At Archbold and Lewis Insurance
we are pleased to provide your health coverage through GoldenRule Insurance.
GoldenRule has been been Providing Health Insurance Products to Meet Individuals'
Needs Since 1946.
Specific Provisions Subject to all policy provisions, the following
expenses are covered.
Basic PlanSM Inpatient Expense Benefits
- Daily hospital room-and-board and nursing services at the most
common semiprivate rate.
- Charges for an intensive care unit.
- Drugs, medicines, dressings, sutures, casts, or other necessary
medical supplies.
- Artificial limbs, eyes, larynx, or breast prosthesis (but not
replacements).
- Professional fees of doctors and surgeons (but not for standby
availability).
- Hemodialysis, processing, and administration of blood or components
- Charges for an operating, treatment, or recovery room for surgery.
- Cost and administration of an anesthetic, oxygen, and other
gases.
- Radiation therapy or chemotherapy and diagnostic tests using radiologic, ultrasonographic, or laboratory services. Outpatient Expense
Benefits
- Charges for outpatient surgery, including the fee made by an
outpatient surgical facility, the primary surgeon, the assistant surgeon,
and/or administration of anesthetic
- Hemodialysis, radiation, and chemotherapy.
- Prescription drugs to protect against organ rejection in transplant
cases.
- Mammography, pap smear, and PSA test fees.
- Hospital emergency room treatment of an injury or illness (subject
to an additional $500 deductible each time the emergency room is used for
injury or illness not resulting in confinement). Outpatient Testing Expense
Benefits
- CAT scan and MRI testing.
- Diagnostic testing, related
to and performed within 14 days prior to surgery or inpatient confinement.
Exclusions
- Expenses incurred for mental or nervous disorders or
substance abuse
- Outpatient prescription drugs (except as provided for under
Outpatient Expense Benefits).
- Outpatient medical services, including doctor office visits
and diagnostic testing (except as provided for under Outpatient Testing
Expense Benefits).
Important Note:Premiums for a Basic PlanSM are significantly less
because coverage is not provided for most outpatient services (doctor office
visits, diagnostic testing, and prescription drugs).
- Copay PlansSM , Plan 100®, Plan 80SM, and MSA Medical Expense
Benefits
- Daily hospital room-and-board and nursing services at the most
common semiprivate rate.
- Charges for an intensive care unit.
- Hospital emergency treatment of an injury or illness (subject
to an additional $100 deductible each time the emergency room is used for
illness not resulting in confinement).
- Surgery at an outpatient surgical center.
- Professional fees of doctors and surgeons (but not for standby
availability).
- Dressings, sutures, casts, or other necessary medical
supplies.
- Professional fees for outpatient services of licensed physical
therapists.
- Diagnostic tests using radiologic, ultrasonographic, or laboratory
services, in or out of the hospital.
- Local ground ambulance service to the nearest hospital for
necessary emergency care. Air ambulance, within the U.S., if requested
by police or medical authorities at the site of an emergency.
- Charges for an operating, treatment, or recovery room for surgery.
- Dental expenses due to an injury which damages natural teeth
if expenses are incurred within six months.
- Surgical treatment
of TMJ disorders.
- Cost and administration of an anesthetic, oxygen, and other
gases.
- Radiation therapy or chemotherapy.
- Prescription drugs.
- Hemodialysis, processing and administration of blood or components.
- Mammography, pap smear, and PSA test fees.
- Artificial
eyes, larynx, breast prosthesis, or basic artificial limbs (but not replacements).
Preventive Care Expense Benefits
- After coverage has been in force 12 months, each adult age
19 or older qualifies for up to $150 of covered expenses per calendar year
for routine physicals, including lab fees.
For information on additional Plan Provisions, including Transplant
Expense Benefit, Limited Exclusion for AIDS or HIV-Related Disease, Notification
Requirements, Preexisting Conditions, General Exclusions, General Limitations,
and Other Plan Provisions, see below.
Provisions That Apply to All Plans
Transplant Expense Benefit
The following types of transplants are eligible for coverage under
the Medical Expense Benefits and the Inpatient Hospital, Surgical, Medical
Expense Benefits provisions: Cornea transplants, artery or vein grafts,
heart valve grafts, prosthetic tissue replacement, including joint replacements
and implantable prosthetic lenses, in connection with cataracts.
Transplants eligible for coverage under the Transplant Expense Benefit
are: Heart, lung, heart/lung, kidney, liver, and bone marrow
transplants. Golden
Rule has arranged for certain hospitals around the country (referred to
as our "Centers of Excellence") to perform specified transplant
services. If you use one of our "Centers of Excellence," the
specified transplant will be considered the same as any other illness and
will include a transportation and lodging incentive (for a family member)
of up to $5,000. Otherwise, covered expenses related to the transplant
will be limited to $100,000 and one transplant in a 12-month period. To
qualify as a covered expense under the Transplant Expense Benefit, the
covered person must be a good candidate and the transplant must not be
experimental or investigational. In considering these issues, we consult
doctors with expertise in the type of transplant proposed.
