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HomeMy WebLinkAboutC87-007 Connecticut General Life Insurance PolicyA t Mailing.- - • Har(f4rd, Connecticut 0615E Home Office: Blomn/ield, Connecticut CONNECTICUT GENERAL LIFE INSURANCE COMPANY POLICYHOLDER: EAGLE COUNTY ADDRESS: Eagle, Colorado POLICY NUHBER: 0488282-03 EFFECTIVE DATE: January 1, 1983 ANNIVERSARY DATE: January 1 GROUP MEDICAL EXPENSE INSURANCE POLICY This policy contains the terms under which the Insurance Company agrees to insure certain Employees and pay benefits. The Insurance Company and the Policyholder have agreed to all of the terms of this policy. L C i CONNECTICUT GENERAL LIFE INSURANCE COMPANY CONTENTS I. BENEFITS SECTION Insuring Provisions - Employees and Dependents 11 Limitations, General - Employees and Dependents 12 Meaical benefits Extension 23 Medical Conversion Privilege 26 Medicare Eligibles 15 Payment of Benefits 20 The Schedule 3 II. PREMIUMS Calculation of Premiums 34 Changes in Premium Rates 34 Due Date 34 Grace Period 36 Moatnly Premium Rates 34 Payment of Premiums 34 III. OTHER PROVISIONS Cancellation of Policy 36 Certificate 40 Claims, Forms ana Notice of Claim 40 Co-ordination of Benefits 19 Definitions 9 Effective Date of Insurance 7 Eligibility for Insurance 5 Termination of Insurance 21 This policy includes tae following pages on date of issue: 1C1, 2MD1 V-1, 3CM1, 5C1, SC2, 7C2, 7C49 9C1, 9C2, 9C3 V-30, 9C13, 9C4 V-1, 9C5 V-2, 11CM1 V-10 Spec., 11CM2 V-8 Spec., 11CM3 V -la, 11CM11 V-2, 11CM12 V-1; 11CM4 V-110 11CM10, 11CM5, 12MD1 V-1, 12MD2, 15MD1 V-3, 19MD1, 19MD2, 19;D3 V-1, 19MM V -s, 20MD1, 21MD1 V-1, 21MD2 V -b, 23MD2, 26MD1 V-1, 26MD2, 34C1, 34MD1 V-2 (1), 34MD1 V-10, 3bCl, 38C1, 40C1, 40C2 GM5800 2MD1 Section 2 V-1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY THE SCHEDULE COMPREHENSIVE MEDICAL BENEFITS Maximum Benetit - Unlimited Alcohol Abuse Maximum (Out-ot-Hospital) - $ 500 Mental Illness Maximum (Out-of-Hospit&l) - $ 1,000 Special care Facility Maximum - $ 1,000 Covered Expense Daily Limit tors Bed and Board - Comprehensive Medical Deductible - The Hospital's most common daily rate for a semi -private room $ 100 . CREDIT FOR COMPREHENSIVE MEDICAL DEDUCTIBLE. The Comprehensive Medical Deductible for any person will be reduced to the extent that the Comprehensive {� Medical Deductible for the prior calendar year was deducted from Covered `. Expenses incurred for that person during October, November and December of such prior year. FAMILY DEDUCTIBLE. Atter Comprehensive Medical Deductibles totaling $300 have been applied in a calendar year for either (a) an Employee and his Dependents or (b) an Employee's Dependents, any Comprehensive hedical Deductible will be waived for that family for the rest of that year. Such $300 will be reduced in any calendar year to the extent that Comprehensive Medical Deductibles were applied for that family during October, November and December of such prior year. GM5800 3CM1 Section 3 CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the New Employee Group Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of Eligible Employees within one year after his insurance ceased. INITIAL EMPLOYEE GROUP. The Initial Employee Group is made up of Employees: (1) in the employ of an Employer on the Effective Date of true policy; or (Z) in the employ of an Employer on the date that Employer becomes an Affiliated Employer. NEW EMPLOYEE GROUP, The New Employee Group is made up of Employees not in the Initial Employee Group. WAITING PERIOD Initial Employee Group: 30 days of Active Service New Employee Group: AFFILIATED EMPLOYERS None CLASSES OF ELIGIBLE EMPLOYEES Each Employee GM5800 5C1 30 days of Active Service Section 5 C l> y CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR DEPENDENT INSURANCE Each Employee will become eligible for Dependent Insurance on the latest date beluw: (1) the tate he becomes eligible for Employee Insurance; (2) the date he acquires his first Dependent; (J) the eiiective date of Dependent lnsurance. GK5800 5C2 section 5 C CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE DATE OF EMPLOYEE INSURANCE Each Employee will become insured for Employee Insurance on the date he becomes eligible for it. if an Employee is not in Active Service ou the oute his insurance would otherwise become effective, it will become effective on the duce he returns to Active Service. GM5800 7C2 Sec tion 7 .C, a' S CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE DATE OF DEPENDENT INSURANCE Each Employee will become insured for Dependent Insurance on the date he becomes eligible for it it he is insured for Employee insurance on that date. If he is not insured for Employee Insurance on that date. his Depenaent Insurance will become effective on the date tie becomes insured for Employee Insurance. It a Dependent, other than a child born while the Employee is insured, is a patient in a Hospital on the date his insurance Would otherwise become eiiective, the eifective date of his insurance will be postponed until the day after he is discharged tram the Hospital. Any reference to an insured Dependent means a Dependent Lor w,tom the Employee is insured. GK5800 7C4 Section 7 l� y CONNECTICUT GENERAL LIFE INSURANCE COMPANY C-' DEFINITIONS C EMPLOYER. The term Employer means the Policyholder and all Affiliated Employers snown in the "Eligibility tur Insurance" section. EMPLOYEE. The term Employee means a full time employee of the Employer, but does not include employees who are part time or temporary or who normally work less than 30 hours a week for the Employer. ACTIVE SEkV10E. An Employee will be coneiaered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if he is performing in the usual way all of the regular dutiEs of his work for the Employer on a full time basis on that day, either at one of the Employer's places of business or at some location to whicu the Employer's business requires him to travel. An Employee will be deemed in Active Service on a day which is not one of the Employer's scheduled work days only it he was in Active Service on the preceding scheduled work days. CM5800 9C1 Section 9 CC S CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS (Continued) DEPEbDENT. The term Dependent means: (1) the lawful spouse of the Employee; and (2) any unmarried child who is (a) less than 19 years old; (b) 19 years but less than 23 years old, enrolled in a school as a full time student and primarily supported by the Employee; (c) ly or more years old and primarily supported by the Employee ana incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child's condition and dependence must be submitted to the Insurance Company within 31 days after the date the Child ceases to quality under (a) or (b) above. During the next cwu years the insurance Company may, from time to time, require proof of the continuation of such condition and dependence. After that, the Insurance Company may require proof no more than once a year. The term child means a child born to the Employee and a child legally adopted by the Employee. It also means a stepchild of the Employee living with the Employee. Anyone who is eligible for the insurance as an Employee will not be considered as a Dependent. No one may be considered as a Dependent of sore than one Employee. G 5800 9C2 Section 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY l . DEFINITIONS (Continued) HOSPITAL CONFINEMENT 08 CONFINED IN A HOSPITAL. A person will be considered Confined in a boapital if he is: (1) a registered bed patient in a Hospital upon the recommendation of a Physician; (2) an outpatient in a hospital because of surgery; (3) receiving emergency care in a Hospital for an Injury on his first visit as an outpatient within 48 hours after the Injury is received; or (4) Partially Confined for treatment of: (a) Cental illness; (b) alcohol abuse, or (c) other related illness. To determine benefits payable, two days of being Partially Contiued in a hospital will be equal to one day of being Confined in a Hospital. The term Partially Confined means continually treated =or at least 3 hours but not more than 12 hours in any 24 hours period. HOSPITAL. The term Hospital means: (1) an institution licensed as a hospital, which: (a) maintains, on the '.rte premises, all facilities necessary for medical and surgical treatment or has a written agreement with another institution licensed to pro- vide surgical treatment; (b) provides such treatment on an inpatient basis, Lor compensation, under the supervision of Physicians; and (c) provides 24-hour service by Registered Graduate nurses; or (2) un institution which qualifies as a hospital, a psychiatric hospital or a tuberculosis hospital, and a provider of services under Medi- care, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals; or (s) an institution which: (a) specializes in treatment of mental ill- ness, alcohol abuse or other related illness; (b) provides residen- tial treatment programs; and (c) is licensed in accordance with the laws of the appropriate legally authorized agency. The term Hospital will not include an institution which is primarily a place for rest, a place for the aged, a place for treatment of drug abuse, or a nursing home. GM5800 9C3 Section V-30 9 CO' r CONNECTICUT GENERAL LIFE INSURANCE COMPANY -- Ic DEF1NiTIONS (Continued) BED AND BOARD. The term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general serviceb ana activities needed for the care of registered bed patients. NECESSARY SERVICES AND SUPPLIES. The term Necessary Services and Supplies includes: (1) -any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during Hospital Confinement; (2) any charges, by whomever made, for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided; and (3) any charges, by whomever made, for the administration of aneataetics during Hospital Confinement. Tae term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees. GH5800 9C13 Section 9 f� L� S CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS (Continuea) PHYSICIAN. The term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where tue policy is issuea if he is: (1) operating within the scope of his license; and (2) performing a service for which oenerits ere provided unser this plan when performed by a Physician. NURSE. The term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation "R.N."I "L.P.N.", or eL.V.Ne"o PSYCHOLOGIST. The term Psychologist means a person who is licensea or certified as a clinical psychologist. Where no licensure or certification exists, the term Psychologist means a person who is considered qualified as a clinical psychologist by a recognised psychological association. It will also include another licensed counseling practitioner whose services are requireu to be covered by law in the locality where the policy is issued if he is: (1) operating within the scope of his license; and (2) performing a service for which benefits are provided under this plan when performed by a Psychologist. EEPENSES INCURRED. An expense is incurred when the service or the supply for which it is incurred is provided. INJURY. The term Injury scans an accidental bodily injury. SICKNESS. The term Sickness means a physical or mental illness. It also includes pregnancy. GX5800 9C4 Section V-1 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS (Continued) SPECIAL CAbE FACILITY. The term Special Care Facility means a licensed institution (other than a Hospital, as aetined) which: (1) specialises in physical rehabilitation; (2) specializes in the diagnosis and treatment of meatal illness; or (3) qualifies as a skilled nursing facility and a. provider of services under Medicare; but only if that institution: (a) maintains on the premises all facilities necessary for medical treatment; (b) provides such treatment, for compensation, under the supervision of Physicians; and (c) provides Nurses' services. MEDICAID. The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended. MEDICARE. The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. REASONABLE AND CUSTOMARY CHARGE. A charge Will be considered Reasonable and Customary if: (1) it is the normal charge made by the provider for a similar service or supply; and (2) it does not exceea the normal charge made by most providers of such service or supply in the locality where the service or supply is received. To determine if a charge is Reasonable and Customary, the nature and severity of the Injury or Sickness being treatea will be considered. GMS800 9C5 Section V-2 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURIhG PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS If an Employee or a Dependent, while insured for these benefits, incurs Covered Expenses, the Insurance Company will pay an amount determined as follows, subject to the Maximum Benefit Provision and to the Mental Illness, Alcohol and Drug Abuse and Special Care Facility Maximum&: 100% of the Covered Expenses first incurred for that Employee or Depen— dent due to an Injury during the 90 day period following the date of the accident, but not more than $500; with respect to all other Covered Expenses, 5U% of the Covered Expenses incurred for or in connection with mental illness, alcohol or drug abuse wnile not Confined in a Hospital; 80% of the Covered Expenses incurred for or in connection with mental illness, alcohol or drug abuse while Confined in a Hospital; and 80% of the remaining Covered Expenses incurred; provided that the applicable Comprehensive Medical Deductible shown in Tne Schedule will first be deducted from such other Covered Expenses incurred for that person in each calendar year. GM5800 11CM1 Section V-10 11 Spec. CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Depeudents COMPREHENSIVE MEDICAL BENEFITS (Continued) FULL PAYMENT AREA. After $2,500 of Covered Expenses have been incurrea in a calendar year and after any applicable deductible amount is satisfied, benefits for that person for the rest of that calendar year will become payable at the rate of 100%. However, the rate of payment for benefits payable for or in connection with mental illness, alcohol or drug abuse will not change. MAXIMUM BENEFIT PROVISION. