Health Insurance Infomation.pdf

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D a m o n t a H e n r y 2 7 5 M o u n t a i n L a n e C o v i n g t o n , G A 3 0 0 1 6



THANK YOU for your purchase of HCC Life Insurance

Company’s Short Term Medical coverage. Please review

your coverage and application carefully. A few important

reminders regarding your coverage are outlined below:

The insurance contains the lifetime maximum,

co-insurance and deductible amounts that you selected

at the time of application. The coverage contains

exclusions for specific conditions and treatments as well

as a pre-existing condition exclusion. The insurance does

not pay for routine physicals or immunizations unless

required by state law. In addition, hernia operations, gall

bladder removal and other selected surgical procedures

are not covered for the first 6 months the coverage is in

force. HCC Life Insurance Company, in no event, willprovide benefits in excess of those specified in the

insurance contract. This insurance is not subject to

guaranteed issuance or renewal.

Getting Medical Treatment:Show your ID card to the medical attendant.Pay the deductible or copay (if applicable).

to us.

After the visit, you will need to submit aClaimant's Statement.

Filing a Medical Claim:Submit original, itemized bills, and anypayment receipts, and claim form

service.hccmis.comA copy of a Claims Statement can beobtained by clicking:

http://www.hccmis.com/downloads

Client Zone

https://zone.hccmis.com/clientzone/

Contact Us

service.hccmis.com

Cancellations (after Free Look period):

Should you wish to cancel, please send a request to [email protected] *Note - the request must include yourpolicy number and needs to come from the email address on file used to purchase the policy.If paying by monthly installments, a request needs to be submitted prior to your next installment date.

can be processed.

x

Free Look Provision:Your insurance contract contains a free look period which allows you to cancel the coverage for any reason.

Coverage. All cancellation requests should be sent to [email protected]

Pre-Existing Conditions:Charges resulting directly or indirectly from any pre-existing condition are excluded from this insurance.If you had an illness, and injury or condition at the time of purchase that you intended to have covered underthis insurance, it will likely not be covered and you should consider using the free look provision.Please refer to the limits set forth in your Short Term Medical insurance provided at the time of purchase.

HCC Medical Insurance Services, LLC

Important:

Act (PPACA). It does not contain many of the coverages required by PPACA. Depending on the time of year andindividual circumstances, you can purchase PPACA compliant individual health insurance plans from your state’sHealth Insurance Marketplace.

!

STM ADMINISTERED BY HCC MEDICAL INSURANCE SERVICESShort-Term Medical



Payment Receipt

For Certificate:

Paid By:Payment Type:Number:Amount:Date Paid:

Credit Card Payments OnlyExpiration Date:

Trans. Code:Auth. Code:

G A 1 6 0 0 0 7 6 8

D a m o n t a H e n r y M a s t e r C a r d

x x x x x x x x x x x x 4 2 0 8 $ 4 6 . 1 5

1 / 3 1 / 2 0 1 6

9 / 1 9

1 3 3 2 3 8 9 1 5 8

9 9 2 0 7 6



Covered Dependents:

Primary Insured:

Certificate #:

Effective Date:

POSSESSION OF THIS CARD DOES NOT GUARANTEE COVERAGE

|

|

FOLD

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• For general questionsregarding Eligibility / Benefits /Claims, please call:

1-800-605-2282 or

1-317-262-2132

• Mail itemized bills includingdiagnosis to:

HCCMIS Claims DepartmentBox No. 2005Farmington Hills, MI48333-2005

• Claims may be submittedelectronically usingPayer ID: HCCMI

Covered Dependents:

Primary Insured:

Certificate #:

Effective Date:

POSSESSION OF THIS CARD DOES NOT GUARANTEE COVERAGE

|

|

FOLD

|

|

• For general questionsregarding Eligibility / Benefits /Claims, please call:

1-800-605-2282 or

1-317-262-2132

• Mail itemized bills includingdiagnosis to:

HCCMIS Claims DepartmentBox No. 2005Farmington Hills, MI48333-2005

• Claims may be submittedelectronically usingPayer ID: HCCMI

G A 1 6 0 0 0 7 6 8

2 / 1 / 2 0 1 6

D a m o n t a H e n r y

G A 1 6 0 0 0 7 6 8

2 / 1 / 2 0 1 6




Includes most prescription drugs

Your nationally recognized VantageAmerica Solutions

Discount Pharmacy Card provides discounts on most FDA

approved prescription drugs. There are no limited drug lists,

no waiting periods and your card is active the moment you

present it to the pharmacy.

