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Cancer & Specified Disease CO9TN Plan Details
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I. READ YOUR POLICY
CAREFULLY
This outline of coverage provides a very brief description of some of
the important features of your policy. This is not the insurance contract
and only the actual policy provisions will control. The policy itself sets
forth, in detail, the rights and obligations of both you and your insurance
company. It is therefore important that you READ YOUR POLICY CAREFULLY!
II. Cancer and Specified Disease coverage is designed to provide you with coverage paying benefits only when certain losses occur as a result of cancer or specified diseases. Coverage is provided for the benefits outlined in Paragraph III. The benefits described in Paragraph III may be limited by Paragraph IV.
III. The benefits of the policy are payable for loss that results from cancer or specified disease under the terms of the policy.
The following are the specified diseases covered by the policy:
| Addison’s Disease | Myasthenia Gravis |
| Botulism | Osteomyelitis |
| Brucellosis | Polio |
| Budd-Chiari Syndrome | Q Fever |
| Cystic Fibrosis | Reye’s Syndrome |
| Diptheria | Rheumatic Fever |
| Encephalitis | Rocky Mountain Spotted Fever |
| Histoplasmosis | Sickle Cell Anemia |
| Legionnaires Disease | Tay-Sachs Disease |
| Lou Gehrig’s Disease | Tetanus |
| Lupus Erythematosus | Trichinosis |
| Malaria | Toxic Shock Syndrome |
| Meningitis | Tuberculosis |
| Multiple Sclerosis | Typhoid Fever |
| Muscular Dystrophy | Whooping Cough |
BENEFITS FOR EXPERIMENTAL TREATMENT ARE PAYABLE ON THE SAME BASIS AS ANY OTHER BENEFIT UNDER THIS POLICY.
We will pay the following benefits for the necessary treatment of cancer or a specified disease:
Hospital Confinement
This pays the daily hospital confinement benefit selected by you for
each of the first 75 days for each period of confinement.
Outpatient Surgery Benefit
This pays a benefit equal to the daily hospital confinement benefit for
outpatient surgery in a hospital or free standing surgical center. Benefit
not payable for skin cancer.
Hospital Confinement for
Dependent Children
This pays an additional $100 per day when a covered dependent child is
confined to a hospital for treatment of cancer or specified disease, up to a
lifetime maximum of 50 days for each dependent child.
Inpatient Prescribed Drugs
and Medicines
This pays the actual charges, up to 25% of your daily hospital
confinement benefit per day for the hospital charges for prescribed drugs
and medicines taken during the first 75 days for each period of hospital
confinement.
Surgical Benefit
This pays up to $7,500 for the actual charges made by the surgeon for
surgery in or out of the hospital as outlined in the Surgical Benefits
Schedule in the policy.
Second and Third Surgical
Opinion
This pays the actual charges incurred for a second, or third if
necessary, surgical opinion.
Anesthesia
This pays up to 25% of the amount payable under the Surgical Benefit for
the administration of an anesthetic.
Physician’s Attendance
This pays the actual charges up to $35 per day for in-hospital
physician’s visits, other than surgeon.
Skin Cancer
This pays the actual charges incurred for removal of skin cancer and
administration of anesthesia during removal. There is a $150 maximum for
each skin cancer under this benefit if multiple skin cancers are not removed
at the same time. If more than one skin cancer is removed at the same time,
there is a $75 maximum for each skin cancer removed after the first. For
purposes of this benefit only, diagnosis may be made by a physician other
than a legally qualified pathologist. Skin cancer will mean basal cell
carcinoma and/or squamous cell carcinoma.
Blood and Plasma
This pays the actual charges for blood, blood plasma and platelets. We
will not pay for blood which is donated or replaced.
Breast Reconstruction/Breast
Prosthesis
This pays the actual charges incurred for an external breast prosthesis
subject to a calendar year maximum of $250. We will pay the actual charges
incurred with a lifetime maximum of $2,500 per breast for the following: (a)
an internal breast prosthesis and its implantation; or, (b) natural tissue
breast reconstruction surgery.
Artificial Limb and
Prosthesis
When an amputation is performed, this pays the actual charges for each:
(a) artificial limb or prosthesis; and (b) reconstructive procedure to affix
or implant it. Limited to a $2,000 lifetime maximum per insured person.
Bone Marrow Transplant
This pays the actual charges up to a lifetime maximum of $25,000 per
insured person for bone marrow transplants or other forms of stem cell
rescue and all related services and supplies. Payable in lieu of any other
benefits payable under this policy, except Transportation and Lodging for
Bone Marrow Donors.
Positive Diagnosis Test
This pays up to $250 for the actual charges incurred for the diagnostic
test that leads to a positive diagnosis within 90 days of such test. Benefit
not payable if same cancer or specified disease recurs.