The following conditions are eligible for bone marrow transplant
coverage: Allogenic bone marrow transplants (BMT) for treatment of:
Hodgkin's lymphoma or non-Hodgkin's lymphoma, severe aplastic anemia, acute
lymphocytic and nonlymphocytic leukemia, chronic myelogenous leukemia,
severe combined immunodeficiency, Stage III or IV neuroblastoma, myelodysplastic
syndrome, Wiskott-Aldrich syndrome, thalassemia major, multiple myeloma,
Fanconi's anemia, malignant histiocytic disorders, and juvenile myelomonocytic
leukemia.Autologous bone marrow transplants (ABMT) for treatment of: Hodgkin's
lymphoma, non-Hodgkin's lymphoma, acute lymphocytic and nonlymphocytic
leukemia, multiple myeloma, testicular cancer, Stage III or IV neuroblastoma,
pediatric Ewing's sarcoma and related primitive neuroectodermal tumors,
Wilms' tumor, rhabdomyosarcoma, medulloblastoma, astrocytoma, and glioma.
Limited Exclusion for AIDS or HIV-Related Disease
AIDS and HIV-related disease is treated the same as any other illness
unless the onset of AIDS or HIV-related disease is: (a) diagnosed before
the coverage has been in force for one year; or (b) first manifested before
the coverage has been in force for one year. If diagnosed or first manifested
before coverage has been in force for one year, AIDS and HIV-related disease
claims will never be covered. Details of this limited exclusion are set
forth in the policy and certificates.
Notification Requirements
You must notify us by phone on or before the day a covered person:·
Begins the fourth day of an inpatient hospitalization; or · Is evaluated
for an organ or tissue transplant. Failure to comply with Notification
Requirements will result in a 20 percent reduction in benefits, to a maximum
of $1,000.If it is impossible for you to notify us due to emergency inpatient
hospital admission, you must contact us as soon as reasonably possible. Our
receipt of notification does not guarantee either payment of benefits or
the amount of benefits. Eligibility for and payment of benefits are subject
to all terms and conditions of the policy.
Preexisting Conditions
Preexisting conditions will not be covered during the first 12 months
after an individual becomes a covered person. This exclusion will not apply
to conditions which are both: (a) fully disclosed to Golden Rule in the
individual's application; and (b) not excluded or limited by our underwriters. A
preexisting condition is an injury or illness: (a) for which a covered
person received medical advice or treatment within 24 months prior to the
applicable effective date for coverage of the illness or injury; or (b)
which manifested symptoms which would cause an ordinarily prudent person
to seek diagnosis or treatment within 12 months prior to the applicable
effective date for coverage of the illness or injury.
General Exclusions
No benefits are payable for expenses which:
- Are due to pregnancy (except for complications of pregnancy)
or routine newborn care (unless optional coverage is selected).
- Are for routine or preventive care unless provided for in the
policy.
- Are incurred while confined primarily for custodial, rehabilitative,
or educational care or nursing services.
- Result from employment-related injury or illness if the covered
person is insured, or is required to be insured, by workers' compensation
insurance under applicable state or federal law.
- Are in relation to, or incurred in conjunction with, investigational
treatment.
- Are for dental expenses or oral surgery, eyeglasses, contacts,
eye refraction, hearing aids, or any examination or fitting related to
these.
- Are for modification of the physical body, including breast
reduction or augmentation.
- Are incurred for cosmetic or aesthetic
reasons, such as weight modification or surgical treatment of obesity.
- Would not have been charged in the absence of insurance.
- Are for eye surgery to correct nearsightedness, farsightedness,
or astigmatism.
- Result from war, intentionally self-inflicted bodily harm (whether
sane or insane), or participation in a felony (whether or not charged).
- Are for treatment of temporomandibular joint disorders, except
as may be provided for under covered expenses.
- Are incurred for animal-to-human organ transplants, artificial
or mechanical organs, procurement or transportation of the organ or tissue,
or the cost of keeping a donor alive.
- Are incurred for marriage, family, or child counseling.
- Are for recreational or vocational therapy or rehabilitation.
- Are incurred for services performed by an immediate family
member.
- Are not specifically provided for in the policy or incurred
while your certificate is not in force.
- Are for any treatment or procedure that either promotes or
prevents conception, or prevents childbirth, such as abortion, sterilization,
treatment of infertility, or artificial insemination.
Benefits will not be paid for services or supplies that are not medically
necessary to the diagnosis or treatment of an illness or injury, as defined
in the policy
General Limitations
- Expenses incurred by a covered person for treatment of tonsils,
adenoids, middle ear disorders, hemorrhoids, hernia, or any disorders of
the reproductive organs, will not be covered during the covered person's
first six months of coverage under the policy. This provision will not
apply if treatment is provided on an "emergency" basis. "Emergency"
means a medical condition manifesting itself by acute signs or symptoms
which could reasonably result in placing a person's life or limb in danger
if medical attention is not provided within 24 hours.