Savings average from 5%-15% off the cash price for brand

drugs and average 15%-40% off the price of generic drugs.

In the event a pharmacy’s price is lower than our discounted

price, you will always receive the lowest price available.

Your VantageAmerica Solutions Discount Pharmacy Card

is widely accepted at over 54,000 participating pharmacies

across the United States, including most national and

regional chains, pharmacy associations, and many local

community pharmacies. If your community pharmacy

is not enrolled, ask them to contact member services

at 1-800-974-3454. We always welcome new participation.

This program applies to your entire family. Everyone

deserves to save. All family members and friends are

eligible for this program. Please present your card every

savings. There are absolutely no restrictions.

For your convenience, we have already activated your card

and your savings will begin immediately. Please detach

card below and present to your local pharmacy.

ALSO DENTAL & IMAGING DISCOUNTS & MORE!

Save Money with your FREE Prescription Discount Card

Easy to Use!

Just present the attached card at a participating pharmac prescription. You will also realize immediate savings of25%-80% on MRI and CT scans and 5%-30% on DiabetiSupplies. Additionally, you can save 10%-35% on DentalCare, and 15% on Hearing Equipment. Simply call thenumbers on your card or visit the websites provided. Or,if you have questions or need assistance of any kind, cal

the Member Service Center at 1-800-975-3322 betweenthe hours of 8:00 am and 5:00 pm (CST). One of ourrepresentatives will be happy to help you get the most froyour complimentary VantageAmerica Solutions DiscountPharmacy Card.

Disclosures:

a. The discount medical card program is NOT healthinsurance.

b. The plan provides discounts at certain health careproviders for medical services.

c. The plan does not make payments directly to theproviders of medical services.

d. The range of discounts for medical or ancillary serviceprovided under the plan will vary depending on the typof provider and medical or ancillary services received.

e. The plan member is obligated to pay for all healthcare services but will receive a discount from thosehealth care providers who have contracted withVantageAmerica Solutions, Inc., a discount medical plaorganization.

Managed and Administered by:

VantageAmerica Solutions, Inc.1275 Milwaukee Avenue

Glenview, IL 60025

ADHV8-12-04

ADHV9-12-04

f ol d h er e

UNI-CAREValid for entire family

www.Beltone.com

Reference # MC 50

1-800-235-866

http://www.lookupdentists.netGroup VAS804106

1-800-308-0374

Group Code: GALAXY

1-877-814-2461

http://vantagediabeticplan.com

1-888-918-3782

PAYMENT MUST BE MADE AT SCHEDULING OR TIME OF SERVICE

Void where Prohibited by Law Process all transactions electronically

Member ID: HCCMIS4575

Group ID: HCCMIS4110

BIN: 610210

RXPCN: PRX

SM

http://lookuprx.net

1-800-974-3454

SM

R1/2016

R1/2016



HCC LIFE INSURANCE COMPANY225 TownPark Drive, Suite 350

Kennesaw, Georgia 30144

866-400-7102

SHORT TERM MEDICAL

INSURANCE POLICY

HCCL STMM IND GA

HCC Life Insurance Company (hereinafter the Company, We, Our, or Us) agrees to pay theinsurance benefits herein provided, subject to the terms and conditions of this Policy. Benefits arepayable in United States Dollars only.

This Policy is issued to the Policyholder (hereinafter the Insured, You or Your) in consideration ofthe application and payment of premiums, to take effect as of the Effective Date. This Policy willterminate as hereinafter provided.

The first premium is due on or before the Effective Date and future premiums are due as statedherein during the continuance of this Policy.

