Hospital Emergency

Room/Physician Benefit

$500Hospital Admission

Benefit

$400Hospital Confinement Benefit ($200 per day)

$950+ + =

The insured has a high fever and goes to the emergency

room.

The physician admits the insured into the hospital.

The insured is released after

two days.

The Aflac group Hospital Indemnity

Plan pays the insured.

*During initial enrollment and for newly eligible employees, coverage is guaranteed-issue.

Pre-Existing Conditions Plan will not pay benefits for any loss or injury that is caused by, contributed to by, or resulting from a pre-existing condition for 12 months after the insured’s effective date or for 12 months from the date medical care, treatment, or supplies were received for the pre-existing condition—whichever is less.


Sample Weekly Rate1

$10.02

7

Hospital Indemnity BenefitsHospital Confinement (per day)

Pays amount shown when an insured is confined within 6 months as a resident bed patient as the result of injuries received in a covered accident or because of a covered sickness; benefit is payable for only one hospital confinement at a time; maximum 180 days per year.

$200

Hospital Admission (per confinement)

This benefit is payable in the amount shown when an insured is admitted to the hospital and confined as a resident bed patient within 6 months of injuries received in a covered accident or because of a covered sickness.Residents of Massachusetts are not eligible for Hospital Admission Benefit amounts in excess of $500.

$500

Hospital Intensive Care (per day)

Benefit will pay the daily amount for each day of confinement to a hospital intensive care unit, not to exceed the 30-day maximum during any one period of confinement. If the member is confined to hospital intensive care unit again within 6 months because of the same or related condition, it will be treated as the same period of confinement. This is paid in addition to the hospital confinement benefit.

$200

Surgical Benefit (per procedure)

The benefit is payable for a surgical procedure as listed in the Schedule of Operations. If an operation is not listed in the Schedule of Operations, the benefit will pay an amount comparable to that which would be payable for the operation listed in the Schedule of Operations (the operation that is nearest in severity and complexity). If two or more surgical procedures are performed at the same time through the same or different incisions, only one benefit, the largest, will be provided.

Up to $2,000

Anesthesia Benefit (per procedure)

When an insured receives benefits for a surgical procedure covered under the Surgical Benefit, the plan pays the appropriate benefit amount shown in the Schedule of Operations for anesthesia administered by a physician in connection with such procedure. However, the Anesthesia Benefit paid will not exceed 25 percent of the amount paid under Surgical Benefit.

Up to $500

Hospital Emergency Room/Physician Benefit (per visit)

Pays amount shown if an insured has treatment as the result of a covered sickness for Physician’s charges ($50), laboratory fees ($25), x-rays ($50) and injections/medications ($25). Limited to the calendar year maximum of $250 per insured or $1,000 per family. Not to exceed a maximum of $50 per visit.

$50

Well Baby Care (per visit)

Pays amount shown for insured baby 12 months of age or younger with no more than 4 visits per calendar year.This benefit is available only with employee and dependent children and family coverages.

$25

Out-of-Hospital Prescription Drug Benefit (per prescription)

Benefit will be paid for each prescription filled for an insured. A prescription drug must (1) be ordered by a doctor; (2) be dispensed by a licensed pharmacist; and (3) be medically necessary for the care and treatment of the patient. No more than 5 prescriptions per calendar year per insured.This benefit does not include benefits for:

• Therapeutic devices or applications;• Experimental drugs;• Drugs, medicines or insulin used by or administered to an insured while they are confined to a hospital,

rest home, extended care facility, convalescent home, nursing home or similar institution;• Immunization agents, biological sera, blood or blood plasma; or• Contraceptive materials, devices, or medications or infertility medication, except where required by law.

$10

Hospital Indemnity (Continued)

This is a brief product overview only. The plan has limitations and exclusions that may affect benefits payable. Refer to pages 15-21 for limitations and exclusions.


8

With heart attacks affecting more than 900,000 people each year and strokes affecting about 795,000 people each year,* Aflac’s Critical Illness Insurance plan can help with the treatment costs of these illnesses and health events. More importantly, the plan helps you focus on recuperation instead of the distraction and stress over the costs of medical and personal bills.

Critical Illness (Policy Series 2800)

How It Works

You enroll in $10,000 benefit Critical Illness

Insurance.

You experiencechest pains and

numbness in the left arm.

You visit the ER. A physician

determines that you have suffered

a heart attack

Aflac group Critical Illness pays a First Occurrence

Benefit of

$10,000

* Heart Disease and Stroke Statistics, 2012 Update, American Heart Association.1 Sample weekly rate is based on guaranteed-issue amount of $10,000 and age 30-39.

Features• Guaranteed-issue available Guaranteed-issue Amounts: Employee up to $10,000 Spouse up to $5,000

• Lump sum benefits are paid directly to you (unless otherwise assigned) following the diagnosis of each covered Critical Illness.

• Benefit amounts available for $5,000 up to $50,000 for the employee and up to $25,000 for the employee’s spouse, not to exceed one half of the employee’s amount.

• Each Dependent Child under age 26 is covered at 50% of the primary insured amount at no additional charge.

• Annual Health Screening Benefit included.

• No deductibles, copayments, or network restrictions—you choose your own medical treatment provider.

30 Day Waiting Period:This plan contains a 30-day “Waiting Period”. This means a no benefit is payable for any Insured Person who has been diagnosed with a Specified Critical Illness before their coverage has been in force 30 days from the Effective Date shown in the Certificate Schedule.

Pre-Existing Conditions: Plan will not pay benefits for any sickness or physical condition starting within 12-months of an Insured’s Effective Date which is caused by or resulting from a Pre-existing Condition.


Sample Weekly Rate1

$2.29

9

BenefitsPrimary Insured $5,000 to $50,000

Spouse - Available for purchase 1 $5,000 - $25,000 (not to exceed 50% of the employee’s amount)

Dependent Child(ren) - No Additional Charge 2 50% of the primary insured’s benefit amount

First Occurrence Benefit (30 Day Waiting Period)

Illnesses Covered Under Plan Percentage of Face Amount

Cancer (Internal or Invasive) 100%

Heart Attack (Myocardial Infarction) 100%

Major Organ Transplant 100%

End-Stage Renal Failure 100%

Stroke (Apoplexy or Cerebral Vascular Accident) 100%

Carcinoma In Situ 3 25%

Coronary Artery Bypass Surgery 3 25%

Additional Occurrence Benefit

If an Insured collects full benefits for a Critical Illness under the plan and later has one of the remaining covered illnesses, then Aflac will pay the full benefit amount for any additional illness. The two dates of diagnosis must be separated by at least 6 months or at least 6 months treatment free for cancer per person and not caused by or contributed to by a Critical Illness for which benefits have been paid.

Re-occurrence Benefit

If an Insured receives full benefit for a covered condition and is later diagnosed with the same condition, Aflac will pay the full benefit again.Occurrences must be separated by at least 12 months or at least 12 months Treatment Free for Cancer. Cancer that has spread (metastasized) even though there is a new tumor will not be considered an additional occurrence unless the Insured has been Treatment Free for at least 12 months.

