Assurity Cancer Plan

Plan Benefits
• First Occurence
• Hospital Confinement
• Experimental Treatment
• Radiation and Chemotherapy
• Immunotherapy
• Cancer Screening Wellness
• Plus . . . much more

Basic Benefits
Provides medical expense benefits caused by cancer and certain other specified diseases by rider for the employee, spouse and covered children with continuous benefit and premium period for life. The Family Rider allows for the addition of family members to the employee’s policy.

Rate Structure
Unisex Rates; Employee Issue Ages: 18-69, Family: Up to Age 69 on spouse and 25 on children if a full-time student in an accredited school. Issue Age is age of last birthday on the day policy is issued.

Underwriting
Pre-existing conditions are not covered during the first two years the policy is in force. Persons with previous history of cancer will be excluded unless added by rider for those with simple skin cancers. Additional question regarding diagnostic tests that have been completed within last 30 days or are scheduled to be performed is also asked. No benefits will be paid during a 30-day waiting period. Conditions that manifest after the policy date will be payable beginning on the 31st day. Definition of manifested: “Symptoms or visible indications that would put an ordinary prudent person on notice that diagnosis, care or treatment by a medical professional should be sought.”

Policy will pay the following specified benefits for each unit for a covered injury:

Hospital Indemnity – pays benefits each day while confined in the hospital for cancer or certain other specified disease for the first 75 days of each period of confinement. There are three options for the daily benefit amount: $150, $250, and $350. (NOTE: The $150 benefit amount is not available in Utah.)

Prescription Drugs and Medicines – pays actual charges up to 25% of daily hospital confinement benefit for the first 75 days of hospital confinement.

Surgical Benefit – pays up to $7,500 for actual charges made by surgeon as shown in Surgical Table in policy.

Anesthesia – pays up to 25% of the amount payable under the Surgical Benefit. Limit of $50 per skin cancer operation.

Additional Surgical Opinions – pays up to $150 for a second opinion. If the second opinion differs from the first, up to $150 for a third opinion.

Artificial Limb and Prosthesis – pays actual charges for prosthesis and reconstructive procedure to affix or implant it up to $2,000 lifetime maximum.

Attending Physician – pays actual charges up to $35 per day for in-hospital physician’s visits.

Private Duty Nurse – pays actual charges up to $150 per day while confined in the hospital when authorized by a physician when a Private Nurse is required.

Radiation, Chemotherapy or Immunotherapy – pays 50% of actual charges for treatments up to $10,000 per month with a lifetime maximum of $50,000.

Experimental Treatment – pays the actual charges up to $25,000 per calendar year for such treatment received in the United States or its territories, except for experimental bone marrow transplants.

Physical and Speech Therapy – pays the actual charges up to $25 per therapy session up to a lifetime maximum of $1,000.

Extended Care Facility – pays up to $60 per day for confinement in such a facility. Confinement must be recommended by a physician and begin within 14 days following a covered hospital stay. Benefits are limited to the number of days of the prior hospital confinement.

Bone Marrow Transplant for Cancer – pays actual charges up to a lifetime maximum of $25,000 for bone marrow transplants or other forms of stem cell rescue and all related services or supplies. Payable in lieu of any other benefits payable under this policy, except Transportation and Lodging for Bone Marrow Donors.

Transportation and Lodging for Bone Marrow Donors - pays (a) actual charges up to $2,500 for medical expenses directly related to such a transplant, (b) pays actual charges for a round trip coach fare on a common carrier or a personal automobile allowance of 50 cents per mile in excess of 50 miles one-way to the city where the transplant is performed, up to 700 miles round trip, and (c) pays actual charges up to $50 per day for lodging and meal expenses when donor has to remain near the hospital. This payment is in lieu of any other benefit payable under this policy when the donor is a person insured under this policy.

Transportation for Non-local Treatment Which Requires Hospital Confinement – pays (a) actual charges for non-local round trip charges by common carrier to the nearest hospital that provides the prescribed treatment or (b) 50 cents per mile for personal automobile expenses in excess of 50 miles one way, up to 700 miles round trip.

Transportation for Non-local Treatment Which Does Not Require Hospital Confinement – pays (a) 50 cents per mile for personal automobile expenses in
excess of 50 miles one way, up to 700 miles round trip with a maximum of $1,500 per calendar year, (b) pays actual charges for round trip coach fare on a common carrier or a personal automobile allowance of 50 cents per mile in excess of 50 miles one-way to the city where the transplant is preformed, up to 700 miles round trip and (c) pays actual charges up to $50 per day for lodging and meal expenses.