All periods indicated herein begin and end at 12:01 A.M. Standard Time at the address of thePolicyholder.

This Policy is delivered in and is governed by the laws of the Georgia.

The benefits and provisions set forth on the following pages, riders or endorsements are a part ofthis Policy as if recited over the parties' signatures.

Signed for HCC Life Insurance Company.

President Corporate Secretary

RIGHT TO EXAMINE POLICY FOR 10 DAYS: If You are not satisfied, return this Policy to Us within10 days after You have received it. All premiums, including all fees, will be refunded and Yourcoverage will be void.

SHORT TERM MEDICAL INSURANCE POLICY

THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLEFOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH

MEDICARE AVAILABLE FROM THE COMPANY.

NOTE: NO CONTINUOUS COVERAGE. This Policy provides coverage for a short term durationonly. It is not renewable.

For service or complaints about this policy, please address any inquiries tothe address shown above or call 1-866-400-7102.



HCCL STMM IND GA

TABLE OF CONTENTS

PART I GENERAL DEFINITIONS ..................................................................... Page 3

PART II ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE ....................... Page 7

PART III TERMINATION OF INSURANCE………………………………………… Page 8

PART IV PREMIUMS ........................................................................................ Page 10

PART V DESCRIPTION OF MEDICAL EXPENSES ........................................ Page 11

PART VI EXCLUSIONS .................................................................................... Page 15

PART VII CLAIM PROVISIONS ......................................................................... Page 18

PART VIII GENERAL PROVISIONS ................................................................... Page 19

PART IX SCHEDULE OF BENEFITS ................................................................ Page 20

OPTIONAL BENEFIT RIDERS, IF ANY

AMENDMENT RIDERS, IF ANY



HCCL STMM IND GA 3

PART I – GENERAL DEFINITIONS

“Accident” means a sudden, unforeseeable event that causes injury to one or more CoveredPersons.

“Complications of Pregnancy” means:

1. Conditions requiring Inpatient treatment (when pregnancy is not terminated);2. Whose diagnoses are distinct from pregnancy but are adversely affected or caused by

pregnancy, such as hyperemesis gravidarum, preeclampsia, acute nephritis, nephrosis,cardiac decompensation, missed abortion and similar medical and surgical conditions ofcomparable severity, but shall not include false labor, occasional spotting, Doctorprescribed rest during the period of pregnancy, morning Sickness, and other similarconditions associated with the management of a difficult pregnancy not constituting anosologically distinct complication of pregnancy; and

3. Non-scheduled or emergency cesarean section, ectopic pregnancy that is terminated,and spontaneous termination of pregnancy that occurs during a period of gestation inwhich a viable birth is not possible.

“Congenital Condition” means a disease or other anomaly existing at or before birth, whetheracquired during development or by heredity.

“Coverage Period” means the length of time which the Insured selected in the Insured’sapplication and approved by us, not to exceed a month period commencing on theEffective Date. The Insured’s Coverage Period is shown in the Schedule of Benefits.

“Covered Person” means an Insured and his eligible dependents for whom coverage is in effectunder this policy, as described in Part II – Eligibility and Effective Date of Insurance Provisionsand the Schedule of Benefits.

“Custodial or Convalescence Care” means any care that is provided to a Covered Person who

is disabled and needs help to support the essential activities of daily living when the CoveredPerson is not under active and specific medical, surgical, or psychiatric treatment that willreduce the disability to the extent necessary for the person to perform the essentials of dailyliving on his own. The essential activities of daily living include:1. personal care such as help in: walking, getting in and out of bed, bathing, eating,

exercising, dressing, using the toilet or administration of an enema;2. homemaking such as preparing meals or special diets;3. moving the patient; and4. acting as companion or sitter.

“Deductible” means the amount of covered expenses that must be paid by a Covered Personbefore benefits are payable under this policy. This amount applies separately to each Covered

Person and must be satisfied during the Coverage Period.

“Doctor” means any duly licensed practitioner who is recognized by the law of the state in whichtreatment is received as qualified to perform the service for which claim is made.