Health Screening Benefit 4- $50

An Insured may receive a maximum of $50 for any one covered screening test per calendar year. Aflac will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the amount payable for the diagnosis of a critical illness. There is no limit to the number of years the Insured can receive the health screening benefit; it will be paid as long as the policy remains in force. This benefit is payable for the covered employee and spouse. This benefit is not paid for Dependent Children. The covered health screening tests include but are not limited to:

• Stress test on a bicycle or treadmill• Fasting blood glucose test, blood test for triglycerides or

serum cholesterol test to determine level of HDL and LDL• Bone marrow testing• Breast ultrasound• CA 15-3 (blood test for breast Cancer)• CA 125 (blood test for ovarian Cancer)• CEA (blood test for colon Cancer)• Chest x-ray

• Colonoscopy• Flexible sigmoidoscopy• Hemocult stool analysis• Mammography• Pap smear• PSA (blood test for prostate Cancer)• Serum protein electrophoresis (blood test for myeloma)• Thermograph

1 The employee may elect to purchase spouse coverage. In order to apply for spouse coverage, the employee must also apply. The spouse amount may not exceed 50% of the employee amount, subject to the minimum face amount of $5,000. If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary Insured and is limited to face amounts between $5,000 and $25,000.

2 Children-only coverage is not available.3 Payment of the partial benefit for Carcinoma in Situ will reduce by 25% the benefit for internal Cancer. Payment of the partial benefit for Coronary Artery

Bypass Surgery will reduce by 25% the benefit for a Heart Attack.4 30 day waiting periodThis is a brief product overview only. The plan has limitations and exclusions that may affect benefits payable. Refer to pages 15-21 for limitations and exclusions.

Critical Illness (Continued)


10

The Importance of Accident InsuranceWhat would the financial impact of an injury mean to you? Are you prepared for high medical costs in addition to everyday household expenditures and lost wages? Out-of-pocket expenses associated with an accident are unexpected, but an accident’s impact on your finances and your well-being certainly can be reduced.

It’s Insurance for Daily LivingAfter an accident, you may have expenses you’ve never considered. Can your finances handle them? In addition, your regular bills, such as the mortgage or rent, car payments and utility bills don’t stop when you’re recuperating from an accident. It’s reassuring to know that an accident insurance plan can be there for you through the many stages of care, from the initial emergency treatment or hospitalization, to follow-up treatments or physical therapy.

Would your family be financially prepared in the event of an accidental death or dismemberment?Included with your plan, accidental death and dismemberment insurance pays you or your beneficiaries a set amount of money if your death or dismemberment is the direct result of an accident. To receive benefits related to an accident, your injuries or death must occur within 90 days of the accident date.

Features• Coverage is 24-hour, on- and off-the-job.• Cash benefits are paid directly to you (unless otherwise specified).• Benefits are payable regardless of any other insurance programs.• Coverage is guaranteed-issue, provided the applicant is eligible for coverage.• No limit on the number of claims an insured can file.• Benefits are available for spouse and/or dependent children.• Accidental Death & Dismemberment benefits included.

Accident Advantage Plus (Policy Series 7800)

How It Works

$200Ambulance

$200Emergency

Room Treatment

$2,400Closed-Reduction

Leg Fracture

$100Appliance

$30one Follow-Up

Treatment

$2,930+ + + =

You injure your legin a coveredaccident and

go to the hospitalvia ambulance.

The emergency room doctor

diagnoses a fracture and treats you.

You leave the hospital oncrutches.

The Aflac group Accident Advantage Plus Plan pays you.


Sample Weekly Rate1

$4.36

1 Sample weekly rate based on employee only coverage

11

Employee and Spouse must be at least 18 years of age, while dependent child need to be under the age of 26.

Accident Benefits per Covered AccidentFracture (diagnosis and treatment within 90 days)

Closed & Open Reduction Benefits $320 - $4,000

Dislocations (diagnosis and treatment within 90 days)

Closed & Open Reduction Benefits $240 - $3,000

Lacerations (treatment and repair within 72 hours)

Amount paid based on length of laceration $25 - $400

Injuries Requiring Surgery

Eye Injuries, Tendons/Ligaments, Ruptured Disc, Torn Knee Cartilage $50 - $600

Burns (treatment within 72 hours; first degree burns not covered)

Second Degree $100 - $1,000

Third Degree $1,000 - $20,000

Medical Fees (for X-rays or doctors services per accident within 72 hours after the covered accident)

Employee or Spouse $125

Child(ren) $75

Accident Follow-Up Treatment

Up to six treatments per covered accident $30

Physical Therapy

Up to six treatments (one per day) per covered accident $30

Emergency Room Benefits

Emergency Room Treatment (treatment in a hospital emergency room within 72 hours after the accident.) $200

Emergency Room Observation (held in a hospital for observation for at least 24 hours, and receive initial treatment within 72 hours after the accident)

$100

Hospital / Rehabilitation Benefits

Hospital Admission (one per Calendar Year) $1,000

Hospital Confinement (Per Day) $200

Hospital Intensive Care (Per Day) (30 days per injury) $400

Rehabilitation Unit Benefit (Per Day) (60 days per calendar year) $75

Emergency Dental Work (injury to sound, natural teeth) $50 - $150

Accidental Death & Dismemberment (within 90 days of accident date)Employee Spouse Children

Accidental Death $50,000 $25,000 $5,000

Accidental Common Carrier Death $100,000 $50,000 $15,000

Single Dismemberment $12,500 $5,000 $2,500

Double Dismemberment $25,000 $10,000 $5,000

Loss of One or More Fingers or Toes $1,250 $500 $250

Partial Amputation of Finger(s) or Toe(s) (including at least one joint) $100 $100 $100

Accident Advantage Plus (Continued)


This is a brief product overview only. The plan has limitations and exclusions that may affect benefits payable. Refer to pages 15-21 for limitations and exclusions.

12

Value Added Services

MeMD Telemedicine

Health Advocate

Medical Bill Saver

The benefits outlined on the following page are included with your enrollment in an Aflac group Accident, Critical Illness or Hospital Indemnity plan

13

Health Advocacy

24/7 access to Personal Health Advocates who start helping from the first call:

• Find doctors, dentists, specialists, hospitals and other providers.• Schedule appointments, treatments and tests.• Resolve benefits issues and coordinate benefits.• Assist with eldercare issues, Medicare and more.• Help transfer medical records, lab results and X-rays.• Work with insurance companies to obtain approvals and clarify coverage.• Services available for your spouse, dependent children, parents and parents-in-law.

Medical Bill Saver™

Health Advocate professionals also help you negotiate medical bills not covered by health insurance:

• Professionals contact providers to negotiate a discount on medical and dental bills over $400.• Professionals negotiate agreements with the provider in payment term and conditions for a reduction in out-of- pocket costs.• Provide a Savings Result Statement to summarize the outcome and payment terms.• Services available for your spouse, dependent children, parents and parents-in-law.

Now, if you have Aflac Group Accident, Group Critical Illness or Group Hospital Indemnity plans, you also have access to three new services that make it easier to access care, reduce out-of-pocket medical expenses and navigate the healthcare system with greater ease.

• Connect with health providers via phone, app or online with MeMD.• Get answers and expert help with Health Advocacy from Health Advocate.• Let advocates negotiate your medical bills with Medical Bill SaverTM, also from Health Advocate

These services are now embedded in your group plan - at no extra charge. Best of all, you can start using them as soon as your Aflac coverage starts.

Value Added Services

Telemedicine

Connect with board-certified, U.S. licensed health providers online for 24/7/365 access to medical care - fast:

• Request consultations via webcam, app or phone call from the convenience of your home or while on the road.• Consultation and treatment for a range of health issues, from allergies and colds to short-term medication refills.• When medically necessary, MeMD providers can submit ePrescriptions electronically for purchase and pick-up

at your local pharmacy.• $35 per visit consultation fee.• Service available for you and your family.