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or Dependent in his lifetime will not exceed the Maximum Benefit shown in The Schedule. However, once a person uses any portion of his Maximum Benefit, on each January 1st the Insurance Company will reinstate the used amount up to $1,000 to be applied to Covered Expenses incurred atter the date of reinstatement. MENTAL ILLNESS MAXIMUM. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or Dependent in a caleuaar r year for or in connection with mental illness while he is not Contined in a Hospital will not exceed the Mental illness Maximum shown in The Schedule. ALCOHOL AND DRUG ABUSE MAXIMUM. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or a Dependent in a calendar year for or in connection with alcohol and drug abuse while he is not Continea in a Hospital will not exceed the Alcohol .nd Drug Abuse Maximum shown in The Schedule. SPECIAL CARE FACILITY MAXIMUM. The total amount of Comprehensive Medical Benetits payable for all expenses incurred for an Employee or a Dependent in a calendar year for charges made by a Special Care Facility will not exceed the Special Care Facility Maximum shown in The Schedule. GM5800 11CM2 Section V -g 11 Space CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS (Continued) COVERED EXPENSES. The term Covered Expenses means the expenses incurred by or on behalf of an Employee or a Dependent for the Class A and Class B Charges listed below, if they are incurred after such person becomes insured for these benefits. Expenses incurred for sucti charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of an Injury or a Sickness. CLASS A CHARGES are: (1) charges made by a Hospital, on its own behalt, for Bed and Board and other Necessary Services and Supplies; except that for any day of hospital Confinement in a private room, Covered Expenses Will not include that portion of charges for Bed and Board Which is more than the Hospital's most common daily rate for a semi -private room. (2) charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provideo. CLASS B CHARGES are any of the charges listed below which do not qualify as Class A Charges: (1) charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient. (2) charges made by a facility licensed to furnish mental health services, on its own behalf, for care and treatment of mental illnessprovided on an outpatient basis. (3) charges made by a facility licensed to furnish treatment of alcohol abuse, on its own behalf, for care and treatment provided on an outpatient basis. (4) charges made by a Special Care Facility, on its own behalf, for medical care and treatment; except that Covered Expenses will not include that portion of such charges for any one day which is more than the Special Care Facility Daily Limit shown in The Schedule. (5) charges made by a Physician or a Psychologist for professional services. (6) charges made by a Nurse, other than a member of the Employee's or Dependent's family, for professional nursing service. GM5800 11CM3 Section V-13 11 d< S CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS (Continued) COVERED EXPENSES (Continued) (7) charges made for anesthetics ano their administration; diagnostic X—ray and laboratory examinations; X—ray, radium, and radioactive isotope treatment; chemotl►erapy; blood transfusious and blood not donated or replaced; oxygen and other gases and their administration; rental or, at the Insurance Company's option, purchase of durable equipment which is solely used for a medical purpose; physical therapy by a licensed phys— ical therapist; prosthetic appliances; dressings; ana arugs and medicines lawfully dispensed only upon the written prescription of a Physician, excluding vitamins. GM5800 11CM11 Section V-2 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL. BENEFITS SECOND OPINION SURGICAL BEWITS. If, as a result of an Injury or a Sickness, an Employee or a Dependent, while insured for these benefits and prior to the pertormance of an Elective Surgical Procedure recommended by a surgeon, asks for an opinion trom auother Physician who is qualified to diagnose and treat that Injury or Sickness, the Insurance Company will pay 100% of the Covered Expenses incurreo for the fee ctargeu for that opinion. If the Employee or Dependent incurs Covered Expenses for diagnostic laboratory or X-ray examin- ations askea for by the Physician who gives that opinion, the Insurance Company will pay 100% of the Covered Expenses so incurred. Payment will be made whether or not the Surgical Procedure is performed. Payment will be subject to all terms of the pglicy except as otherwise provided in this section. The benefits described above are not subject to the Comprehensive Medical Deductible. LIMITATIONS. No payment will be mane for expenses incurred in connection with: (1) cosmetic or dental Surgical Procedures not covered under the policy; (2) minor Surgical Procedures that are routinely performed in a Physician's oftice, such as incision and drainage for abscess or excision of benign lesions; (3) an opinion obtaiaeo more than b months after a surgeon hab first recommended the Elective Surgical Procedure; (4) an opinion rendered by the Physician who performs the Surgical Procedure. Other Limitations are shown in the "General Limitations" section. Eo payment will be made under any other section of the policy for expenses incurred to the extent that benefits are payable for those expenses under this ,section. BLECTIVE SURGICAL PROCEDURE. The term Elective Surgical Procedure means a Surgical Procedure which is not considered emergency in nature and which may be avoided without undue risk to the individual. GM5800 I1CM12 Section V-1 11 d CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BhhEFITS (Continued) EXPENSES NOT COVERED. Covered Expenses will not include, and no payment will be made tor, expeuses incurred (1) for or in connection with cosmetic surgery unless (a) the Employee or Dependent receives an injury, while insured for these benefits, which results in bodily damage requiring the surgery; or (b) it qualifies as reconstructive surgery performed on the Employee or Dependent following surgery, and both the surgery ano the reconstructive surgery are medically necessary; or (c) it is performed on a Dependent who is less than 16 years old. (1) tor eyeglasses, hearing aids or examinations Lor prescription or fitting thereof. (3) for or in connection with treatment of the teeth or periodontium unless such expenses are incurred for: (a) charges made for or in connection with dental work due to an Injury to sound natural teeth sustained while ;,. the Employee or Dependent is insured for these benetits; or (b) charges made by a Hospital for Bed and Board or Nece.sary Services and Supplies. (4) for which benefits are not payable according to the "General Limitations" section. i� 05800 lIC244 Section V-11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS (Continued) EXPENSES NOT COVERED (Continued) (b) Lor or in connection with an Injur or Sickness which is a Pre-existing Condition after benefits equal to 1150 have become payable, unless those expenses are incurred after the earlier oi: (a) a 90 -day period, which ends while the Employee or Dependent is insured for these benetits, during which he receives no treatment, incurs no expenses and receives no diagnosis from a Physician in connection with that Injury or Sickness; or (b) a one year period curing which such Employee or Dependent is continuously insured for these benefits. PRE-EXISTING CONDITION. A Pre-existing Condition is an Injury or a Sickness for which an Employee or a Dependent receives treatment, incurs expenses or receives a diagnobis from a Physician during the 90 days prior to the date such Employee or Dependent becomes insured for these benefits. The term Preexisting Conaitioa will also include any condition wuicn is related to any such Injury or Sickness. GM5800 11CH10 Section 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITb (Continued) COMMON ACCIDENT. If an Employee ana one or more of his insured Dependents or it two or more of nis insured Dependents are -injured in the same accident and incur Covered Expenses for those injuries in the calendar year in which the accident occurs, not more than one Compreneusive Medical Deductible will oe deducted from the total Covered Expenses incurred for those persons during the rest of that calendar year. MULTIPLE BIRTH. Not more than one Comprehensive Medical Deductible will be deducted from the total Covered Expenses incurred in a calendar year for two or more Dependents born in a multiple birtn if those Covered Expenses are incurred in the same calendar year in which they are born and are due to: (1) premature birth; (2) abnormal congenital condition; or (3) Injury which is received or Sickness which starts not more than 30 days after their birth. GM5800 11015 Section 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY 's GENEkAL LIMITATIONS No payment will be made for expenses incurred; (1) for or in connection wits an injury arising out of, or in the course of, any employment for wage or profit; (2) for or in connection with a Sickness which is covered under any workers' compensation or similar law; (3) fur charges made by a Hospital owned or run by the United States Government; (4) to the extent that payment is unlawful where the Employee or Dependent resides when the expenses are incurred; (5) for charges which the Employee or Dependent is not legally required to pay; (b) for charges which would not have been made i1 the Employee or Dependent had no insurance; (7) to the extent that they are more than Reasonable and Customary Charges; (8) for charges for unnecessary care, treatment or surgery; (9) for or in connection with custodial care, education or trainiug; (10) to the extent that the Employee or Dependent is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; (11) for experimental drugs or substances not approved by the Food and Drug Administration, or for drugs labeled; "Caution - limited by Federal law to investigational use"; (12) for or in connection with experimental procedures or treatment methods not approved by the American Medical Association or the appropriate medical specialty society. CM5800 12MD1 Section V-1 12 IR C4, CONNECTICUT GENERAL LIFE INSURANCE COMPANY GENERAL LIMITATIONS (Continued) No payment will be made for expenses incurred by an Employee or a Dependent to the extent that benetits are paid or payable for those expenses under the sandatury part of any auto insurance policy written to comply with: (a) a "no-fault" insurance law; or (b) an uninsured motorist insurance law. The Insurance Company