- Covered expenses will not include more than what was determined
to be the reasonable and customary charge for a service or supply.
- Transplants eligible for coverage under the Transplant Expense
Benefit are limited to two transplants in a ten-year period.
- Charges for an assistant surgeon are limited to 20 percent
of the primary surgeon's covered fee.
- Covered expenses for surgical treatment of TMJ will be limited
to $10,000 per covered person.
- All diagnoses or treatments of mental disorders, as defined
in the policy, including substance abuse will be limited to a lifetime
maximum benefit of $3,000. Covered expenses for outpatient diagnosis or
treatment of mental disorders will be further limited to $50 per visit.
As with any other illness or injury, inpatient care which is primarily
for educational or rehabilitative care will not be covered.
- Covered outpatient expenses relating to diagnosis or treatment
of any spine or back disorders will be limited to a maximum of $2,000 per
calendar year. CAT scan and MRI tests are not subject to this limitation.
- Covered expenses will be limited to no more than a 34-day supply
for any one outpatient prescription drug order or refill. Other Plan ProvisionsEffective
Date: For injuries, the effective date will be the later of: (a) the requested
effective date, if any, shown on the application; or (b) the date upon
which the application is actually received by Golden Rule at its Home Office.
The effective date for illnesses will be the same as for injuries
if you are replacing prior coverage within 62 days of application for this
coverage and disclose replacement information on the initial application
for insurance. If replacement information is not disclosed on the initial
application for insurance, the effective date for illnesses will be the
15th day after the effective date for injuries. Illnesses that begin prior
to that 15th day will be treated as a preexisting condition and will not
be covered until the individual has been a covered person for 12 months.
Premium: We may adjust the premium rates from time to time. Premium
rates are set by class, and you will not be singled out for a premium change
regardless of your health. The policy plan, age and sex of covered persons,
type and level of benefits, time the certificate has been in force, and
your place of residence are factors that may be used in setting rate classes.
Premiums will increase the longer you are insured.
Dependents: For purposes of this coverage, eligible dependents
are your lawful spouse and eligible children. Eligible children must be
unmarried, living with and financially dependent on you, and under 19 years
of age, or under 23 years of age if attending an accredited college or
vocational school on a full-time basis.
Termination of a Covered Person:
A covered person's coverage will
terminate on the date that person no longer meets the eligibility requirements,
or if the covered person commits fraud or intentional misrepresentation.
Continued Eligibility Requirements:
A covered person's eligibility
will cease on the earlier of the date a covered person
- Enters the armed forces on an active full-time basis;
- Ceases to be a dependent; or
- Becomes insured under an individual plan providing medical
or hospital, surgical, or medical services or benefits. (This does not
apply to stand-alone cancer-/ICU-/-accident-only policies.)
Renewability: You may renew coverage by paying the premium as
it comes due. We may decline renewal only:
- For failure to pay premium; or
- If we decline to renew all certificates just like yours issued
to everyone in the state where you are then living. Underwriting:
Coverage
will not be issued as a supplement to other health plans that you may have
at the time of application.
Home Health Care: To qualify for benefits, home health care must
be:
- Provided in lieu of medically necessary inpatient care in a
hospital or hospice; and
- Provided through a licensed home health care agency.
Covered expenses for home health aide services will be limited to seven
visits per week and a lifetime maximum of 365 visits. Registered nurse
services will be limited to a lifetime maximum of 1,000 hours. Hospice Care: To
qualify for benefits, a Hospice Care program for a terminally ill covered
person must be licensed by the state in which it operates. Benefits for
inpatient care in a hospice will be limited to 90 days in a covered person's
lifetime. Covered expenses for room and board are limited to the most common
semiprivate room rate of the hospital or nursing home with which the hospice
is associated. Benefits for outpatient care will be limited to $1,500 in
a covered person's lifetime.
Arbitration: The policy contains an arbitration provision to resolve
many claims disputes without litigation. The decision of the arbitrators
will be final and binding unless prohibited by your state. There is also
a provision that provides for resolution of disputes over medical necessity.
Group
-- COB: If, after coverage is issued, a covered person becomes insured under
a group plan, benefits will be determined under the Coordination of Benefits
(COB) clause. COB allows two or more plans to work together so that the
total amount of all benefits will never be more than 100 percent of covered
expenses. COB also takes into account medical coverage under auto insurance
contracts. Medicare -- Carve-Out: Covered persons who reach the age of Medicare
eligibility will be provided an alternative health insurance benefit called
"Carve-out." Basically, "Carve-out" pays the difference
between what Golden Rule benefits normally would pay and what is paid or
payable by Medicare, whether or not the covered person is covered by Medicare.
Complete coverage details are provided in the policy and certificates.
In most cases, coverage will be determined by the master policy issued
in Illinois and subject to Illinois law.
You may see more about or GoldenRule Products at
www.goldenrule.com
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