Medical Bill Saver has restrictions for negotiations on in-network deductibles and co-insurance in Arizona, Colorado, District of Columbia, Il linois, Indiana, New Jersey, New York, North Carolina, Ohio, South Dakota, Texas, Utah and Vermont. Value Added Services are not available to residents of Idaho. State availability may vary.

14

Limitations & Exclusions

15

HOSPITAL INDEMNITY

PRE-EXISTING CONDITION LIMITATIONA pre-existing condition means, within the 12-month period prior to the insured’s effective date, conditions for which medical advice or treatment was received or recommended.We will not pay benefits for any loss or injury that is caused by, contributed to by, or resulting from a pre-existing condition for 12 months after the insured’s effective date or for 12 months from the date medical care, treatment, or supplies were received for the pre-existing condition—whichever is less.A claim for benefits for loss starting after 12 months from the effective date of the insured’s certificate will not be reduced or denied on the grounds that it is caused by a pre-existing condition.Pregnancy is considered a pre-existing condition if conception was before the coverage effective date.Treatment means consultation, care, or services provided by a physician. This includes diagnostic measures and taking prescribed drugs and medicines.If the certificate is issued as a replacement for a certificate previously issued under this plan, then the pre-existing condition limitation provision of the new certificate applies only to any increase in benefits over the prior certificate. Any remaining pre-existing condition limitation period of the prior certificate continues to apply to the prior level of benefits.EXCLUSIONS We will not pay benefits for loss caused by pre-existing conditions (except as stated in the Pre-Existing Condition Limitation provision above).We will not pay benefits for loss contributed to by, caused by, or resulting from:1. War – Participating in war or any act of war, declared or not, or participating in

the armed forces of or contracting with any country or international authority. We will return the prorated premium for any period not covered by this certificate when the insured is in such service.

2. Suicide – Committing or attempting to commit suicide, while sane or insane.3. Self–Inflicted Injuries – Injuring or attempting to injure yourself intentionally.4. Traveling – Traveling more than 40 miles outside the territorial limits of the

United States, Canada, Mexico, Puerto Rico, the Bahamas, Virgin Islands, Bermuda, and Jamaica.

5. Racing – Riding in or driving any motor–driven vehicle in a race, stunt show or speed test.

6. Aviation – Operating, learning to operate, serving as a crewmember on, or jumping or falling from any aircraft, including those, which are not motor–driven.

7. Intoxication – Being legally intoxicated, or being under the influence of any narcotic, unless such is taken under the direction of a physician.

8. Illegal Acts – Participating or attempting to participate in an illegal activity, or working at an illegal job.

9. Sports – Participating in any organized sport: professional or semi–professional.

10. Routine physical exams and rest cures.11. Custodial care. This is care meant simply to help people who cannot take

care of themselves.12. Treatment for being overweight, gastric bypass or stapling, intestinal bypass,

and any related procedures, including complications.13. Services performed by a relative.14. Services related to sex change, sterilization, in vitro fertilization, reversal of a

vasectomy or tubal ligation.15. A service or a supply furnished by or on behalf of any government agency

unless payment of the charge is required in the absence of insurance.16. Elective abortion.17. Treatment, services, or supplies received outside the United States and its

possessions or Canada.18. Injury or sickness covered by Worker’s Compensation.19. Dental services or treatment.20. Cosmetic surgery, except when due to medically necessary reconstructive

plastic surgery.21. Mental or emotional disorders without demonstrable organic disease.22. Alcoholism, drug addiction, or chemical dependency.

Continental American Insurance Company is not aware of whether a Employee will receive benefits from Medicare, Medicaid, or a state variation.

If Employees or their dependent(s) are subject to Medicare, Medicaid, or a state variation, any and all benefits under this plan could be assigned.This means that the Employees may not receive any of the benefits in the plan.As a result, please check the coverage in all health insurance policies a Employee

may already have or may have before the Employee buy this insurance to verify the absence of any assignments or liens.TERMINATIONSAn Employee’s insurance will terminate on the earliest of:• The date the plan is terminated;• The 31st day after the premium due date, if the required premium has not been

paid;• The date an insured no longer meets the definition of an Employee with an

active Independent Employee agreement with an approved Motor Carrier that appears in the Master Application’s Schedule A, unless the insured takes advantage of the portability privilege.

• The premium due date which falls on or first follows the Employee’s 70th birthday; or

• The date a Employee no longer belongs to an eligible class.Insurance for an insured spouse or dependent child will terminate the earliest of:• The date the plan is terminated;• The date the spouse or dependent child ceases to be a dependent; or• The premium due date following the date we receive written request to

terminate coverage for an insured’s spouse and/or all dependent children.If the group master policy and/or certificate terminates, we will provide coverage for claims arising from covered accidents or sickness that occurred while the plan was in force.DEFINITIONSInjury or Injuries – Accidental bodily injury or injuries caused solely by or as the result of a covered accident.Covered Accident – An accident, which occurs on or after the insured’s effective date, while the insured’s certificate is in force, and which is not specifically excluded.Sickness – An illness, infection, disease or any other abnormal condition, which is not caused solely by or the result of an injury.Covered Sickness – An illness, infection, disease or any other abnormal physical condition which is not caused solely by or the result of any injury which:1. Occurs while the insured’s coverage is in force; and2. Was not treated or for which the insured did not receive advice within 12

months before the insured’s effective date; and3. Is not excluded by name or specific description in the plan.

Calendar Year – The period beginning on the policy effective date and ending on December 31 of the same year. Thereafter, it is the period beginning on January 1 and ending on December 31 of each following year.Doctor or Physician – A person, other than the insured, or a member of the insured’s immediate family, who:• Is licensed by the state to practice a healing art;• Performs services which are allowed by his or her license; and• Performs services for which benefits are provided by the Plan.

Hospital – A place that:• Is legally licensed and operated as a hospital;• Provides overnight care of injured and sick people;• Is supervised by a doctor;• Has full-time nurses supervised by a registered nurse;• Has on-site or pre-arranged use of X-ray equipment, laboratory and surgical

facilities; and• Maintains permanent medical history records.A hospital is not:• A nursing home;• An extended-care facility;• A convalescent home;• A rest home or a home for the aged;• A place for alcoholics or drug addicts; or• A mental institution.

Hospital Intensive Care Unit – A place that:1. Is a specifically designated area of the hospital called an intensive care unit

that provides the highest level of medical care and is restricted to patients who are critically ill or injured and who require intensive comprehensive observation and care;

2. Is separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement;

3. Is permanently equipped with special lifesaving equipment for the care of the critically ill or injured;

4. Is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit on a twenty four hour basis; and

5. Has a doctor assigned to the intensive care unit on a full-time basis.

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A hospital intensive care unit is not any of the following step-down units:1. A progressive care unit;2. A sub-acute intensive care unit;3. An intermediate care unit;4. A private monitored room;5. A surgical recovery room;6. An observation unit; or7. Any facility not meeting the definition of a hospital intensive care unit as defined

in the plan.Dependent Children – An Employee’s natural child(ren), stepchildren, foster children, legally adopted child(ren) or child(ren) placed for adoption, who are under age 26.An Employee’s natural children will be covered from the moment of live birth provided the birth was after the effective date of the Dependent Children Benefit Rider. No notice or additional premium is required if the Dependent Children Benefit Rider is already in force. Newborn children are not covered from the time of birth unless Dependent Children Benefit Rider coverage is already in force and effective prior to birth.Coverage on dependent children will terminate on the child’s 26th birthday. However, if any child is incapable of self-sustaining employment due to mental retardation or physical handicap and is dependent on his parent(s) for support, the above age of twenty-six 26 provision shall not apply. Proof of such incapacity and dependency must be furnished to the Company within 31 days following such 26th birthday.Spouse – An Employee’s legal spouse who is between the ages of 18–64 and who is named on the enrollment application.Treatment – Consultation, care or services provided by a physician including diagnostic measures and taking prescribed drugs and medicines.