Will take into account any adjustment option chosen under such part by the Employee or Dependent. Gtl5800 12MD2 section 12 t� S CONNECTICUT GENERAL LIFE INSURANCE COMPANY MEDICARE ELIGIBLES The Medical Expense Insurance for an Employee or a Dependent who is age 6.5 or older and eligible for Medicare will be modified as follows: (1) If expenses are incurred for which benefits are payable under both this plan and Part A of Medicare, benefits will be payable under this plan only for those expenses so incurred which exceed the amount payable under Part A of Medicare. (Y) the amount payable under this plan for expenses incurred for which benefits are payable under both this plan and Part B of Medicare will be reduced by the amount payable for those expenses under Part B of Medicare. (3) The Comprehensive Medical Deductible will apply only to Covered Expenses incurred for prescription drugs and charges made by a Nurse. For an Employee or a Dependent who is less than age 65 and eligible for Medicare, the amount payable under this plan Will be reduced so that the total amount payable by the Insurance Company and Medicare will be no more than lU0% of the expenses incurred. The Insurance Company will assume the amount payable under: (1) Part A of Medicare for a person who is eligible for that Part with out premium payment, but nas not applied, to be the amount ue would receive if he had applied. (1) Part B of Medicare for a person who is entitled to be enrolled ir. that Part, but is not, to be the amount he would receive if he were enrolled. A person is'considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him. G 5800 15MD1 section V-3 15 C, CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO—ORDINATION OF BENEFITS If a person covered under this policy (called "this Plan") is also covered under one or more other Plans, the benefits payable for him from this Plan will be co—ordinated with the benefits payable for him from all other Plans. Co—ordination of Benetits will be used to determine the benefits payable for a person for any Claim Determination Period if, for the Allowable Expenses incurred in that Period, the sum of (a) and (b) below would exceed those Allowable Expenses: (a) the benefits that would be payable from this Plan without co—ordination; and (b) the benefits that would be payable from all other Plans without Co—ordination of Benefits provisions in those Plans. The Denetits that would be payable from this Plan for Allowable Expenses incurred in any Claim Determination Period without Co—ordination of Benefits will be reauced to the extrnt required so that the sum of: (a) those reduced benefits; and (b) all the benefits payable for those Allowable Expeuses from all other Plans; will not exceed the total of those Allowable Expenses. Benefits payable from all other Plans include the benefits that would have been payable had proper claim been made for them. CH5800 19MD1 Section 19 ec -✓ Q/ CONNECTICUT GENERAL LIFE INSURANCE COMPANY "S CO-ORDINATION OF BENEFITS (Continued) However, the benefits of another Plan will be ignored when the benefits of this Plan are determined if: (a) the BeneLit Determination Rules would require this Plan to determine its benefits before that Plan; and (b) the other Plan has a provision that co-ordinates its benefits with those of this Plan anu would, based on its rules, determine its benefits after this Plan. Wtien Co-ordination of Benefits reduces the total amount otherwise payable in a Claim Determination Period for a person covered under this Plan, each benefit that would be payable in the absence of Co-ordination of Benefits will be reduced in proportion. The reduced amount will be charges against any applicable benefit limit of this Plan. The Insurance Company reserves the right to release to or obtain from any other insurance company or other organization or person any information which, in its opinion, it needs Lor the purpose of Co-ordination of Benefits. When payments which should have been made under this Plan based on the terms of this section have been made under any other Plans, the Insurance Company will have the right to pay to any organizations asking these payments the amount it IS determines to be warranted. Amounts paid in this manner will be considered to be benefits paid under this Plan. The Insurance Company will be released from all liability under this Plan to the extent of these payments. When an overpayment has been made by the Insurance Company, at any time, it will have the rigat to recover that payment, to the extent of the excess, from the person to whom it was made or any other insurance company or organization, as it may determine. CK5800 19MD2 Section 19 CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDINATION OF BENEFITS (Continued) BENEFIT DETERMINATION RULES. The rules below establish the order in which beneiits will be determined: (1) Tne benefits of a Plan which covers the person for whom claim is made other than as a dependent will be determined before a Plan which covers that person as a dependent. (2) The beneiits of a Plan which covers the person for whom claim is made as a dependent of a male will be determined before a Plan which covers that person as a dependent of a Lemale; except that, in the case of a dependent child of divorced or separated parents, the following rules will apply. If there is a court decree which establishes financial responsibility for medical, dental or other health care of the child, the benefits of the Plan which covers the child as a uependent of the parent so responsible will be determined before any other plan; otherwisc: (a) The benefits uL a Plan which covers the child as a dependent of the parent with custody will be determined before a Plan which covers the child as a dependent of a stepparent or a parent without custoay. (b) The benefits of a Plan which covers the child as a dependent of a stepparent will be determined before a plan which covers the child as a dependent of the parent without custody. (3) When the above rules do not establish the order, the benefits of a Plan which has covered the person for whom claim is made for the longer period of time will be determined before a Plan which has covered the person for the shorter period of time. GM58000 19MD3 Section V-1 19 C CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDIKAT10N OF BENEFITS (Continued) DEFINITIONS PLAN. Plan means any: (1) group, blanket or group franchise insurance coverage; (2) service plan contracts, group or individual practice or other prepayment plans; or (3) coverage under any labor-management trusteed plans, union welfare plan&, employer organizations plans, or employee benefit organization plans; which provides medical, dental or vision care beuetits or services. It does not include coverage under individual policies or contracts. Each Plan or part ut a Plan which has the right to co-ordinate benefits will be considered a separate Plan. ALLOWABLE EXPENSE. Allowable Expense means any necessary, reasonable anu customary item or expense at least a part of which is covered by any one of the Plans that covers the person for whom claim is made. When the benefita from a Plan are in the corm of services, not cash payments, the reasonable case► value of each service is both an Allowable Expense and a benefit paid. CLAIM DETERMINATION PERIOD. Claim Determination Period means a calendar year or that part of a calendar year in which the person has been covered under this Plan. GH5800 19MD4 section 19 V-3 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PAYMENT OF BEWITS TO WHOM PAYABLE. All medical benefits are payable to the Employee. However, at the option of the Insurance Company ano with the consent of the Policyholder, all or any part of the medical benefits may be paid directly to the person or institution on wr►ose charge claim is based. It any person to whom benefits are payable is a minor or, in the opinion of the Insurance Company, is not able to give valid receipt for any payment due him, such payment will be made to his legal guardian. However, if no request for payment nas been made by his legal guardian, the Insurance Company may, at its option, make payment to the person or institution appearing to have assumed his custody ano support. It an Employee dies while medical benefits remain unpaid, the Insurance Company may choose to make direct payment to any of the following living relatives of the Employee: spouse, mother, father, child or children, brothers or sisters; or to the executors or administrators of the Employee's estate. Payment iu the manner described above will release the Insurance Company from all liability to the extent of any payment made. TIME OF PAYMENT. Medical benefits will be paid by the Insurance Company when it receives due proof of loss. GH5800 2OMD1 Section 20 CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF INSURANCE For Employees The insurance on an Employee will cease on the earliest date below: (1) the date the Employee ceases to be in a Class of Eligible Employees or ceases to qualify as an Employee; (2) the last day for which the Employee has made any required cuntribution for the insurance; (.3) the data the policy is cancelled; (4) the date the Employee's Active Service encs, except as art forth below. TEMPORARY LAYOFF OR LEAVE OF ABSENCE. If an Employee's Active Service ends due to temporary layoff or leave of absence, the insurance will be continued until the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. However, the insurance will not be continued for more than 60 days past the date the Employee's Active Service ends. INJURY OR SICKNESS. If an Employee's Active Service ends due to an Injury or a Sickness, the insurance will be continued while the Employee remains totally and continuously disablea as a result of the Injury or Sickness until the date the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. RETiR$MENT. If an Employee's Active Service ends because he retires, the insurance will be continued until the date on which the Policyholuer: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. Any continuation of insurance must be based on a plan which precludes individual selection. GH58OU 21HD1 Section V-1 21 C - L� 1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF 1NSURAKE (Continued) For Dependents An Employee's insurance for all of his Dependents will cease on the earliest date balow: (1) the date the Employee's insurance for himself ceases, except in the case of death; (2) the date the Employee ceases to be in a class of Employees eligible for Dependent Insurance; (3) the last day for which the Employee has made any required contribution for Dependent Insurance; (4) the date Dependent Insurance is cancelled. An Employee's insurance for any one of his Dependents will cease on the date the Dependent no longer qualities as a Dependunt. DEPENDENT MEDICAL INSURANCE AFTER EMPLOYEE'S DEATH. If an Employee is insured for Medical Expense Insurance when he dies, any of itis Dependents who are then insured for Medical Expense Insurance, except a Dependent who is eligible for Medicare, will remain so insured without further payment of premiums for them. However, the insurance on any of those Dependents will cease on the earliest date below: (1) the last day of the 24th month atter the Employee's death; (2) the date of remarriage of a surviving spouse, if any; (3) the date that Dependent qualifies for Medicare; (4) the date that Dependent ceases to qualify as a Dependent for a reason other than lack of primary support by the Employee. The Dependent benefits payable after the Employee dies will be those in effect for that Employee's Dependents on the day prior to his death. GM5800 21MD2 Section V-6 21 I'M CONNECTICUT GENERAL LIFE INSURANCE COMPANY MEDICAL BENEFITS EXTENSION Any expense incurred within one year after a person's Comprehensive Medical Benefits cease will oe deemed to be incurred while he is insured it such expense is for an Injury or a Sickness which causes him to be Totally Disabled from the day his insurance ceases until that expense is incurred. The terms of this Medical Benefits Extension will not apply to (a) a child born as a result of a pregnancy which exists wnen a person's benerits cease; or (b) any person when he becomes insured under another group policy for medical beneiits. TOTALLY DISABLED. An Employee will be considered Totally Disabled it, because of an Injury or a