Adult Companion Transportation and Lodging - pays the following expenses for one adult companion to be near insured when insured is confined in a nonlocal hospital (a) up to a maximum of $1,500 per calendar year for actual charges for non-local round trip coach fare by a common carrier to the nearest hospital that provides the prescribed treatment or 50 cents per mile for personal automobile expenses in excess of 50 miles one-way, up to 700 miles round trip and (b) pays actual charges up to $50 per day for lodging and meal expenses limited to the number of days of each confinement.

Outpatient Positive Diagnostic Testing – pays actual charges up to $250 for the diagnostic test that leads to a positive diagnosis within 90 days of the test.

Outpatient Surgery – pays a benefit equal to the daily hospital confinement benefit for outpatient surgery in a hospital or ambulatory surgical center.

Skin Cancer – pays up to $150 for actual charges for the removal of skin cancer when diagnosis is made by a physician, other than a legally qualified pathologist.

Ambulance – pays actual charges up to $75 per trip to transfer an insured person to the hospital for confinement as an inpatient.

Hospice – pays actual charges up to $100 per day up to a lifetime maximum of $7,500.

Government or Charity Hospital – pays actual charges up to $200 per day for confinement in a government or charity hospital. Payment is in lieu of all other policy benefits.

Blood and Blood Plasma – pays the actual charges for blood, blood plasma and platelets. Policy does not pay for blood that is donated or replaced.

Breast Cancer / Breast Reconstruction / Breast Prosthesis – pays a benefit equal to the daily hospital confinement benefit for a minimum of 48 hours of inpatient care following a mastectomy and for a minimum of 24 hours following a lymph node dissection for the treatment of breast cancer. Lifetime maximum of $2,500 per breast.

Cancer (Wellness) Screening Tests – pays up to $100 per year for cancer screening test. Tests covered are:

• Mammography Screening
• CEA (blood test for colon cancer)
• Pap Smear (test only)
• Colonoscopy
• CA125 (blood test for ovarian cancer)
• Chest X-ray
• PSA (blood test for prostate cancer)
• Thermography
• Hemocult Stool Specimen
• Serum Protein Electrophoresis
• Flexible Sigmoidoscopy

Home Health Care Services – when services are provided by a Home Health Care Agency, policy pays (a) up to $60 per day for services provided at home, not to exceed 180 days per calendar year, (b) up to $100 per day for Private Duty Nursing, not to exceed 15 days per calendar year, and (c) pays actual charges for a physician’s visit up to $40 per day not to exceed 15 days per calendar year. Benefits herein are not payable under provisions of this policy.

Hairpiece Benefit – pays a one-time benefit of up to $150 for a hairpiece when hair loss is a result of cancer treatment.

Rental or Purchase of Durable Medical Equipment – pays the actual charges up to $1,000 per calendar year for (a) a respirator or similar medical device, (b)
brace, (c) crutches, (d) hospital bed or (e) wheel chair.

Professional Mental Health Consultation – pays actual charges up to $50 per session not to exceed a lifetime maximum of $250.

Extended Benefits – If a covered hospital confinement lasts for more than 75 days in a row, policy pays usual and customary charges for hospital room and board, medicines, lab test and other normal charges, up to $1,000 per day beginning on the 76th day. Payable after the 75th day in lieu of all other policy benefits.

Waiver of Premium – premiums of the insured person will be waived while that person is receiving treatment for cancer or specified disease for which benefits are payable.

Specified Disease Benefits - The benefits of the policy will be extended to pay for the loss that results from the following specified diseases:

Intensive Care Rider
Provides a Daily Benefit (you choose $300 or $600) if an Insured Person is confined to a Hospital’s Intensive Care Unit, up to a maximum of 20 days per period of confinement.

Wellness Claims
An employee can file a wellness claim by fax, call-in or mail. If a bill is not included with the claim form, a scheduled amount will be paid. (Scheduled amounts are listed on the claim form). Employees can also call in their wellness claim at (888) 358-8808 x36.

Cancer or other Specified Disease Claims: You may file a claim for cancer or specified diseases by completing an Assurity Claim Form. Please make sure to include all pertinent information as stated on the form. Should you have any questions on how to file or submit a claim, please contact Assurity Customer Service.

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