CRITICAL ILLNESS

LIMITATIONS AND EXCLUSIONSThis Certificate contains a 30-day “Waiting Period”. This means a no benefit is payable for any Insured Person who has been diagnosed with a Specified Critical Illness before their coverage has been in force 30 days from the Effective Date shown in the Certificate Schedule. If an Insured is first diagnosed during the “Waiting Period”, benefits for treatment of that Critical Illness will apply only to loss commencing after 12 months from their Effective Date; or, at the Employee’s option, they may elect to void the Certificate from the beginning and receive a full refund of premium.The date of diagnosis of a Critical Illness must be separated from the date of diagnosis of a subsequent different Critical Illness by at least 6 months, or at least 6 months Treatment Free for Cancer. The date of diagnosis of a Critical Illness must be separated from the date of diagnosis of a subsequent same Critical Illness by at least 12 months, or at least 12 months Treatment Free for Cancer. Cancer that has spread (metastasized) even though there is a new tumor will not be considered an additional occurrence unless the Insured has been Treatment Free for at least 12 months.The applicable benefit amount will be paid if the date of diagnosis occurs after the Waiting Period, the date of diagnosis occurs while the Insured’s coverage is in force; and the cause of the illness is not excluded by name or specific description.Benefits will not be paid for loss due to:

1. Intentionally self-inflicted injury or action;2. Suicide or attempted suicide while sane or insane;3. Illegal activities or participation in an illegal occupation;4. War, whether declared or undeclared or military conflicts, participation in an

insurrection or riot, or civil commotion;5. Substance abuse;6. Pre-Existing Conditions.

No benefits will be paid for diagnosis made or Treatment received outside the United States.

PRE-EXISTING CONDITION LIMITATION“Pre-existing Condition” means a sickness or physical condition which, within the 12-month period prior to the Effective Date of the certificate resulted in an Insured Person’s receiving medical advice or Treatment.We will not pay benefits for any sickness or physical condition starting within 12-months of an Insured’s Effective Date which is caused by or resulting from a Preexisting Condition.A claim for benefits for loss starting after 12-months from an Insured’s Effective Date will not be reduced or denied on the grounds that it is caused by a Pre-

existing Condition.A condition will no longer be considered preexisting at the end of 12 consecutive months starting and ending after an Insured’s Effective Date.

DEFINITIONSCancer means a malignant tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of distant tissue. Cancer includes Leukemia. Excluded are Cancers that are non-invasive such as:

1. Pre-malignant tumors or polyps;2. Carcinoma in Situ;3. Any skin Cancers except melanomas;4. Basal cell carcinoma and squamous cell carcinoma of the skin; and5. Melanoma that is diagnosed as Clark’s Level I or II or Breslow less than .77mm.

Cancer is also defined as disease which meets the diagnosis criteria of malignancy established by The American Board of Pathology after a study of the histocytologic architecture or pattern of the suspect tumor, tissue or specimen.Carcinoma in Situ means Cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue.Cancer and/or Carcinoma in Situ must be diagnosed in one of two ways:1. Pathological Diagnosis - A Pathological Diagnosis of Cancer or Carcinoma in Situ is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This type of diagnosis must be done by a Certified Pathologist whose diagnosis of malignancy is in keeping with the standards set up by the American Board of Pathology.2. Clinical Diagnosis - A Clinical Diagnosis of Cancer or Carcinoma in Situ is based on the study of symptoms.We will pay benefits for a Clinical Diagnosis only if:

1. A Pathological Diagnosis cannot be made because it is medically inappropriate or life-threatening; and

2. There is medical evidence to support the diagnosis; and3. A doctor is treating an Insured for Cancer and/or Carcinoma in Situ.

Heart Attack (Myocardial Infarction) means the death of a portion of the heart muscle (myocardium) resulting from a blockage of one or more coronary arteries. Heart Attack does not include any other disease or injury involving the cardiovascular system. Cardiac Arrest not caused by a Myocardial Infarction is not a Heart Attack. The diagnosis must include all of the following criteria:

1. New and serial Electrocardiographic (EKG) findings consistent with Myocardial Infarction;

2. Elevation of cardiac enzymes above generally accepted laboratory levels of normal in case of creatine physphokinase (CPK), a CPK-MB measurement must be used; and

3. Confirmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms.

Stroke means apoplexy (due to rupture or acute occlusion of a cerebral artery), or a cerebral vascular accident or incident, which began on or after an Insured’s Effective Date. Stroke does not include Transient Ischemic Attacks and attacks of Verterbrobasilar Ischemia. We will pay a benefit for Stroke which produces permanent clinical neurological sequela following an initial diagnosis made after any applicable Waiting Period. We must receive evidence of the permanent neurological damage provided from Computed Axial Tomography (CAT scan) or magnetic Resonance Imaging (MRI). Stroke does not mean head injury, transient ischemic attack or chronic cerebrovascular insufficiency.Renal Failure (Kidney Failure) means the end stage Renal Failure presenting as chronic, irreversible failure of both of your kidneys to function. The kidney failure must necessitate regular renal dialysis, hemo-dialysis or peritoneal dialysis (at least weekly); or which results in kidney transplantation. Renal Failure is covered, provided it is not caused by a traumatic event, including surgical traumas.Coronary Artery Bypass Surgery – undergoing open heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts, but excluding procedures such as, but not limited to balloon angioplasty, laser relief, stints or other non-surgical procedures.Major Organ Transplant – Having a Major Organ Transplant means undergoing surgery as a recipient of a transplant of a human heart, lung, liver, kidney, or pancreas.Insured Person(s) –

1. If Employee coverage is shown in the Certificate Schedule, we insure the Employee.

2. If coverage is for the Spouse of an eligible Employee, we insure the Insured as shown on the Certificate Schedule.

3. Coverage for Dependent Children may be included in an attached rider (if applicable).

4. If any person who would otherwise be an Insured is specifically excluded from coverage by endorsement to the Certificate or by the application, then such person shall not be an Insured.

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5. Any other additions to the Insured class must be added by endorsement after applying to the Company.

Successor Insured - If the Insured dies while covered under this plan, then the surviving spouse shall become the Insured if such spouse is an Insured Person. If there is no surviving spouse covered under this plan, then this plan shall terminate on the next premium due date. Dependent Children – means your natural children, step-children, foster children, legally adopted children or children placed for adoption, who are under age 26.Your natural Children born after the Effective Date of this Rider will be covered from the moment of live birth. No notice or additional premium is required.Coverage on a Dependent Child(ren) will terminate on the child’s 26th birthday. However, if any child is incapable of self-sustaining employment due to mental retardation or physical handicap and is dependent on his parent(s) for support, the above age of twenty-six (26) shall not apply. Proof of such incapacity and dependency must be furnished to the Company within thirty-one (31) days following such 26th birthday.Date of Diagnosis - The date of diagnosis is:

1. For Cancer and or/or Carcinoma in Situ: The day the tissue specimen, blood samples and /or titer(s) are taken on which the diagnosis of cancer or carcinoma in situ is based. This includes recurrence of a previously diagnosed cancer provided the insured is free of any signs or symptoms and is treatment free for that cancer for 12 consecutive months.