Sickness; (1) he is unable to perform the basic duties of his occupation; and (2) he is not performing any other work or engaging in any other occupation for wage or profit. A Dependent will be considered Totally Disabled if, because of an Injury or a Sickness: (1) tie is utiable to engage in the normal activities oL a person of the same . age, sex and ability; or G) in the case of a Dependent who normally works Lor wage cr profit, he is not performing such work. GH5800 23MD2 Section 23 n, C 41) CONNECTICUT GENERAL LIFE INSURANCE COMPANY r MEDICAL CONVERSION PRIVILEGE For Employees and Dependents When an Employee's or a Dependent's Medical Expense Insurance ceases, he may be eligible to be insured under an individual policy of medical care benefits (called the Converted Policy). A Converted Policy will be issued by the Insurance Company only to a person who is Entitled to Convert, and only if he applies in writing and pays the first premium for the Converted Policy to the Insurance Company within 31 days after the date his insurance ceases. Evidence of good nealth is not needed. EMPLOYEES ENTITLED TO CONVERT. An Employee is Entitled To Convert hedical Expense Insurance for himself and all of his Dependents who were insured when his insurance ceased, except a Dependent who is eligible for Medicare or would be Overiusured, but only if: (1) The Employee hes beeu insured for at least three consecutive months under this policy or under this and a prior policy issued to the Policyholder. (2) The Employee's insurance ceased because (a) he was no longer in Active Service; (b) he was no longer eligible for Medical Expense Insurance; or (c) the policy cancelled. (3) The Employee is not eligible for Medicare. C(4) The Employee would not be Overinsured. A retired Employee may apply for a Converted Policy within 31 days atter his retirement date in place or any continuation of his insurance that may be available under this plan when he retires, if he is otherwise Entitled to Convert. DEPENDENTS ENTITLED TO CONVERT. The following Dependents are also Entitled to Converts (1) a child whose insurance under this plan ceases because he no longer qualifies as a Dependent or because of the Employee's death; (2) a spouse whose insurance under this plan ceases due to divorce, annulment of marriage or the Employee's death; (3) the Dependents of an Employee, if the Employee is not Entitled to Convert solely because he is eligible for Medicare; but only if that Dependent: (a) was insured when the Employee's insurauce ceased; (b) is not eligible for Medicare; and (c) would not be Overinsured. GK5800 26MD1 Section V-1 26 CONNECTICUT GEN RAL LIFE INSURANCE COMPANY MEDICAL CONVERSION PRIVILEGE (Continued) For Employees and Dependents OVERINSURED. A person will be considered Overinsured if either (1) or (2) occurs. (1) His insurance under tnis plan is replaced by similar group coverage within 31 days. (2) The benefits under the Converted Policy, combined with Similar Benefits, result in an excess of insurance based on the lasurance Company's underwriting standards for inuividual policies. Similar Benefice are: (a) those for which the person is covered by another hospital, surgical or medical expense insurance policy or a hospital or medical service subscriber contract, or a medical practice or other prepayment plan or by any other plan or program; or (o) those for whict; the person is eligible, whether or not covered, under any plan of group coverage on an insured or uninsured basis; or (c) those available for the person by or through any state, provincial or federal law. CONVERTED POLICY. The Converted Policy will be oue of the Insurance Company's current offerings at the time the first premium is received based on its rules for Converted Policies. It will comply with the laws of the jurisdiction where the group medical policy is issued. However, if the applicant for the Converted Policy resides elsewhere, the Converted Policy will be on a form which meets the conversion requirements of the jurisdiction where he resides. The Converted Policy need not provide major medical coverage unless it is required by the laws of the jurisdiction in which the Converted Policy is issued. The Converted Policy will be issued to the Employee if he is Entitled to Convert, insuring him and those Dependents for whom he may convert. If the Employee is not Entitled to Convert and his spouse and children are, it will be issued to the spouse, covering all such Dependents. Otherwise, a Converted Policy will be issued to each Dependent who is Entitled to Convert. The Converted Policy will take effect on the day after the person's insurance under this plan ceases. The premium on its ettective date will be based on: (a) class of risk and age; and (b) benefits. The Converted Policy may not exclude any pre-existing condition not excluded by this plan. During the first 12 months the Converted Policy is in affect, the amount payable under it will be reduced to that the total amount payaole under the Converted Policy and the Medical Benefits Extension of this plan will not be more than the amount that would have been payable under this plan if the person's insurance had not ceased. After that, the amount payable under the Converted Policy will be reduced by any amount still payable under the Medical Benefits Extension of this plan. i The Insurance Company or the Policyholder will give the Employee, on request, further details of the Converted Policy. 6MM8OU 26MD2 Section 26 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS PREMIUM PAYMENT. The first premium will be due on the Effective Date. After that, premium will be due monthly uuless the Policyholder and the Insurance Company agree on some other method of premium payment. The Policyholder and tae Insurance Company may agree to chan6e the method of premium payment from time to time. Premiums are payable at the Home Office of the Insurance Company or to an authorised agent of the Insurance Company. PREMIUM DUE DATE. After the Effective Date, the Premium Due Date will be the day of the month with the same number as the Anniversary Date or the last day of a month in which there is no day with the same number as the Anniversary Date* it the Policyholder and the Insurance Company agree that premiums will be paid on a quarterly, semiannual or annual basis, the Premium Due Date will be at the appropriate regular interval, quarterly, semiannually or annually. MONTHLY STATEMENT DATE. It premiums are to be paid monthly, the Monthly Statement Date will be the same as the Premium Due Date. If premiums are to be paid on a quarterly, semiannual or annual basis, the Monthly Statement Date will be tae say in each month with the same number as the Premium Due Date. MONTHLY PREMIUM STATEMENT. It premiums are due monthly, a Monthly Premium Statement will be prepared as of the Premium Due Date. This Monthly Premium Statement will show the premium due. If premiums are due quarterly, semiannually or annually, a Monthly Premium Statement will be preparers, as of the Monthly Statement Date for the time from the. Monthly Statement Date to the next Premium Due Date. This Monthly Statement will railect any pro rata premium charges and credits due to changes in the number of insured persons and changes in insurance amounts that took place in the preceding month. SIMPLIFIED ACCOUNTING. To simplify the accounting process, premium adjustments will be made on the Monthly Statement Date that is the same as or next follows the date that (1), (2) or (3) below take' place. (1) A person becomes insured. (2) The amount of insurance on a person changes, but not due to a revision of The Schedule. (3) A person ceases to be insured. GM5800 34C1 Section 34 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) MONTHLY PREMIUM RATE. The monthly premium rate per Employee is as follows: For persons age 65 or older who are eligible for Medicare For Employee Insurance For Dependent Insurance $71.38 For all other persons $56.24 . $94.60 CALCULATION OF PREMIUMS. The montnly premium will be calculated as follows: (1) Multiply the number of Employees insured on the Premium Due Date in each rate class shown in the "Monthly Premium Rate" section oy the premium rate in effect on that date for that class. (2) Aad the results. If premiums are to be paid other than monthly, the method of calculation is the same. However, the rate for each class is first changed to a quarterly, semiannual or annual rate by multiplying it by 2.9852, 5.9557 or 11.827 respectively. All results are taken to the nearer cent. If the Policyholder and the Insurance Company agree to a change in tee metuod of premium payment or to a change in the Anniversary Date, a pro rata adjustment will be made in the premium due. GM5800 34MD1 Section Y-2 34 (1) CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) CHANGES IN PREMIUM RATES. Any premium rate may be changed by the Insurance Company from time to time with at least 31 days advance written notice. No change in rates will be made until 12 months after the Effective Date. An increase in rates will not be made more often tnau once in a 12 month period. However, the Insurance Company may change rates immediately if, in its opinion, its liability is altered by any change in state or federal lav or by a revision in the insurance under the policy. Any such change in rates will tare effect on the effective date of the change in law or chaude in tine insurance. If an increase in rates takes place on a date that is not a Premium Due Date, a pro rata premium will be due on the date of the increase. The pro rata premium will apply for the increase from the date of the increase to the next Premium Due Date. if a decrease in rates takes place on a date that is not a Premium Due Date, a pro rata credit will be granted. The pro rata credit will apply for the decrease from the date of the decrease to the next Premium Due Date. As of any Anniversary Date after the policy has been in force for 12 months, the Insurance Company may grant a credit in such amount as it may determine, based on experience. The experience under this policy may be combined with the experience under other group insurance policies issued by the Insurance Comp"Ly to the Policyholder. The experience for the insurance unuer this policy for persous who are age 6� or older and eligible for Medicare may be combined with the experience under other policies issued by the Insurance Company providing similar insurance for such persons. EAperience for Pooled Coverage under this policy may be combined with the experience for coverage which is deemed pooled under other group insurance policies providing similar insurance issued by the Insurance Company. POOLED COVERAGE. Pooled Coverage means any benefits payable in a calendar year for a person that are payable for him: 1. in that year and the next one; and 2. after benefits totaling $30,000 have already been paid in that year for him. CM5800 34MD1 Section V-10 34 N CONNECTICUT GENERAL LIFE INSURANCE COMPANY CANCELLAZION OF POLICY The Policyholder slay cancel the policy as of any Premium Due Date by giving written notice to the Insurance Company before that nate. The Insurance Company spay cancel the policy as of any Premium Due Date if the number or insurea Employees is less than �15 or less than 7A of those eligible. Dependent Insurance may be cancelled as of any Premium Due Date if the number of Employees insurea for their Dependent& in less than 75% of those eligible. If a premium is not paid when due, the policy will automatically be cancelled as of the Premium Due Date, except as act forth below. GRACE PERIOD. It, before a Premium Due Date, the Policyholder has not given written notice to the Insurance Company that the policy is to be cancelled, a Grace Period of 31 days will be granted for the payment of each premium after the initial premium. the policy will stay in effect during that time. If auy premium is not paid by the end of the Grace Period, the policy will automatically be cancelled at the end of the Brace Period; except that, if the Policyholder has given written notice in advance of an earlier date of cancellation, the policy will be cancelled ab of the earlier date. The Policyholder will be liaole to the Insurance Company for any unpaid premium for the time the policy Was in force.. GH5e00 3601 section 3b c CONNECTICUT GENERAL LIFE INSURANCE COMPANY MISCELLANEOUS PROVISIONS EXECUTION OF