Cancer Screening Tests
This pays up to $100 per calendar year for each insured
person for cancer screening tests.
Radiation, Radioactive
Isotopes Therapy, Chemotherapy, or Immunotherapy
This pays 50% of the first $50,000 of the actual charges incurred each
calendar year as provided for below. After that we will pay 100% of the
actual charges incurred each calendar year as provided for below. Limited to
a lifetime maximum amount of $125,000 for each insured person:
(a) teleradio therapy using either natural or artificial propagated
radiation when used for the purpose of modification or destruction of
cancerous tissue. This includes the actual charges for Radiation Treatment
Delivery only. It does not include charges for Clinical Treatment Planning,
Clinical Treatment Management, Medical Radiation Physics, Dosimetry,
Treatment Devices or special services;
(b) interstitial or intracavity application of radium or radio-active isotopes in sealed or non-sealed sources when used for the purpose of modification or destruction or cancerous tissue;
(c) cytotoxic chemical substances and their administration. This includes the actual charges for only those chemical substances which modify or destroy cancerous tissue and does not include other drugs or medicines given in conjunction with this treatment;
(d) hormonal therapy and its administration when used for treatment of cancer or covered specified diseases; (e) immunotherapy and its administration when used for treatment of cancer or covered specified diseases. In addition to the $125,000 lifetime benefit, we will pay the actual charges related to the above benefit up to $250 per calendar year for: (a) physical examinations; (b) checkups; (c) laboratory test; (d) diagnostic X-rays; (e) treatment consultation and planning related to this benefit; or (f) supportive and protective care drugs.
Private Duty Nursing Service
This pays the actual charges up to $150 per day for private duty nursing
care and attendance while confined in a hospital. The maximum number of days
of care payable will be equal to the number of days of covered hospital
confinement.
Ambulance Benefit
This pays the actual charges per trip to transfer an insured person to
the hospital for confinement as an inpatient. We will also pay the actual
charges for transportation from one medical facility to another and the trip
home from the hospital upon discharge. Limited to $5,000 per calendar year
for air ambulance service.
Transportation
For non-local covered treatment which requires hospital confinement,
this pays: (a) double the actual charges for round trip coach fare on a
common carrier to the nearest hospital that provides the prescribed
treatment; or (b) 50¢ per mile for personal automobile expense in excess of
50 miles one way, not to exceed 700 miles round trip.
Transportation
For non-local covered treatment which does not require hospital
confinement, this pays: (a) 50¢ per mile for personal automobile expenses in
excess of 50 miles one way, not to exceed 700 miles round trip up to a
maximum of $1,500 per calendar year; and (b) the actual charges up to $50
per day for lodging and meal expenses. Benefit is limited to the number of
days covered treatment is received.
Adult Companion Lodging and
Transportation
This pays the following expenses for one adult companion to be near you
or any insured person when such insured person is confined in a non-local
hospital for covered treatment: (a) the actual charges up to $50 per day for
lodging and meal expenses (this benefit is limited to the number of days of
the confined person’s covered hospitalization); and (b) up to a maximum of
$1,500 per calendar year for the actual charges of round trip coach fare on
a common carrier or a personal automobile allowance of 50¢ per mile, limited
to 700 miles round trip. This benefit will be payable to an adult companion
residing in the continental United States.
Transportation and Lodging
for Bone Marrow Donors
This pays the following expenses for the transportation and lodging of a
bone marrow donor when the donor is either an insured person, or someone
donating to an insured person: (a) the actual charges up to $2,500 for
medical expenses directly relating to the transplant; (b) the actual charges
for round trip coach fare on a common carrier or a personal automobile
allowance of 50¢ per mile in excess of 50 miles one-way to the city where
the transplant is performed; and (c) the actual charges up to $50 per day
for lodging and meal expenses when the donor is asked to remain near the
hospital. When an insured person is the
donor, this benefit is payable in lieu of any other benefit payable under
this policy.
Extended Care Facility
This pays up to $60 per day for confinement in an Extended Care
Facility. Such confinement must be recommended by the physician and begin
within 14 days of a covered hospital confinement. Benefits will be limited
to the number of days of the prior covered hospital confinement.
Mammograms
Pays the expense incurred for mammography screening. Benefits are limited to
a baseline mammogram for women 35 to 40 years old; a mammogram every two
years (or more frequently based on the recommendation of the woman’s
physician) for women 40 to 50 years old; and an annual mammogram for women
50 years of age and older.
Hospice Care
This pays the actual charges up to $100 per day for care provided by a
hospice if insured person is diagnosed as terminally ill. Limited to six
months for confinement in a hospice care center including designated areas
of a hospital or the insured’s home.