2. For Heart Attack: The date that the death (infarction) of a portion of the heart muscle occurred based on the criteria listed under the Heart Attack definition.

3. For Stroke: The date a Stroke occurred based on documented neurological deficits and neuro-imaging studies.

4. For end stage Renal Failure: The date that your doctor or physician recommends that you begin renal dialysis.

5. For Major Organ Transplant surgery or Coronary Artery Bypass Surgery: The date the surgery occurs for covered transplants or covered Coronary Artery Bypass Surgery.

Treatment means consultation, care or services provided by a physician including diagnostic measures and taking prescribed drugs and medicines.Treatment Free means a period of time without the consultation, care or services provided by a physician including diagnostic measures and taking prescribed drugs and medicines. For the purpose of this definition “treatment” does not include maintenance drug therapy or routine follow-up visits to verify if cancer or carcinoma in situ has returned.Waiting Period means the number of days after the Effective Date before we will pay benefits for loss due to a Critical Illness. We won’t pay benefits for a Critical Illness that begins during the Waiting Period.Maintenance Drug Therapy means ongoing hormonal therapy, immunotherapy or chemo-prevention therapy that may be given following the full remission of a cancer due to primary treatment. It is meant to decrease the risk of cancer recurrence rather than the palliative or suppression of a cancer that is still present.Symptoms mean the subjective evidence of disease or physical disturbance.Signs mean the subjective evidence of disease or physical disturbance observed by a physician or other member of the medical profession, acting within the scope of their license.

ACCIDENT

LIMITATIONS AND EXCLUSIONSWe will not pay benefits for injury, total disability, or death contributed to, caused by, or resulting from:• War – participating in war or any act of war, declared or not; participating in the

armed forces of, or contracting with, any country or international authority. We will return the prorated premium for any period not covered by this certificate when you are in such service.

• Suicide – committing or attempting to commit suicide, while sane or insane.• Sickness – having any disease or bodily/mental illness or degenerative

process. We also will not pay benefits for any related medical/surgical treatment or diagnostic procedures for such illness.

• Self-Inflicted Injuries – injuring or attempting to injure yourself intentionally.• Racing – riding in or driving any motor-driven vehicle in a race, stunt show, or

speed test.• Intoxication – being legally intoxicated, or being under the influence of any

narcotic, unless taken under the direction of a Doctor. Legally intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred.)

• Illegal Acts – participating or attempting to participate in an illegal activity, or

working at an illegal job.• Sports – participating in any organized sport –professional or semi-professional.• Cosmetic Surgery – having cosmetic surgery or other elective procedures that

are not medically necessary or having dental Treatment except as a result of a covered accident.

TERMINATIONSAn Employee’s coverage will terminate on whichever occurs first:• The date the master policy is terminated.• The 31st day after the premium due date, if the premium has not been paid.• The date an insured no longer meets the definition of an Employee with an


• The date an insured no longer belongs to an eligible class.If the master policy and/or certificate terminates, we will provide coverage for claims arising from covered accidents that occurred while the plan was in force.

DEFINITIONSAccidental Injury or Injuries means bodily injury or injuries resulting from an unforeseen and unexpected traumatic event that meets the definition of covered accident.Calendar Year is defined as January 1 through December 31 of the same year.Covered Accident means an unforeseen and unexpected traumatic event resulting in bodily Injury. An event meets the qualifications of covered accident if it:• Occurs on or after the Plan’s Effective Date,• Occurs while coverage is in force, and• Is not specifically excluded.

Dependent Children are your or your spouse’s natural children, step-children, legally adopted children, or children placed for adoption who are younger than age 26.However, there is an exception to the age-26 limit listed above. This limit will not apply to any child who is incapable of self-sustaining employment due to mental or physical handicap and is dependent on a parent for support. You or your spouse must furnish proof of this incapacity and dependency to the Company within 31 days following the child’s 26th birthday.Doctor is defined as a person who is:• Legally qualified to practice medicine,• Licensed as a physician by the state where treatment is received, and• Licensed to treat the type of condition for which a claim is made.

A doctor does not include you or your family member.Family member (as referenced under the definition of Doctor and the Family Lodging Benefit) includes the Employee’s spouse, who is defined as a Employee’s legal wife or husband, as well as the following members of the insured’s immediate family:• Son.• Daughter.• Mother.• Father.• Sister.• Brother.

This includes step-family members and family-members-in-law.Hospital refers to a place that:• Is legally licensed and operated as a hospital;• Provides overnight care of injured and sick people;• Is supervised by a doctor;• Has full-time nurses supervised by a registered nurse;• Has on-site or pre-arranged use of x-ray equipment, laboratory, and surgical

facilities; and• Maintains permanent medical history records.

A hospital is not:• A nursing home;• An extended-care facility;• A convalescent home;• A rest home or a home for the aged;• A place for alcoholics or drug addicts; or• A mental institution.

Hospital Intensive Care Unit refers to a specifically designed hospital facility that provides the highest level of medical care and is restricted to patients who are

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critically ill or injured, Hospital intensive care units must be:• Separate and apart from the surgical recovery room;• Separate and apart from rooms, beds, and wards customarily used for patient

confinement;• Permanently equipped with special life-saving equipment to care for the critically

ill or injured; and• Under constant and continuous observation by nursing staffs assigned to the

intensive care units on an exclusive, full-time basis.Psychiatrist is a doctor of medicine who specializes in the diagnosis and treatment of mental disorders.Psychologist is a clinical mental health professional who works with patients and is not a doctor of medicine who typically provides medical interventions and drug therapies, but provides analysis and counseling.Rehabilitation Unit is a unit of a hospital providing coordinated multidisciplinary physical restorative services. These services must be provided to inpatients under a doctor’s direction. The doctor must be knowledgeable and experienced in rehabilitative medicine. Beds must be set up and staffed in a unit specifically designated for this service.Spouse is the legal wife or husband who is at least age 18 and who is named on the enrollment application.Treatment or Medical Treatment is the consultation, care, or services provided by a doctor. This includes receiving any diagnostic measures and taking prescribed drugs and medicines.

DISABILITY

We will pay all applicable benefits if the covered Employee’s disability is caused by a covered sickness or covered injury and if it occurs while this coverage is in force.All benefits are subject to the limitations and exclusions, pre-existing condition limitations, and other plan terms.Benefits will be paid for only one disability at a time, even if the disability is caused by more than one sickness, more than one injury, or a sickness and an injury. We reserve the right to meet with the covered Employee while a claim is pending, or to use an independent consultant and doctor’s statement to determine whether the covered Employee is qualified to receive disability benefits.The covered Employee must be under the care and attendance of a doctor for these benefits to be payable. Benefits will cease on the date of the covered Employee’s death.

LIMITATIONS AND EXCLUSIONSA. We will not pay benefits whenever coverage provided by this plan is in violation

of any U.S. economic or trade sanctions. If the coverage violates U.S. economic or trade sanctions, such coverage shall be null and void.