POLICY. The policy is executed at the Home Ottice of the Insurance Company. The Post Office &duress of the Insurance Company is Hartford. Connecticut. CONSIDERATION. The policy is issued to the Pulicyholder in consideratiou of the application and payment of premiums. INSURANCE LATA. The Policyholder will give the Insurance Compauy all or the data that it needs to calculate the premium and all other data that it may reasonutly require;. Failure of clie Policyholder to give this data will nut void or continue an Employee's insurance. The Insurance Company has the right to examine the Policyholder's records relative to these benefits at any reasonable time While the policy is in effect. It also has this rignt until all rignts and obligations under the policy are finally uetermined. MALE PRONOUN. The sale pronoun as used herein will be deemeu to incluae the female. CM5800 38C1 Section 38 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PROVISIONS ZNTIRE CONTRACT. The entire contract will be wade up of the policy, toe application of the Policyholder, a copy of which is attached to the policy, and the applications, if any, :,t the Employees. POLICY CHANGES. Changes may be made in the policy only by amendment signed by the Policyholder and by the Insurmnce Company acting through its President, Vice President, Secretary, or Assistant Secretary. No agent may change or waive any terms of the policy. STAILKENTS NOT WARRANTIES. All statements made by the Policynolder or by an insured Employee will, in the absence of fraud, be deemed representations and not warranties. No statement made oy the Policyholder or by the Employee to obtain insurance will be used to avoid or reduce the insurance unless it is made iu writing and is signed by the Policyholder or the Employee and a copy is sent to the Policyholder, the Employee or his Beneficiary. NOTICE OF CLAIM. Written notice of claim must be given to the Insurance Company within 30 days after the occurrence or start of the loss on which claim is based. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written notice was given as soon as was reasonably possible. CLAIM FORMS. When the Insurance Company receives the notice or claim, it will give to the claimant, or to the Policyholder for the claimant, the claim forma it uses for filing proof of loss. If the claimant does not get these claim forms within 15 days after the Insurance Company receives notice of claim, he will be cousidered to have met the prooi of loss requireme„ts if he submits written proof of loss within 90 days after the date of loss. This proof must describe the occurrence, character and extent of the loss for which claim is made. PROOF OF LOSS. Writteu proof of loss must be given to the Insurance Company within 90 days after the date of the loss for which claim is made. If written proof of loss is not given in that time, the claim will not be invalidated nor reduced if it is shown that written proof of loss was given as soon as was reasonably possible. PHYSICAL EXAMINATION, The Insurance Company, at its own expenme, will have the right to examine any person for whom claim is pending as often as it may reasonably require. M5800 40C1 Section 40 t'G ;--,j CONNECTICUT GENERAL LIFE INSURANCE COMPANY PROVISIONS (Continued) LEGAL ACTIONS. No action at law or in equity will be brought to recover or, the policy until at least 60 days after proof of loss has been filed with the Insurance Company. No action will be brought at all unless brought witnin 3 years atter the time within which proof of loss is required Ly the policy. TIME LIMITATIONS. If any time limit set forth in the policy for giving notice of claim or proof of loss, or for bringing any action at law or in equity is less than that permitted by the law of the state in which the Employee lives when the policy is issueu, then tae time limit provided in the policy is extended to a6ree with the minimum permitted by the law of that state. PHYSIC LAN/PATIENT RELATIONSHIP. The Employee will have the right to choose any physician who is practicing legally. The Insurance Company will in no way disturb the physician/patient relationsuip. CERTIFICATES. The Insurance Company will issue to the Policyholder for delivery to each insured Employee an individual certificate. The Policyholder will be responsible for distributing the certificates to its Employees. The certificate will show the benefits provided under the policy. It will set forth any changes in benefits due to age and to whom benefits will be paid. Nothing in the certificate will change or void the terms of the policy. GK5800 40C2 section 40 tc Mailing-17:esa: Harlford,Connecticut 06152 Home Office: Bloo»&ld, Connecticut CONNECTICUT GENERAL LIFE INSURANCE COMPANY POLICYHOLDER: EAGLE COUNTY ADDRESS: Eagle, Colorado POLICY NUMBER: 0488282-04 EFFECTIVE DATE: January 1, 1983 ANNIVERSARY DATE: January 1 GROUP DENTAL EXPENSE INSURANCE POLICY This policy contains the terms under which the insurance Company agrees to insure certain Employees and pay benefits. N CCS CONNECTICUT GENERAL LIFE INSURANCE COMPANY CONTENTS I. BENEFITS SECTION Dental Benefits Extension 23 Insuring Provisions - Employee and Dependent 11 Limitations, General - Employee and Dependent 12 Medicare Eligibles 15 Payment of Benefits 20 Schedules 3 S 4 II. PREMIUMS Calculation of Premiums 34 Changes in Premium Rates 34 Due Date 34 Grace Period 36 Monthly Premium Rates 34 Payment of Premiums 34 III. OTHER PROVISIONS Cancellation of Policy 36 Certificate 40 Claims, Forms and Notice of Claim 40 Co-ordination of Benefits 19 Definitions 9 Effective Date of Insurance 7 Eligibility for Insurance 5 Termination of Insurance 21 This policy includes the following pages on date of issue: 1C1, 2DE1, 3DE1 V-1, 4DSS1 RC -80, 4DSS2 RC, 4DSS3 RC -80, 4DSS4 RC, 4DSS5 RC, 4DSS6 RC -50, 4DSS7 RC, 4DSS8 RC -50, 5C1, 5C2, 7C2, 7C4 V-1, 9C19 9C2, 9DE1, 11DE1 V-3, 11DE2, 11DE3, 11DE40 11DE5, 12DE1, 12MD2, 15DE1 V-1, 19MD1, 19MD2, 19MD3 V-1, 19MD4 V-3, 20DE1, 21MD1, 21DE1 V-4, 23D E1, 34C1, 34DM1, 36C1, 38C1, 40C1, 40C2 GM5800 2DE1 Section 2 CONNECTICUT GENERAL LIFE INSURANCE COMPANY THE SCHEDULE MAXIMUM BENEFIT Calendar Year $1,000 ORTHODONTIA MAXIMUM Lifetime $1,000 DENTAL DEDUCTIBLE Calendar Year $ 50 The Deductible shown above applies to Dental Services in Classes II, III and IV. CREDIT FOR DEDUCTIBLE AMOUNT. The Dental Deductible for any calendar year for any person will be reduced to the extent that the Dental Deductible for the prior calendar year was deducted from Covered Expenses incurred for that person during October, November and December of such prior year. FAMILY DEDUCTIBLE. After Dental Deductibles totaling $150 have been applied in a calendar year for either (a) an Employee and his Dependents or (b) an Employee's Dependents, any Dental Deductible will be waived for that family for the rest of that year. Such $150 will be reduced in any calendar year to the extent that Dental Deductibles were applied for that family during October, November and December of such prior year. CM5800 3DE1 section 3 V-1 C,. CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE Covered Dental Expenses will include expenses incurred for Dental Services listed in this Schedule. The Insurance Company may agree to accept, an Covered Dental Expenses, expenses for services not listed. To be considered, services should be identified in terms of the American Dental Association Uniform Code on Dental Procedures and Nomenclature and/or by description and submitted to the Insurance Company. The Insurance Company will determine the Maximum Covered Expense for services that it accepts. The Maximum Covered Expense so determined will be consistent with the maximums listed. A temporary Dental Service is included in the allowance for the final Dental Service and is not a separate Dental Service. Dental Service Number Dental Service CLASS I SERVICES — The Maximum Covered Expenses• for any Class I Service is 80% of the Reasonable and Customary Charge. DIAGNOSTIC — GENERAL Oral Examinations — Only 2 per person in any 12 consecutive months. 0110 Initial oral examination 0120 Periodic oral examination Emergency Treatment 9110 Emergency treatment to relieve dental pain when no other definitive Dental Services are performed. (Any X-ray taken in connection with such treatment is a separate Dental Service.) Radiographs (X-rays) 0210 Complete series (with or without bitewings) — Only one per person, including Panoramic film, in any 36 consecutive months. Single Periapical 0220 First Film 0230 Each Additional Film GM5800 4DSS1 Section 4 RC -80 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Dental Service Number CLASS I SERVICES (Continued) Bitewing - Only 2 charges per person in any 12 consecutive months. 0212 Two Films 0214 Four or more Films 0330 Panoramic - maxilla and mandible Single Film PREVENTIVE Dental Prophylaxis (Cleaning) - Only 2 per person in any 12 consecutive months. 1110 Persons 14 or more years old 1120 Persons less than 14 years old 4910 Periodontal Prophylaxis Fluoride Treatments - Limited to persons less than 19 years old. Only one per person in any 12 consecutive months. Prophylaxis in connection with fluoride treatment is a separate Dental Service. 1230 Topical application of acid fluoride phosphate, one treatment Sealants. 1350 Topical application on a posterior tooth for a person less than 14 years old - Only one treatment per tooth in any 36 consecutive months. Space Maintainers - Limited to non -orthodontic treatment. 1510 Fixed Unilateral Type GN5800 4DSS2 Section RC 4 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Humber Dental Service CLASS II SERVICES - The Maximum Covered Expense for any Class II Service is 80% of the Reasonable and Customary Charge. ANESTHESIA - The administration of a general anesthetic is a Dental Service covered by this Schedule only: (a) when medically necessary in conjunction with oral or dental surgery; and (b) if the anesthetic agent produces a state of unconsciousness with absence of pain sensation over the whole body. 9220 General Anesthesia RESTORATIVE (BASIC) Amalgam Restorations (Fillings) Primary (Baby) Teeth 2110 One Surface 2120 Two Surfaces Permanent Teeth 2140 One Surface 2150 Two Surfaces Silicate Restorations (Fillings) 2210 Silicate Cement, per restoration Acrylic or Plastic Restorations (Fillings) 2310 Acrylic or Plastic Composite Acrylic Resin 2330 One Surface 2331 Two Surfaces ENDODONTICS A final restoration performed in conjunction with root canal therapy and pulpotomy is a separate Dental Service. Pulp Capping 3110 Direct Pulp Cap Pulpotomy 3220 Vital Pulpotomy CM5800 4DSS3 Section 4 RC -60 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Number Dental Service CLASS II SERVICES (Continued) Root Canal Therapy - Any X-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Dental Service. (Apicoectomy in conjunction with root canal therapy is a separate Dental Service.) 3310 One Canal 3330 Three Canals PERIODONTICS Surgical Services - Flap entry and closure is part of the allowance for osseous surgery and osseous graft and not a separate Dental Service. 