“Eligible Dependent” means:1. The Insured’s lawful spouse; and2. The Insured’s unmarried children who are less than age 19. An unmarried child who is

less than age 26 may also be included if the child is enrolled full-time in an accredited

s i x ( 6 )



HCCL STMM IND GA 4

school or college; however, if such child is prevented from being enrolled due to illnessor injury, he or she shall still be considered an eligible dependent.

Coverage for an unmarried dependent child who is incapable of sustaining employment byreason of mental retardation or physical disability as determined by the Department of HumanResources, who became so incapacitated prior to the attainment of the limiting age set forth

above, and who is chiefly dependent upon the Insured for support and maintenance shall notterminate. Coverage shall continue so long as this policy remains in force and the dependentremains in such condition. Proof of such incapacity must be given to Us within thirty-one (31)days of the child’s attainment of the limiting age.

Dependent children may include stepchildren, foster children, legally adopted children, childrenof adopting parents pending finalization of adoption procedures, and children for whomcoverage has been court-ordered.

Dependent children (other than those for whom coverage has been court-ordered) must beprimarily dependent on the Insured for principal support and maintenance.

“Durable Medical Equipment” means medical equipment that can withstand repeated use, isprescribed by a Physician, and is appropriate for use in the home. Covered DME is limited to astandard basic Hospital bed and/or a standard basic wheel chair.

“Effective Date” means the date the Insured’s (and Eligible Dependents’ if applicable) coverageunder this policy is effective.

“Experimental Treatment” means in Our discretion a treatment, drug, device, procedure, supplyor service and related services (or any portion thereof, including the form, administration ordosage) for a particular diagnosis or condition when any one of the following exists:1. The treatment, drug, device, procedure, supply or service is in any clinical trial or a

Phase I, II or III trial.

2. The treatment, drug, device, procedure, supply or service is not yet fully approved orrecognized (for other than experimental, investigational, research or clinical trialpurposes) by the National Cancer Institute (NCI), Food & Drug Administration (FDA), orother pertinent governmental agency or professional organization.

3. The results are not proven through controlled clinical trials with results published in peer-reviewed English language medical journals, to be of greater safety and efficacy thanconventional treatment, in both the short and long term.

4. The treatment, drug, device, procedure, supply or service is not generally acceptedmedical practice in the state where the Covered Person resides or as generally acceptedthroughout the United States as determined in Our discretion, by reference to any one ormore of the following: peer-reviewed English-language medical literature, consultationwith physicians, authoritative medical compendia, the American Medical Association, or

other pertinent professional organization or governmental agency.5. The treatment, drug, device, procedure, supply or service is described as investigational,

experimental, a study, or for research or the like in any consent, release or authorizationwhich the Covered Person, or someone acting on his or her behalf, may be required tosign.

The fact that a procedure, service, supply, treatment, drug, or device may be the only hope forsurvival will not change the fact that it is otherwise experimental in nature.



HCCL STMM IND GA 5

“Extended Care Facility” means an institution, other than a Hospital, operated and licensedpursuant to law, that provides:1. Permanent and full-time facilities for the continuous skilled nursing care of three (3) or

more sick or injured persons on an Inpatient basis during the convalescent stage of theirillnesses or injuries;

2. Full-time supervision of a Doctor;

3. Twenty-four (24) hour a day nursing service of one or more Nurses; and4. Is not, other than incidentally, a rest home or a home for custodial care or for the aged.

Extended Care Facility does not include an institution that primarily engages in the careand treatment of drug addiction or alcoholism.

“Home Health Care Agency” means an entity licensed by state or local law operated primarily toprovide skilled nursing care and therapeutic services in an individual’s home and:1. Which maintains clinical records on each patient;2. Whose services are under the supervision of a Doctor or a licensed graduate registered

nurse (RN); and3. Which maintains operational policies established by a professional group including at

least one Doctor and one licensed graduate registered nurse (RN).

“Home Health Care Plan” means a program for continued care and treatment of an individualestablished and approved in writing by the individual’s attending Doctor. As part of the plan, anattending Doctor must certify that proper treatment of the Injury or Sickness would requirecontinued confinement in a Hospital in the absence of the services and supplies.