B. We will not pay benefits whenever fraud is committed in making a claim under this coverage or any prior claim under any other Aflac coverage for which you received benefits that were not lawfully due and that fraudulently induced payment.

C. We will not pay benefits for disability that is caused by or occurs as a result of:1. Any act of war, declared or undeclared; insurrection; rebellion; or act of

participation in a riot.2. Actively serving in any of the armed forces, or units auxiliary thereto, including

the National Guard or Reserve.3. An intentionally self-inflicted injury.4. A commission of a crime for which the Employee has been convicted; we

will not pay a benefit for any period of disability during which the Employee is incarcerated.

5. Travel in, or jumping or descent from any aircraft, except when a fare-paying passenger in a licensed passenger aircraft.

6. Having cosmetic surgery or other elective procedures that are not Medically Necessary.

7. Mental illness as defined.8. Alcoholism or drug addiction.

For off-job coverage, the following limitations and exclusions will apply:9. An injury that arises from any employment.10. Injury or sickness that is covered by Worker’s Compensation.

PRE-EXISTING CONDITIONS LIMITATIONPre-existing Condition is an illness, disease, infection, disorder, pregnancy, or injury that existed within the 12-month period before the effective date of coverage.

For a condition to have been pre-existing:• A doctor must have advised, diagnosed, or treated the covered Employee, or• Symptoms existed that would ordinarily cause a prudent person to seek

medical advice or treatment.We will not pay benefits for any disability resulting from or affected by a pre-existing condition if the disability was diagnosed within the 12-month period after the effective date of coverage.We will not reduce or deny a claim for benefits for any disability due to a pre-existing condition that was diagnosed more than 12 months after the effective date of coverage.Pregnancy LimitationWithin the first nine months of the effective date of coverage, we will not pay benefits for a disability that is caused by, or occurs as a result of, pregnancy or childbirth. Disability due to complications of pregnancy will be covered to the same extent as a covered sickness.After this coverage has been in force for nine months from the effective date of coverage, disability benefits for childbirth will be payable. The maximum period of disability allowed for disability due to childbirth is six weeks for non-cesarean delivery and eight weeks for cesarean delivery, less the elimination period, unless proof is furnished that disability continues beyond these time frames due to complications of pregnancy.

SEPARATE PERIODS OF DISABILITYSame or Related ConditionsSeparate periods of disability resulting from the same condition or a related condition are considered a continuation of the prior disability if they are not separated by 180 days or more.Once the maximum Disability Benefit has been paid, the covered Employee will not be eligible for a new Disability Benefit due to the same or a related condition for 180 days after all the following conditions are met:• The Employee has been released by a doctor from the prior disability.• The Employee is no longer disabled.• The Employee is no longer qualified to receive any disability benefits under the

certificate.After the disability benefit period, the Employee may continue coverage if all of the following conditions are met:• The Employee returns to work within 90 days after the benefit period ends.• Premium payments for the coverage resume upon return to work.• The group master policy is still in force upon return to work.

Unrelated CausesSeparate periods of disability resulting from unrelated causes are considered a continuation of the prior disability if they are not separated by the covered Employee returning to work at a full-time job for 30 consecutive days, during which the Employee is performing the material and substantial duties of that job.Once the maximum Disability Benefit has been paid, the Employee will not be eligible for a new Benefit for disability due to an unrelated cause, until 30 consecutive days after all the following conditions are met:• The Employee has been released by a doctor from a prior disability.• The Employee is no longer qualified to receive any disability benefits under this

certificate.After the disability benefit period, the Employee may continue coverage if all of the following conditions are met:• The Employee returns to work within 90 days after the benefit period ends.• Premium payments for the coverage resume upon return to work.• The group Policy is still in force upon return to work.

Periods of disability meeting either of these separation requirements will begin a new Disability Benefit Period, subject to a new elimination period.

TERMINATION OF A EMPLOYEE’S INSURANCEA covered Employee’s insurance will terminate on whichever occurs first:• The date the plan is terminated.• The 31st day after the premium due date, if the premium has not been paid.• The date an insured no longer meets the definition of a Employee with an


• The date the Employee no longer belongs to an eligible class.• The Employee attaining age 75.

If the covered Employee’s coverage ends, we will provide coverage for claims that arise from short-term disability that was first diagnosed while your coverage was in force.

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DEFINITIONSActively at Work refers to a covered Employee’s ability to perform his regular duties for a full normal workday. The covered Employee may perform these activities either at his regular place of business or at a location where the covered Employee may be required to travel to perform his regular duties.Base Annual Pay is the covered Employee’s annual income from his full-time job with the policyholder. This pay excludes overtime pay, bonuses, or any other special pay.Benefit Period is the maximum number of days after the elimination period, if any, for which the covered Employee can be paid benefits for any period of disability. Each new benefit period is subject to a new elimination period.For the purposes of this calculation, a “month” is defined as 30 days for which benefits are paid.Complications of Pregnancy refers to:• Conditions requiring medical treatment that comes before or comes after the

termination of a pregnancy. The diagnoses for this medical treatment must be distinct from pregnancy but either adversely affected by pregnancy or caused by pregnancy. For a condition to be a complication of pregnancy, it must constitute a classifiably distinct pregnancy complication. Examples of such complications of pregnancy are:

o Acute nephritis,o Nephrosis,o Cardiac decompensation,o Missed abortion,o Disease of the vascular, hemopoietic, nervous, or endocrine systems, ando Similar medical and surgical conditions of comparable severity.

• Further complications of pregnancy include:o Hyperemesis gravidarum and pre-eclampsia requiring hospital confinement,o Ectopic pregnancy that is terminated, ando Spontaneous termination of pregnancy that occurs during a period of

gestation in which a viable birth is not possible.Complications of pregnancy do not include:• Multiple gestation pregnancy.• False labor.• Occasional spotting.• Morning sickness.

Other similar conditions associated with a difficult pregnancy are not considered complications of pregnancy.Cesarean deliveries are not considered complications of pregnancy. Disability• Total Disability refers to the Employee being under the care and attendance of

a doctor due to a condition that causes his inability to perform the material and substantial duties of his full-time job with their Motor Carrier. To qualify as total disability, the Employee may not be working at any job.

• Partial Disability refers to the Employee’s being under the care and attendance of a doctor due to a condition that causes his inability to perform the material and substantial duties of his full-time job. To qualify as partial disability, the Employee is able to work at any job earning less than 80 percent of the base annual pay of his full-time job at the time he became disabled.

Doctor is defined as a person who meets all the following criteria:• A person who is legally qualified to practice medicine,• A person who is licensed as a physician by the state where treatment is

received, and• A person who is licensed to treat the type of condition for which a claim is made

A doctor does not include the Employee or the Employee’s family member.Elimination Period is the number of continuous days at the beginning of the Employee’s period of disability for which no benefits are payable. Each new benefit period is subject to a new elimination period.Employee is a person who meets eligibility requirements set by the Master Application and who is covered under this plan. Employee means the eligible person whose coverage under the certificate becomes effective. The Employee is named on his certificate schedule. The Employee is always the covered eligible Employee under the group master policy.Family Member includes anyone related to the Employee in the following manner: spouse, brothers or sisters (includes stepbrothers and stepsisters); children (includes stepchildren); parents (includes stepparents); grandchildren, father- or mother-in-law; and spouses, as applicable.Full-Time Job refers to a job at which the Employee works, performing his occupational duties for pay or benefits, for the required number of hours per week.Injury refers to an off-the-job or on-the-job bodily injury not otherwise excluded. An

injury meets all the following criteria:• It is directly caused by a covered accident.• It is not caused by sickness, disease, bodily infirmity, or any other cause.• It occurs on or after the effective date of coverage and while coverage is in force.