4220 Gingival Curettage, per quadrant 4260 Osseous Surgery, per quadrant If more than one periodontal surgical service is performed per quadrant only the one with the largest Maximum Covered Expense is a Dental Service. Adjunctive Services Periodontal Scaling and Root Planing 4340 12 or More Teeth PROSTHODONTICS - REMOVABLE - MAINTENANCE Any adjustment of or repair to a denture within 6 months of its installation is not a Dental Service. Adjustments to Dentures 5410 Complete Denture GM5600 4DSS4 Section RC 4 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Number Dental Service CLASS II SERVICES (Continued) Repairs to Dentures Repair Broken Denture 5620 With Damaged Teeth, Including Replacement of First Broken Tooth Additions to Partial Dentures to Replace Extracted Teeth 5650 Per Tooth, not involving Clasp Relining Complete Upper or Lower Denture 5750 Laboratory PROSTHODONTICS - FIBED BRIDGES - MAINTENANCE Repairs _ 6640 Replace Broken Facing with Acrylic Other Services , 6930 Recement Bridge ORAL SURGERY Local anesthetic, analgesic and routine post-operative care are part of the allowance for each Dental Service. Simple Extractions 7110 First Tooth 7120 Each Additional Tooth Surgical Extractions - Per Tooth 7210 Erupted 7220 Soft Tissue Impaction 7230 Partial Bony Impaction 7240 Complete Bony Impaction GE5800 4DS85 Section RC 4 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service lumber Dental Service CLASS III SERVICES - The Maximum Covered Expense for any Class III Service is 502 of the Reasonable and Customary Charge. RESTORATIVE (MAJOR) Gold or Crown restorations are Dental Services only When the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, silicate, acrylic or plastic restoration. Gold Inlay Restorations 2530 Three Surfaces 2540 Onlay, per Tooth (in addition to above) Crowns - Single Restorations 2720 Plastic with Gold 2750 Porcelain with Gold Cast Cold 2790 Full 2810 Three-fourths 2830 Stainless Steel CM5800 4 DSS6 Section RC -50 4 fc- CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Number Dental Service CLASS III SERVICES (Continued) PROSTHODONTICS - RE210VABLE - INSTALLATION The Dental Services listed below include 6 months post -installation care. Complete (Full) Dentures Complete 5110 Upper 5120 Lower Immediate 5130 Upper 5140 Lower Partial Dentures Acrylic Base, with Two Clasps 5231 Lower, with Chrome Lingual Bar 5251 Upper, with Chrome Palatal Bar Cast Base, with Two Clasps 5241 Lower, with Chrome Lingual Bar 5261 Upper, with Chrome Palatal Bar PROSTHODONTICS - FIRED BRIDGES - INSTALLATION Bridge Pontics 6210 Cast Gold 6240 Porcelain Fused to Gold 6250 Plastic Processed to Gold Abutments Crowns 6720 Plastic Processed to Gold 6750 Porcelain Fused to Gold 6790 Full Cast Gold GM5800 4DSS7 Section RC 4 y 40 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL SERVICES SCHEDULE (Continued) Dental Service Humber Dental Service CLASS IV SERVICES - The Maximum Covered Expense for any Class IV Service is 50% of the Reasonable and Customary Charge. Each month of active treatment is a separate Dental Service. ORTHODONTICS Comprehensive Full Banded Orthodontic Treatment 8020 Preliminary study including X-rays, diagnostic casts and treatment plan and first month of active treatment including all active treatment and retention appliances 8030 Active treatment per month after the first month Other Orthodontic Treatment - Only one appliance per person. Fixed or Cemented Appliance -� 8120 For Tooth Guidance 8220 To Control Harmful Habits GM5800 4DSS8 section 4 RC -50 CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the New Employee Group Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of Eligible Employees within one year after his insurance ceased. INITIAL EMPLOYEE GROUP The Initial Employee Group is made up of Employees: (1) in the employ of an Employer on the Effective Date of the policy; or (2) in the employ of an Employer on the date that Employer becomes an Affiliated Employer. NEW EMPLOYEE GROUP. The New Employee Group is made up of Employees not in the Initial Employee Group. WAITING PERIOD Initial Employee Group: New Employee Group: AFFILIATED EMPLOYERS Drone CLASSES OF ELIGIBLE EMPLOYEES Each Employee 30 days of Active Service 30 days of Active Service GM5800 SCI Section 5 C CONNECTICUT GENERAL.LIFE INSURANCE COMPANY ELIGIBILITY FOR DEPENDENT INSURANCE 4 Each Employee will become eligible for Dependent Insurance on the latest date below: (1) the date he becomes eligible for Employee Insurance; (2) the date he acquires his first Dependent; (3) the effective date of Dependent Insurance. GM5800 5C2 Section 5 S CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE MATE OF EMPLOYEE INSURANCE Each Employee will become insured for Employee Insurance on the date he becomes eligible for it. If an Employee is not in Active Service on the date his insurance would otherwise become effective, it will become effective on the date he returns to Active Service. GM5800 7C2 Section 7 CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE DATE"OF DEPENDENT INSURANCE Each Employee will become insured for Dependent Insurance on the date he becomes eligible for it if he is insured for Employee Insurance on that date. If he is not insured for Employee Insurance on that date, his Dependent Insurance will become effective on the date he becomes insured for Employee Insurance. Any reference to an insured Dependent means a Dependent for whom the Employee is insured. GM5800 7C4 Section 7 V-1 'r. C r CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS EMPLOYER. The term Employer means the Policyholder and all Affiliated Employers shown in the "Eligibility for Insurance" section. EMPLOYEE. The term Employee means a full time employee of the Employer, but does not include employees who are part time.or temporary or who normally work less than 30 hours a week for the Employer. ACTIVE SERVICE. An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if he is performing in the usual way all of the regular duties of his work for the Employer on a full time basis on that day, either at one of the Employer's places of business or at some location to which the Employer's business requires him to travel. An Employee will be �";-emed in Active Service on a day which is not one of the Employer's scheduled work days only if he was in Active Service on the preceding scheduled work days. CM5800 9C1 Section 9 'f Y CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS Continued DEPENDENT. the term Dependent means: (1) the lawful spouse of the Employee; and (2) any unmarried child who is (a) less than 19 years old; (b) 19 years but less than 23 years old, enrolled in a school as a full time student and primarily supported by the Employee; (c) 19 or more years old and primarily supported by the Employee and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child's condition and dependence must be submitted to the Insurance Company within 31 days after the date the child ceases to qualify under (a) or (b) above. During the next two years the Insurance Company may, from time to time, require proof of the continuation of such condition and dependence. After that, the Insurance Company may require proof no more than once a year. The term child means a child born to the Employee and a child legally adopted by the Employee. It also means a stepchild of the Employee living with the Employee. Anyone who is eligible for the insurance as an Employee will not be considered as a Dependent. No one may be considered as a Dependent of more than one Employee. GM5800 9C2 section 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS (Continued) DENTIST. The term Dentist means a person practicing dentistry or oral surgery within the scope of his license. It will also include a physician operating within the scope of his license when he performs any of the Dental Services described in the policy. MEDICAID. The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended. MEDICARE. The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. REASONABLE AND CUSTOMARY CHARGE. A charge will be considered Reasonable and Customary if: (1) it is the normal charge made by the provider for a similar service; and (2) it does not exceed the normal charge made by most providers of such service in the locality where the service is received. To determine if a charge is Reasonable and Customary, the nature and severity of the condition being treated will be considered. GM5800 9DE1 Section 9 C 4 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents DENTAL BENEFITS If an Employee or a Dependent incurs Covered Expenses, the Insurance Company will: (1) deduct any Dental Deductible that applies from the Covered Expenses first incurred in a calendar year for that person; and (2) pay for the other Covered Expenses incurred in that calendar year up to the Maximum Covered Expense determined from the Dental Services Schedule for each Dental Service subject to the Alternate Benefit Provision. The Dental Deductible is shown in The Schedule. MISSING TEETH LIMIT. No payment will be made for first replacement of teeth that are missing when a person becomes insured for these benefits. After a person has been continuously insured for these benefits for 24 months, this limit will no longer apply. ORTHODONTIA PROVISION. The total amount payable for all expenses incurred for an Employee or a Dependent in his lifetime for Orthodontics will not be more than the Orthodontia Maximum shown in The Schedule. Payments for Comprehensive Full Banded Orthodontic Treatments are made in installments. Payment of benefits will be made every 3 months. The first payment becomes payable when the appliance is installed. Later payments are payable at the end of each 3 -month period. In determining the first installment, the Insurance Company assigns 25% of the charge for the entire course of treatment to the appliance. The rest of such charge is prorated over the estimated duration of such treatment. These payments are made only for services performed while a person is insured. If insurance or treatment on an Employee or a Dependent ceases during a 3 -month period, the amount payable for that period will be prorated. MAXIMUM BENEFIT PROVISION. The total amount payable for all expenses incurred for an Employee or a Dependent in a calendar year for other than Orthodontics will not be more than the Maximum Benefit shown in The Schedule, CM5800 11DRI Section v-3 11 N r l CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents DENTAL BENEFITS (Continued) COVERED EXPENSES. The term Covered Expenses weans expenses incurred by or on behalf of an Employee or a Dependent for charges made by a Dentist for the performance of a Dental Service listed in the Dental Services Schedule. Covered Expenses will include only those expenses incurred for such charges when the Dental Service: (1) is performed by or under the direction of a Dentist; (2) is essential for the necessary care of the teeth; and (3) starts and is completed while the person is insured. Any portion of charges for a Dental Service that exceeds the Maximum Covered Expense shown for that service in the Dental Services Schedule is not included. A Dental Service is deemed to start when the actual performance of the service starts except that: (1) for fixed bridgework and full or partial dentures, it starts when the first impressions are taken aad/or abutment teeth fully prepared. (2) for a crown, inlay or onlay, it starts on the first date of preparation of the tooth involved. (3) for root canal therapy, it starts when the pulp chamber of the tooth is opened. ALTERNATE BENEFIT PROVISION. When more than one Dental Service could provide suitable treatment based on common dental standards, the Insurance Company will determine the Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. GM5800 llDE2 Section 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents DENTAL BENEFITS (Continued) PREDETERMINATION OF BENEFITS. The term Predetermination of Benefits means a review by the Insurance Company of a Dentist's description of planned treatment and expected charges, including those for diagnostic X-rays. This review should be made whenever extensive dental work is proposed. The information should be sent to the Insurance Company before the dental work is started. If there is a major change in the treatment plan, a revised plan should be sent to the Insurance Company. The expenses that will be included as Covered Expenses will be determined by the Insurance Company and are subject to the Alternate Benefit Provision. When there has not been a Predetermination of Benefits, the Insurance Company will determine the expenses that will be included as Covered Expenses at the time the claim is received. Predetermination of Benefits does not guarantee payment. The estimate of benefits payable may change based on the benefits, if any, for which the person qualifies at the time services are completed. GM5800 11DE3 Section 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents DENTAL BENEFITS (Continued) EXPENSES NOT COVERED. Covered Expenses will not include, and no payment will be made for, expenses incurred for: (1) services performed solely for cosmetic reasons. (2) replacement of a lost or stolen appliance. (3) replacement of a bridge, crown or denture within five years after the date it was originally installed unless: (a) such replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or (b) the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while the Employee or Dependent is insured for these benefits. (4) any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards. (5) procedures, appliances or restorations (except full dentures) whose main purpose is to: (a) change vertical dimension; (b) diagnose or