Home Health Care Services
This pays the following expenses when services are provided by a Home
Health Care Agency: (a) up to $60 per day for services provided at home, not
to exceed a maximum of 180 days per calendar year; (b) up to $100 per day
for Private Duty Nursing, not to exceed a maximum of 15 days per calendar
year; and (c) actual charges for physician’s visits up to $40 per day not to
exceed 15 days per calendar year.
Extended Benefits
If a covered hospital confinement lasts for more than 75 days in a row,
this pays up to $1,000 per day for the usual and normal charges for hospital
room and board, medicines, laboratory tests, and any other charges,
beginning on the 76th day. Payable in lieu of all other benefits during the
same time period.
Government or Charity
Hospital
This pays $200 per day for confinement in a government or charity
hospital. Payable in lieu of all other benefits except First Occurrence
Benefit (if selected), Transportation and Lodging Benefit, and Adult
Companion Lodging and Transportation Benefit.
Hairpiece Benefit
This pays a one-time benefit of up to $150 per insured person for a
hairpiece when hair loss is a result of cancer treatment.
Rental or Purchase of Durable
Medical Equipment
This pays the actual charges for the following pieces of medical
equipment, not to exceed $1,000 per calendar year: (a) a respirator or
similar mechanical device; (b) brace; (c) crutches; (d) hospital bed; or (e)
wheel chair.
Physical or Speech Therapy
This pays the actual charges up to $25 per session not to exceed a
policy lifetime maximum of $1,000.
Professional Mental Health
Consultation
This pays the actual charges up to $50 per session not to exceed a
policy lifetime maximum of $250 for consultation with a mental health
professional.
Tutorial
This pays the actual charges up to $25 per session, not to exceed a
policy lifetime maximum of $1,250 for a tutor while a covered dependent
child under age 19 is receiving treatment for a covered cancer or specified
disease.
Waiver of Premium
Premiums will be waived starting with the first policy renewal date
following a 90-day period of disability by the principal insured if the
disability begins before age 65 due to cancer or a covered specified
disease. We will waive the premium as long as the principal insured remains
disabled and is receiving treatment for cancer or specified disease for
which benefits are payable.
OPTIONAL BENEFIT RIDERS
(check if applied for and additional
premium, if any, paid):
INTERNAL CANCER FIRST OCCURRENCE
BENEFIT RIDER FORM 8209
Benefit Options:
$2,500 or $5,000
Pays the first time an insured person is diagnosed as having internal
cancer.
IV. EXCEPTIONS AND LIMITATIONS
PRE-EXISTING CONDITIONS -
LIMITATIONS FOR CERTAIN CONDITIONS
Benefits will not be payable for loss caused by pre-existing conditions
during the first two years the policy is in force. After the two year
period, loss due to such conditions will be payable unless specifically
excluded from coverage. The two year period is measured from the effective
date of coverage for each insured person. A pre-existing condition means a
cancer or specified disease which is first diagnosed prior to the effective
date of coverage for each insured person. Conditions which are: (a) fully
disclosed to us on the application; and (b) not excluded or limited by us
are not considered pre-existing conditions.
EXCEPTIONS - WHAT WE WILL NOT
PAY FOR
The policy pays only for loss
resulting from cancer or specified diseases. It DOES NOT cover:
(a) Any other disease or sickness.
(b) Injuries.
(c) Any disease or incapacity that has been caused, complicated, worsened, or affected by cancer or a specified disease or as a result of cancer or specified disease treatment.
(d) Hospital confinement or expenses that are incurred prior to the effective date of coverage regardless of the date of positive diagnosis.
(e) Bone Marrow Transplants except as provided in the Bone Marrow Transplant benefit (Benefits for bone marrow transplants are limited to a lifetime maximum of $25,000. No other benefits are payable for such treatment).
(f) Care and treatment received outside the United States or its territories.
(g) Hospital confinement or expenses that are incurred in a government or charity hospital, except as specifically provided in the Government or Charity Hospital benefit.
INTOXICANTS AND NARCOTICS
We will not be liable for any loss sustained or contracted as the result
of an insured person being physically or mentally impaired due to being
under the influence of alcohol or any narcotic, unless administered on the
advice of a physician. "Being under the influence of alcohol", for purposes
of this policy, means a blood alcohol
level of 0.08 or more. The insured person’s alcohol or narcotic impairment
must be the cause or contributing cause of his or her injuries, irrespective
of whether those injuries occurred while the insured person was driving a
motor vehicle or engaged in any other activity.
This Outline of Coverage is not a contract. It is intended only as a general description of the policy provisions in the planning of your insurance program. The benefits are determined by the terms and conditions of the policy alone. IN ALL CASES, CONSULT YOUR POLICY FOR FULL DETAILS.