Medically Necessary refers to treatment, services, or supplies that are necessary and appropriate for the diagnosis or treatment of a sickness or an injury based upon generally accepted medical practice.Mental Illness is defined as a total disability resulting from psychiatric or psychological conditions, regardless of cause. Mental Illness includes but is not limited to the following: bipolar affective disorder (manic-depressive syndrome), delusional (paranoid) disorders, psychotic disorders, somatoform disorders (psychosomatic illness), eating disorders, schizophrenia, anxiety disorders, depression, stress, post-partum depression, personality disorders and adjustment disorders. It also includes any other condition usually treated by a doctor, mental health provider, or other qualified provider using psychotherapy, psychotropic drugs or other similar modalities used in the treatment of the above conditions.Off-the-Job Injury means an Injury that occurs while the Employee is not working at any job for pay or benefits.On-the-Job Injury means an Injury that occurs while the Employee is working at any job for pay or benefits.Period of Disability means the length of time the Employee is either totally disabled or partially disabled from one or more causes. It starts the first full day of total disability or partial disability after the Employee ceases to be actively at work for the policyholder. It ends on the earlier of the following two dates:• The date the Employee ceases to be totally disabled or partially disabled, or• The date the Employee returns to an actively at work status for any approved

Motor Carrier.Sickness refers to a covered illness, disease, infection, or any other abnormal physical condition. Sickness must meet all the following criteria:• It must not be caused by an injury.• It first manifested and was first treated after the effective date of coverage.• It occurs while coverage is in force.

Treatment or Medical Treatment is the consultation, care, or services provided by a doctor. This includes receiving any diagnostic measures and taking prescribed drugs and medicines.

TERM LIFE

BENEFIT CONDITIONS, LIMITATIONS, AND EXCLUSIONS • If a covered person, whether sane or insane, dies by suicide within two years of

the date of certificate, our liability for death proceeds is limited to the premiums paid.

• If the age of a covered person has been misstated, and if the amount of premium is based on age, an adjustment of premiums will be made based on the covered person’s true age.

• If age is a factor in determining eligibility or amount of insurance and there has been a misstatement of age, the insurance coverages, benefit amounts (or both) for which the covered person is insured will be adjusted in accordance with the covered person’s true age. Any such misstatement of age shall neither continue insurance otherwise validly terminated nor terminate insurance otherwise validly in force.

• If it is determined after the death of a covered person that the covered person’s age was misstated, the amount of insurance will be that which the premiums would have purchased at the correct age.

• If the policyholder fails to report any employee’s termination of coverage while the group’s master policy remains in effect, our liability will be limited to a return of premium retroactive to the date on which insurance should have been terminated, less any claims paid during this period. In no event will we refund more than two months premium.

• We must receive proof of loss within 90 days after a loss occurs or starts.• Any change in beneficiary must be made to us in writing. The change will be

effective as of the date signed.

LIMITATIONS AND EXCLUSIONS - ACCIDENTAL DEATH, LOSS OF SIGHT AND DISMEMBERMENT BASIC BENEFIT AND RIDER, TOTAL DISABILITY WAIVER OF PREMIUM, AND OPTIONAL QUALITY OF LIFE ACCELERATION BENEFITNo Accidental Death, Loss of Sight and Dismemberment Benefits or Total Disability Waiver of Premium Benefits are payable or available when the death or loss:

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• Was caused directly or indirectly, wholly or partly, from suicide or attempted suicide, whether sane or insane, or any intentionally self-inflicted Injury; or

• Resulted from or occurred while committing an assault or felony, or resisting or fleeing from arrest; or

• Resulted from or occurred while participating in a riot or insurrection; or• Was caused by voluntarily taking, absorbing, or inhaling poison, poison gas, or

fumes; or• Was intentionally inflicted by any person (If the covered person is an innocent

bystander having no relationship to an altercation, it is covered.); or• Was incurred during travel, flight, or descent from any kind of aircraft, unless

the covered person was being transported as a fare-paying passenger on a regularly scheduled flight (This exclusion does not apply to airline employees flying while working, traveling for pleasure, or traveling to and from a job assignment.); or

• Was caused by disease, illness, or bacterial infection (if the infection occurs because of an injury, it is covered).

In addition to the exclusions listed above, the following limitations also apply to the Accidental Death, Loss of Sight and Dismemberment Basic Benefit and Rider:• The loss must occur within 180 days after the accidental injury.• This benefit terminates for the covered person when this benefit is paid.• Substance abuse* (This does not exclude a loss brought about by the use of

drugs prescribed by and used as directed by a physician.);• War or act of war, whether declared or undeclared*;• Service in the armed forces of any country or organization or in units auxiliary

thereto*;• Intoxication*; or• Racing a self-propelled vehicle on a racetrack, on a public road, or at another

place*.If two or more accidents cause losses covered by this benefit, we will not pay more than 100% of the Accidental Death Benefit shown on the certificate schedule for all such losses combined. This does not apply to the Seat Belt Benefit*.* These exclusions apply to the Accidental Death, Loss of Sight and Dismemberment Benefit Rider only.In addition to the exclusions listed above, the following limitations and exclusions will also apply to the Total Disability Waiver of Premium and Optional Quality of Life Acceleration Benefit:Premiums will not be waived if total disability:• Results from neurosis, psychoneurosis, psychopathy, psychosis, or mental

and emotional disease or disorder without demonstrable organic cause (This exclusion will not apply to Alzheimer’s disease, Parkinson’s disease, or senile dementia.).

• Results from substance abuse (This exclusion will not apply to a condition brought about by the employee’s use of drugs prescribed by and taken in accordance with the directions of a physician).

In addition to the exclusions listed above, the following limitations and exclusions will also apply to the Total Disability Waiver of Premium:Premiums are only waived in the event of a total disability suffered by the named employee shown on the certificate schedule.The employee’s coverage will not continue beyond the employee’s attained age of 65.Any loss due to a pre-existing condition will not be covered if the loss begins with 12 months after the covered person’s effective date of insurance. However, premiums may be waived for a loss due to a pre-existing condition of a covered person who was covered by a replaced plan and by this plan on its original effective date. If this plan’s Pre-Existing Condition Exclusion has been satisfied, we will waive premiums. If the employee does not satisfy this plan’s Pre-Existing Condition Exclusion, but can satisfy the replaced plan’s Pre-Existing Condition Exclusion, then we will waive premiums. If the employee does not satisfy the Pre-Existing Condition Exclusion of this plan or that of the replaced plan, premiums will not be waived. In addition to the exclusions listed above, the following limitations and exclusions will also apply to the Accelerated Benefit for Terminal Illness and Optional Quality of Life Acceleration Benefit:If two or more Accelerated Benefits for Terminal Illness are payable on behalf of the same covered person under the plan for the same or related sickness, injury, or other loss, we will pay only one Accelerated Benefit for Terminal Illness. The covered person is entitled to choose the Accelerated Benefit for Terminal Illness.The sum of all Accelerated Benefits for Terminal Illness payable under the plan—and its optional benefits and riders—will not exceed the amount of life insurance shown on the covered person’s Certificate Schedule.