treat conditions or dysfunction of the temporomandibular joint; (c) stabilize periodontally involved teeth; or (d) restore occlusion. (6) porcelain or acrylic veneers of crown or pontics on or replacing the upper and lower first, second and.third molars. (7) bite- registrations; precision or semi -precision attachments; or splinting. GM5800 11DE4 Section 11 C) CONNECTICUT GENERAL. _ f INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents DENTAL BENEFITS (Continued) EXPENSES NOT COVERED (Continued) (8) a surgical implant of any type including any prosthetic device attached to it. (9) instruction for plaque control, oral hygiene and diet. (10) dental services that do not meet common dental standards. (11) services that are deemed to be medical services. (12) services and supplies received from a hospital. (13) services for which benefits are not payable according to the "General Limitations" section. In addition, these benefits will be reduced so that the total payment under (1) and (2) below will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under: (1) this plan; and (2) any medical expense plan or prepaid treatment program sponsored or made available by the Policyholder. GM5800 11D15 section 11 i� l� s CONNECTICUT GENERAL LIFE INSURANCE COMPANY GENERAL LIMITATIONS No payment will be wade for expenses incurred: (1) for or in connection with an injury arising out of, or in the course of, any employment for wage or profit; (2) for or in connection with a sickness which is covered under any workers' compensation or similar law; (3) for charges made by a Hospital owned or run by the United States Government; (4) to the extent that payment is unlawful where the Employee or Dependent resides when the expenses are incurred; (S) for charges which the Employee or Dependent is not legally required to pay; (6) for charges which would not have been made if the Employee or Dependent had no insurance; (7) to the extent that they are more than Reasonable and Customary Charges; (8) for charges for unnecessary care, treatment or surgery; (9) to the extent that the Employee or Dependent is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; (10) for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society. GM5800 12DE1 section 12 s 7 CONNECTICUT GENERAL LIFE INSURANCE COMPANY GENERAL LIMITATIONS (Continued) No payment will be made for expenses incurred by an Employee or a Dependent to the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with: (a) a "no-fault" insurance law; or (b) an uninsured motorist insurance taw. The Insurance Company will take into account any adjustment option chosen under such part by the Employee or Dependent. GM5800 12MD2 Section 12 CONNECTICUT GENERAL LIFE INSURANCE COMPANY MEDICARE ELIGIBLES The Dental Expense Insurance for an Employee or a Dependent who is eligible for Medicare will be modified as follows: The amount payable under this plan will be reduced so that the total amount payable by the Insurance Company and Medicare will be no more than 100% of the expenses incurred. The Insurance Company will assume the amount payable under: (1) Part A of Medicare for a person who is eligible for that Part without premium payment, but bas not applied, to be the amount he would receive if he had applied. (2) Part B of Medicare for a person who is entitled to be enrolled in that Part, but is not, to be the amount he would receive if he were enrolled. A person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him. GM5800 15DRI section V-1 15 t� CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDINATION OF BENEFITS If a person covered under this policy (called "this Plan") is also covered under one or more other Plans, the benefits payable for him from this Plan will be co-ordinated with the benefits payable for him from all other Plans. Co-ordination of Benefits will be used to determine the benefits payable for a person for any Claim Determination Period if, for the Allowable Expenses incurred in that Period, the sum of (a) and (b) below would exceed those Allowable Expenses: (a) the benefits that would be payable from this Plan without co-ordination; and (b) the benefits that would be payable from all other Plans without Co-ordination of Benefits provisions in those Plans. The benefits that would be payable from this Plan for Allowable Expenses incurred in any Claim Determination Period without Co-ordination of Benefits will be reduced to the extent required so that'the sum of: (a) those reduced benefits; and (b) all the benefits payable for those Allowable Expenses from all other Plans; will not exceed the total of those Allowable Expenses. Benefits payable from all other Plans include the benefits that would have been payable had proper claim been made for them. "00 19MD1 Section 19 CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDINATION OF BENEFITS (Continued) However, the benefits of another Plan will be ignored when the benefits of this Plan are determined if; (a) the Benefit Determination Rules would require this Plan to determine its benefits before that Plan; and (b) the other Plan has a provision that co-ordinates its benefits with those of this Plan and would, based on its rules, determine its benefits after this Plan. When Co-ordination of Benefits reduces the total amount otherwise payable in a Claim Determination Period for a person covered under this Plan, each benefit that would be payable in the absence of Co-ordination of Benefits will be reduced in proportion. The reduced amount will be charged against any applicable benefit limit of this Plan. The Insurance Company reserves the right to release to or obtain from any other insurance company or other organization or person any information which, in its opinion, it needs for the purpose of Co-ordination of Benefits. When payments which should have been made under this Plan based on the terms of this section have been made under any other Plans, the Insurance Company will \.� have the right to pay to any organizations making these payments the amount it determines to be warranted. Amounts paid in this manner will be considered to be benefits paid under this Plan. The Insurance Company will be released from all liability under this Plan to the extent of these payments. When an overpayment has been made by the Insurance Company, at any time, it will have the right to recover that payment, to the extent of the excess, from the person to whom it was made or any other insurance company or organization, as it may determine. IN GM5800 19MD2 Section 19 t CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDINATION OF BENEFITS (Continued) BENEFIT DETERMINATION RULES. The rules below establish the order in which benefits will be determined: (1) The benefits of a Plan which covers the person for whom claim is made other than as a dependent will be determined before a Plan which covers that person as a dependent. (2) The benefits of a Plan which covers the person for whom claim is made as a dependent of a male will be determined before a Plan which covers that person as a dependent of a female; except that, in the case of a dependent child of divorced or separated parents, the following rules Will apply. If there is a court decree which establishes financial responsibility for medical, dental or other health care of the child, the benefits of the Plan which covers the child as a dependent of the parent so responsible will be determined before any other plan; otherwise: (a) The benefits of a Plan which covers the child as a dependent of the parent with custody will be determined before a Plan which covers the child as a dependent of a stepparent or a parent without custody. (b) The benefits of a Plan which covers the child as a dependent of a stepparent will be determined before a plan which covers the child as a dependent of the parent without custody. (3) When the above rules do not establish the order, the benefits of a Plan which has covered the person for whom claim is made for the longer period of time will be determined before a Plan which has covered the person for the shorter period of time. GM58000 19MD3 Section V-1 19 C i� CONNECTICUT GENERAL LIFE INSURANCE COMPANY CO-ORDINATION OF BENEFITS (Continued) DEFINITIONS PLAN. Plan means any: (1) group, blanket or group franchise insurance coverage; (2) service plan contracts, group or individual practice or other prepayment plans; or (3) coverage under any labor-management trusteed plans, union welfare plans, employer organisations plans, or employee benefit organization plans; which provides medical, dental or vision care benefits or services. It does not include coverage under individual policies or contracts. Each Plan or part of a Plan which has the right}to co-ordinate benefits will be considered a separate Plan. ALLOWABLE EXPENSE. Allowable Expense means any necessary, reasonable and customary item or expense at least a part of which is covered by any one of the Plans that covers the person for whom claim is made. When the benefits from a Plan are in the form of services, not cash payments, the reasonable cash value of each service is both an Allowable Expense and a benefit paid. CLAIM DETERMINATION PERIOD. Claim Determination Period means a calendar year or that part of a calendar year in which the person has been covered under this Plan. GM5800 19MD4 section Io v-3 CONNECTICUT GENERAL LIFE INSURANCE COMPANY �-- . PAYMENT OF BENEFITS TO WHOM PAYABLE. All dental benefits are payable to the Employee. However, at the option of the Insurance Company and with the consent of the Policyholder, all or any part of the dental benefits may be paid directly to the person or institution on whose charge claim is based. If any person to whom benefits are payable is a minor or, in the opinion of the Insurance Company, is not able to give a valid receipt for any payment due him, such payment will be wade to his legal guardian. However, if no request for payment has been made by his legal guardian, the Insurance Company may, at its option, make payment to the person or institution appearing to have assumed his custody and support. If an Employee dies while dental benefits remain unpaid, the Insurance Company may choose to make direct payment to any of the following living relatives of the Employeei' spouse, mother, father, child or children, brothers or sisters; or to the executors or administrators of the Uployee's estate. Payment as described above will release the Insurance Company from all liability to the extent of any payment made. TIME OF PAYMENT. Dental benefits will be paid by the Insurance Company when it receives due proof of loss. GH5800 20DE1 Section ft.ft C N tu J CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF INSURANCE For Employees The insurance on an Employee will cease on the earliest date below: (1) the date the Employee ceases to be in a Class of Eligible Employees or ceases to qualify as an Employee; (2) the last day for which the Employee has made any required contribution for the insurance; (3) the date the policy is cancelled; (4) the date the Employee's Active Service ends, except as set forth below. TEMPORARY LAYOFF OR LEAVE OF ABSENCE. If an Employee's Active Service ends due to temporary layoff or leave of absence, the insurance will be continued until the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. However, the insurance will not be continued for more than 60 days past the date the Employee's Active Service ends. INJURY OR SICKNESS. If an Employee's Active Service ends due to an Injury or a Sickness, the insurance will be continued while the Employee remains totally and continuously disabled as a result of the Injury or Sickness until the date the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. Any continuation of insurance must be based on a plan which precludes individual selection. GM5600 21MD1 Section 21 CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF INSURANCE (Continued) For Dependents An Employee's insurance for all of his Dependents will cease on the earliest date below: (1) the date the Employee's insurance for himself ceases, except in the case of death; (2) the date the Employee ceases to be in a class of Employees eligible for Dependent Insurance; (3) the last day for which the Employee has made any required contribution for Dependent Insurance; (4) the date Dependent Insurance is cancelled. An Employee's insurance for any. one of his Dependents will cease