“Hospital” means an institution operated by law for the care and treatment of injured or sickpersons; has organized facilities for diagnosis and surgery or has a contract with anotherhospital for these services; and has 24-hour nursing service. Hospital excludes any institutionthat is primarily a rest home, nursing home, convalescent home, a home for the aged, or analcoholism or drug addiction treatment facility.

“Immediate Family” means the parents, spouse, children, or siblings of a Covered Person, orany person residing with a Covered Person.

“Injury” means accidental bodily Injury of a Covered Person:1. Caused by an Accident; and2. That results in covered loss directly and independently of all other causes.

All Injuries sustained in one Accident, including all related conditions and recurring symptoms ofthe Injuries, will be considered one injury.

“Inpatient” means a person who incurs medical expenses for at least one day’s room and boardfrom a Hospital.

“Insured” means a person who meets the eligibility requirements for an Insured as stated in theapplication and this policy, and whose coverage under this policy has become effective and hasnot terminated.

“Medically Necessary” means the care, service or supply is:1. Prescribed by a Doctor for the diagnosis or treatment of an Injury or Sickness; and



HCCL STMM IND GA 6

2. Appropriate, according to conventional medical practice for the Injury or Sickness in thelocality in which the care, service or supply, is given.

“Mental and Nervous Disorder” means a “biologically-based” mental disorder, includingSchizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoiaand other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and

dementia, Affective disorders, and any other "biologically-based" mental disorders appearing inthe most recent edition of the Diagnostic and Statistical Manual of the American PsychiatricAssociation (the "DSM").

“Outpatient” means a person who incurs medical expenses at Doctor’s offices and freestandingclinics, and at Hospitals when not admitted as an Inpatient.

“Regular and Customary Activities” means an Insured Person can carry on a substantial part ofthe standard and commonly practiced activities of a person in good health of the same sex andage. Activities performed while confined in a Hospital or other medical institution may not beused to meet this requirement.

“Routine Physical Exam” means examination of the physical body by a Doctor for preventive orinformative purposes only, and not for the diagnosis or treatment of any condition.

“Sickness” means Sickness or disease of a Covered Person that:1. Is treated by a Doctor while the person is covered under this policy; and2. Results directly and independently of all other causes in loss covered by this policy.

“Substance Abuse” means the overindulgence in and dependence on a psychoactive leading toeffects that are detrimental to the individual's physical health or mental health, or the welfare ofothers.

“Surgery or Surgical Procedure” means an invasive diagnostic procedure; or the treatment of

Injury or Sickness by manual or instrumental operations performed by a Doctor while the patientis under general or local anesthesia.

“Total Disability” (or “Totally Disabled”) means the Insured is disabled and prevented fromperforming the material and substantial duties of his or her occupation. For Dependents,“Totally Disabled” means the inability to perform a majority of the normal activities of a person oflike age in good health.

“Urgent Care Center” means a medical facility separate from a hospital emergency departmentwhere ambulatory patients can be treated on a walk-in basis without an appointment andreceive immediate, non-routine urgent care for an Injury or Sickness presented on an episodicbasis.

“Usual and Customary” charges means the following:1. A usual fee is defined as the charge made for a given service by a Doctor to the majority

of his or her patients; and2. A customary fee is one that is charged by the majority of Doctors within a geographic

area for the same services. Geographic area means the same, or similar, city or townwhere the health care service was performed including the surrounding areas with zipcodes that begin with the same first 3 digits. All benefits are limited to Usual andCustomary charges.



HCCL STMM IND GA 7

PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE

Coverage will be effective for an Insured and his Eligible Dependent(s) as of the approvedEffective Date, provided:1. The Insured meets the eligibility requirements set forth in the application and this policy;2. The Insured's Application is approved by Us;

3. The first premium payment is received on or before the Effective Date;4. The Insured is not confined at home or in a Hospital or medical institution as of the

Effective date; and5. The Insured is engaging in his Regular and Customary Activities as of the Effective date.