LIMITATIONS AND EXCLUSIONS – ACCELERATED BENEFIT FOR TERMINAL ILLNESS• We must receive consent of all irrevocable beneficiaries.• We must receive a claim form for this benefit during the lifetime of the terminally

ill covered person.• Only one Accelerated Benefit for Terminal Illness for each terminal illness shall

be paid on behalf of the covered person per lifetime.• A physician must diagnose a covered terminal illness.• We will not be liable for any payment made or action taken before we receive

and acknowledge notice of the death of the terminally ill covered person.• The employee should seek assistance from a personal tax advisor before

making a claim for the Accelerated Benefit for Terminal Illness to determine any tax impact.

The Accidental Death, Loss of Sight and Dismemberment Benefit provided by the plan will not increase or decrease the Accelerated Benefit for Terminal Illness.

LIMITATIONS AND EXCLUSIONS – OPTIONAL QUALITY OF LIFE ACCELERATION BENEFITChildren are not eligible to be insured under the rider. We must receive consent of all irrevocable beneficiaries. Only those long term care services specifically listed and defined in the rider are covered. No Accelerated Benefit is payable under the rider ifChronic Illness:• Results from the covered person’s occupation; or• Results from sickness or injury covered under any Worker’s Compensation or

occupational disease law; orNo Accelerated Benefit is payable under the rider for:• Services for care or treatment provided by a relative; or• Services for care or treatment provided in a government facility (unless otherwise

required by law); or• Shopping, housekeeping or transportation services; or• Services for care or treatment incurred outside the United States and its

territories or Canada; or• Services or items covered by Title XVIII of the Social Security Act or Medicare

deductibles and coinsurance amounts. The indemnity benefits are payable, regardless of what Medicare pays, or do not pay.

All certificate provisions apply to the rider, unless inconsistent with or changed by the rider. The incontestability provision of the certificate applies to the rider from the rider issue date.

DENTAL

EXCLUSIONS No Benefits are payable under the Policy for the Services listed below. In addition, the Services listed below will not be recognized toward the satisfaction of any Deductible:1. Any Services which are not included in the Schedule of Covered Procedures;2. Any Service started or appliance installed before the Effective Date or after the

Termination Date, except in those instances noted in this Certificate;3. Any Service, which may not reasonably be expected to successfully correct

the patient’s dental condition for a period of at least 3 years, as determined by Us;

4. Any procedure We determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature;

5. Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;

6. Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures;

7. Appliances, Services or procedures relating to:a. the change or maintenance of vertical dimension;b. restoration of occlusion (unless otherwise noted in the Schedule of Covered

Procedures—only for occlusal guards);c. splinting;d. correction of attrition, abrasion, erosion or abfraction;

21

NOTICES

If this coverage will replace any existing individual policy, please be aware that it may be in the Employee’s best interest to maintain their individual guaranteed-renewable policy.Continental American Insurance Company is not aware of whether any Employees receive benefits from Medicare, Medicaid, or a state variation. If any Employees or dependents are subject to Medicare, Medicaid, or a state variation, any and all benefits under this plan could be assigned. This means that any such Employees may not receive any of the benefits in the plan. As a result, Employees should please check the coverage in all health insurance policies those Employees already have or may have before such Employees buy this insurance to verify the absence of any assignments or liens.The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company, 2801 Devine Street, Columbia, South Carolina 29205.

e. bite registration; orf. bite analysis;

8. Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;

9. Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;

10. Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;

11. Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a Covered Procedure in the Schedule of Covered Procedures;

12. Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized Services or attachments unless such procedures are listed as Covered Procedures in the Schedule of Covered Procedures;

13. Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of Claim forms, infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than Us, personal supplies (e.g., water pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;

14. Prescription drugs, premedication, pharmaceuticals, or analgesia;15. Dental disease, defect or injury caused by a declared or undeclared war or any

act of war or terrorism or taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;

16. Dental treatment not approved by the American Dental Association or which is clearly experimental in nature;

17. Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if You did not purchase the coverage that is available to You;

18. Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency Treatment performed outside of the United States are limited to a maximum of $100 per Plan Year;

19. The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a Natural Tooth extracted while the Person is insured under the Policy;

20. The initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a Natural Tooth extracted while the Person is insured under the Policy, provided that tooth was not an abutment to an existing partial denture. Frequency Limitations for replacement of dentures and bridges are stated in the Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the Person was insured under the Policy;

21. The replacement of teeth beyond the normal complement of 32;22. The replacement of an existing removable partial denture with a fixed partial

denture unless upgrading to a fixed partial denture is essential to the correction of the Covered Person’s dental condition;

23. 24 Local anesthetic, including light anesthetic, as a separate fee;24. Any Treatment Plan which involves full-mouth reconstruction by the removal

and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these Services;

25. Services with respect to congenital (hereditary) or developmental (before birth) malformations, except during the 31 day period immediately following the birth of Your Child, including but not limited to; cleft palate, maxillary and mandibular (upper and lower) malformations, enamel hypoplasia (lack of development), fluorosis, and anodontia;

26. Dental care paid for, required, or provided by or under the laws of a national, state, local or provincial government, or treatment furnished within a hospital or other facility owned or operated by a national or state government unless the Insured Person has a legal obligation to pay;

27. Dental services performed in a hospital and related hospital fees;28. Services covered under an existing medical plan;29. The portion of an expense which is in excess of the reasonable charge;30. Fees associated with a cancelled or missed appointment;31. General anesthesia and I.V. sedation, unless deemed medically necessary as

determined by a professional consultant. “Medically necessary” means that the general anesthesia and I.V. sedation is determined by Us to meet all of the following:a. Required to meet the health care needs of the Claimant; andb. Consistent (in scope, duration, intensity and frequency of treatment) with

scientifically based guidelines of national dental or research organizations or governmental agencies accepted by Us; and

c. Consistent with the diagnosis of the covered dental procedure; andd. Required for reasons other than the comfort or convenience of the Claimant;

ande. Of demonstrated medical value and medical effectiveness.

Missing Teeth LimitationWe will not pay benefits for replacement of teeth missing on a Covered Person’s Effective Date of insurance under this Certificate for the purpose of the initial placement of a full denture, partial denture or fixed bridge. In addition, such replacement will not be recognized toward the satisfaction of any Deductible. However, expenses for the replacement of teeth missing on the Effective Date will be considered for payment as follows:1. The initial placement of full or partial dentures will be considered a Covered

Procedure if the placement includes the initial replacement of a Natural Tooth extracted while the Covered Person is covered under the Group Policy;

2. The initial placement of a fixed bridge will be considered a Covered Procedure if the placement includes the initial replacement of a Natural Tooth extracted while a Covered Person is covered under the policy. However, the following restrictions will apply:a. Benefits will only be paid for the replacement of the teeth extracted while a

Covered Person is covered under the Group Policy;b. Benefits will not be paid for the replacement of other teeth which were

missing on the Covered Person’s Effective Date.c. Missing teeth limitation will be waived after a Covered Person has been

covered under the plan for (3) three continuous years unless it is a replacement of an existing unserviceable prosthesis.

EG_12.19.16Copyright © 2016. Homeland HealthCare, LLC All Rights Reserved.

(844) 275-2721Monday - Friday 8:00 a.m. - 7:00 p.m.

(Central Standard Time)

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