on the date the Dependent no longer qualifies as a Dependent. DEPENDENT DENTAL INSURANCE AFTER EMPLOYEE'S DEATH. If an Employee is insured for Dental Expense Insurance when he dies, any of his Dependents who are then insured for Dental Expense Insurance will remain so insured without further payment of premiums for them. However, the insurance on any of those Dependents will cease on the earliest date below: (1) the last day of the 24th month after the Employee's death; (2) the date of remarriage of a surviving spouse, if any; (3) the date that Dependent ceases to qualify as a Dependent for a reason other than lack of primary support by the Employee. The Dependent benefits payable after the Employee dies will be those in effect for that Employee's Dependents on the day prior to his death. GM5800 21DE1 Section Y-4 21 was': 1.4 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DENTAL BENEFITS EXTENSION An expense incurred in connection with a Dental Service that is completed after a person's benefits cease will be deemed to be incurred while he is insured if: (1) for fixed bridgework and full or partial dentures, the first impressions are taken and/or abutment teeth fully prepared while he is insured and the device installed or delivered to his within 3 calendar months after his insurance ceases. (2) for a crown, inlay or onlay, the tooth is prepared while he is insured and the crown, inlay or oulay.installed within 3 calendar months after his insurance ceases. (3) for root canal therapy, the pulp chamber of the tooth is opened while he is insured and the treatment is completed within 3 calendar months after his insurance ceases. There is no extension for any Dental Service not shown in (1), (2) or (3) above. GM5800 23DE1 Section 23 l` 1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS PREMIUM PAYMENT. The first premium will be due on the Effective Date. After that, premium will be due monthly unless the Policyholder and the Insurance Company agree on some other method of premium payment. The Policyholder and the Insurance Company may agree to change the method of premium payment from time to time. Premiums are payable at the Home Office of the Insurance Company or to an authorised agent of the Insurance Company. PREMIUM DUE DATE. After the Effective Date, the Premium Due Date will be the day of the month with the same number as the Anniversary Date or the last day of a month in which there is no day with the same number as the Anniversary Date. If the Policyholder and the Insurance Company agree that premiums will be paid on a quarterly, semiannual or annual basis, the Premium Due Date will be at the appropriate regular interval, quarterly, semiannually or annually. MONTHLY STATEMENT DATE. If premiums are to be paid monthly, the Monthly Statement Date will be the same as the Premium Due Date. If premiums are to be paid on a quarterly, semiannual or annual basis', the Monthly Statement Date will be the day in each month with the same number as the Premium Due Date. MONTHLY PREMIUM STATEMENT. If premiums are due monthly, a Monthly Premium Statement will be prepared as of the Premium Due Date. This Monthly Premium Statement will show the premium due. If premiums are due quarterly, semiannually or annually, a Monthly Premium Statement will be prepared as of the Monthly Statement Date for the time from the Monthly Statement Date to the next Premium Due Date, This Monthly Statement will reflect any pro rata premium charges and credits due to changes in the number of insured persons and changes in insurance amounts that took place in the preceding month. SIMPLIFIED ACCOUNTING. To simplify the accounting process, premium adjustments will be made on the Monthly Statement Date that is the same as or next follows the date that (1), (2) or (3) below takes place. (1) A person becomes insured. (2) The amount of insurance on a person changer, but not due to a revision of The Schedule. (3) A person ceases to be insured. GM5800 34C1 Section 34 f CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) MONTHLY PREMIUM FATE. The monthly premium rate per Employee is as follows: For Employee For Dependent Insurance Insurance $ 8.96 $ 19.16 CALCULATION OF PREMIUMS. The monthly premium will be calculated as follows: (1) Multiply the number of Employees insured on the Premium Due Date in each rate class shown in the "Monthly Premium Rate" section by the premium rate in effect on that date for that class. (2) Add the results. If premiums are to be paid other than monthly,,,the method of calculation is the same. However, the rate for each class is first changed to a quarterly, semiannual or annual rate by multiplying it by 2.9852, 5.9557 or 11.8227 respectively. All results are taken to the nearer cent. If the Policyholder and the Insurance Company agree to a change in the method of premium payment or to a change in the Anniversary Date, a pro rata adjustment will be made in the premium due. CHANGES IN PREMIUM RATES. Any premium rate may be changed by the Insurance Company from time to time with at least 31 days advance written notice. No change in rates will be made until 12 months after the Effective Date. An increase in rates will not be made more often than once in a 12 month period. However, the Insurance Company may change.rates immediately if, in its opinion, its liability is altered by any change in state or federal law or by a revision in the insurance under the policy. Any such change in rates will take effect on the effective date of the change in law or change in the insurance. If an increase in rates takes place on a date that is not a Premium Due Date, a pro rata premium will be due on the date of the increase. The pro rata premium will apply for the increase from the date of the increase to the next Premium Due Date. If a decrease in rates takes place on a date that is not a Premium Due Date, a pro rata credit will be granted. The pro rata credit will apply for the decrease from the date of the decrease to the next Premium Due Date. As of any Anniversary Date after the policy has been in force for 12 months, the Insurance Company may grant a credit in such amount as it may determine, based on experience. The experience under this policy may be combined with the experience under other group insurance policies issued by the Insurance Company to the Policyholder. GM5800 34MD1 Section 34 rz') CONNECTICUT GENERAL LIFE INSURANCE COMPANY CANCELLATION OF POLICY The Policyholder may cancel the policy as of any Premium Due Date by giving written notice to the Insurance Company before that date. The Insurance Company may cancel the policy as of any Premium Due Date if the number of insured Employees is less than 25 or less than 75% of those eligible. Dependent Insurance may be cancelled as of any Premium Due Date if the number of Employees insured for their Dependents is less than 75% of those eligible. If a premium is not paid when due, the policy will automatically be cancelled as of the Premium Due Date, except as sat forth below. GRACE PERIOD. If, before a Premium Due Date, the Policyholder has not given written notice to the Insurance Company that the policy is to be cancelled, a Grace Period of 31 days will be granted for the payment of each premium after the initial premium. The policy will stay in affect during that time. If any premium is not paid by the end of the Grace Period, the policy will automatically be cancelled at the end of the Grace Period; except that, if the Policyholder has given written notice in advance of an earlier date of cancellation, the policy will be cancelled as of the earlier date. The Policyholder will be liable to the Insurance Company for any unpaid premium for the time the policy was in force. GM5800 36C1 Rection 36 } i' CONNECTICUT GENERAL LIFE INSURANCE COMPANY MISCELLANEOUS PROVISIONS c RXECUTION OF POLICY. The policy is executed at the dome Office of the Insurance Company. The Post Office address of the Insurance Company is Hartford, Connecticut. CONSIDERATION. The policy is issued to the Policyholder in consideration of the application and payment of premiums. INSURANCE DATA. The Policyholder will give the Insurance Company all of the data that it needs to calculate the premium and all other data that it may reasonably require. Failure of the Policyholder to give this data will not void or continue an Employee's insurance. The Insurance Company has the right to examine the Policyholder's records relative to these benefits at any reasonable time while the policy is in effect. It also has this right until all rights and obligations under the policy are finally determined. MALE PRONOUN. The sale pronoun as used herein will be deemed to include the female. GH5800 38C1 Section 38 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PROVISIONS ENTIRE CONTRACT. The entire contract will be made up of the policy, the application of the Policyholder, a copy of which is attached to the policy, and the applications, if any, of the Employees. POLICY CHANGES. Changes may be made in the policy only by amendment signed by the Policyholder and by the Insurance Company acting through its President, Vice President, Secretary, or Assistant Secretary. No agent may change or waive any terms of the policy. STATEMENTS NOT WARRANTIES. All statements made by the Policyholder or by an insured Employee will, in the absence of fraud, be deemed representations and not warranties. No statement made by the Policyholder or by the Employee to obtain insurance will be used to avoid or reduce the insurance unless it is made in writing and is signed by the Policyholder or the Employee and a copy is sent to the Policyholder, the Employee or his Beneficiary. NOTICE OF CLAIM. Written notice of claim must be given to the Insurance Company within 30 days after the occurrence or start of the loss on which claim is based. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written notice was given as soon as was reasonably possible. CLAIM FORMS. When the Insurance Company receives the notice of claim, it will give to the claimant, or to the Policyholder for the claimant, the claim forms it uses for filing proof of loss. If the claimant does not get these claim forms within 15 days after the Insurance Company receives notice of claim, he will be considered to have met the proof of loss requirements' if he submits written proof of loss within 90 days after the date of loss. This proof must describe the occurrence, character and extent of the loss for which claim is made. PROOF OF LOSS. Written proof of loss must be given to the Insurance Company within 90 days after the date of the loss for which claim is made. If written proof of loss is not given in that time, the claim will not be invalidated nor reduced if it is shown that written proof of loss was given as soon as was reasonably possible. PHYSICAL EXAMINATION. The Insurance Company, at its own expense, will have the right to examine any person for whorl claim is pending as often as it may reasonably require. CM5800 40C1 Section LA .l % CONNECTICUT GENERAL LIFE INSURANCE COMPANY 1 PROVISIONS (Continued) LEGAL ACTIONS. No action at law or in equity will be brought to recover on the Policy until at least 60 days after proof of loss has been filed with the Insurance Company. No action will be brought at all unless brought within 3 years after the time within which proof of loss is required by the policy. TIME LIMITATIONS. If any time limit set forth in the policy for giving notice of claim or proof of loss, or for bringing any action at law or in equity is less than that permitted by the law of the state in which the Employee lives when the policy is issued, then the time limit provided in the policy is extended to agree with the minimum permitted by the law of that state. PHYSICIAN/PATIENT RELATIONSHIP. The Employee will have the right to choose any physician who is practicing legally. The Insurance Company will in no way disturb the physician/patient relationship. CERTIFICATES. The Insurance Company will issue to the Policyholder for delivery to each insured Employee an individual certificate. The Policyholder will be responsible for distributing the certificates to its Employees. The certificate will show the benefits provided under the policy. It will set forth any changes in benefits due to age and to whom benefits will be paid. Nothing in the certificate will change or void the terms of the policy. GM5800 4002 Section 40