If the Insured is not engaged in his Regular and Customary Activities or is confined in a Hospitalor medical institution on the Effective Date, coverage will begin the first day he can engage inhis Regular and Customary Activities and is not confined in a Hospital or medical institution.

The Company will require satisfactory evidence of insurability for each Insured and EligibleDependent.

Newborn Child Coverage: A child of the Insured born while this policy is in force is covered forInjury and Sickness (including necessary care and treatment of congenital defects, birthabnormality and premature birth), as well as routine newborn care for the first 31 days. Thechild is covered from the moment of birth until the 31st day of age. A notice of birth together withadditional premium must be submitted to us within 31 days of the birth in order to continuecoverage for Injury and Sickness beyond the initial 31-day period.

Adopted Children Coverage: A minor child who comes under the charge, care and control ofthe Insured while this policy is in force is covered for Injury and Sickness provided the Insuredfiles a petition to adopt. The coverage of such child will be the same as provided for othermembers of the Insured’s family. Such child shall be covered from the date of placement in theInsured’s home if the Insured applies for coverage and pays any required premium within 31

days after the date of placement. However, coverage shall begin at the moment of birth if thepetition for adoption, application for coverage and payment of premium occurs within 31 daysafter the child’s birth. Such child’s coverage will not be subject to any pre-existing conditionslimitation provided by this policy. Coverage for such minor child will continue unless the petitionfor adoption is dismissed or denied.

.



HCCL STMM IND GA 8

PART III - TERMINATION OF INSURANCE

Coverage of a Covered Person under this policy shall automatically terminate on the earliest ofthe following dates:1. The date the Coverage Period expires;2. The end of the last period for which the last required premium payment was made for

the Insured’s or Covered Person’s insurance;3. The date a Covered Person receives the Coverage Period Maximum Benefit Amount;4. The date the Covered Person enters the armed forces of any country, state or

international organization, other than for reserve duty of 30 days or less;5. The premium due date that coincides with or next follows the date on which the Insured

is no longer eligible;6. For a Dependent spouse, the first day of the month following the date of a valid decree

of divorce from the Insured; or

7. The date We specify that the Covered Person’s insurance is terminated because ofmaterial misrepresentation, fraud, or omission of information on any application form, orin requesting the receipt of benefits under this policy.

The Company will refund the premium paid, if any, for coverage beyond the termination datesstated above within thirty (30) days of such termination.

Following divorce from the Insured, coverage for a Dependent spouse and Dependent child(ren)may be continued for the remainder of the Coverage Period provided the required premiums arepaid. A Dependent child who is no longer eligible due to attainment of the maximum age willalso have this right.

At the death of an Insured, all rights and privileges as a Covered Person under this policy willtransfer to the surviving Dependent spouse. The Dependent spouse will then be considered anInsured instead of a Dependent. In the event the Dependent spouse remarries, coverage under

this policy for the Dependent Spouse and Dependent child(ren), if any, will end on the first dayof the month following the date of that marriage. If no surviving Dependent spouse, or at thedeath of a surviving Dependent spouse, all rights and privileges as a Covered Person under thispolicy will transfer to each Dependent child, if any, and he will be considered the Insured insteadof a Dependent.

If the Insured selected the Pay In Advance option in the Insured's Application and We receivedall required premium for the Coverage Period, premium will be reimbursed to the Insured for theperiod of time, if any, between the date coverage terminates in accordance with the aboveprovisions and the end of the Coverage Period.

Extension of Benefits

If a covered Bodily Injury or Sickness commences while this policy is in force as to a CoveredPerson, benefits otherwise payable under this policy for the Injury or Sickness causing the TotalDisability will also be paid for any Eligible Expenses incurred after the termination of insurancefor a Covered Person if, from the date of such termination to the date such expenses areincurred, the Covered Person is Totally Disabled by reason of such Injury or Sickness. Suchbenefits shall be payable only during the continuance of such disability until the earlier of:1. The date the Total Disability ends;2. The date when treatment for the Total Disability is no longer required;



HCCL STMM IND GA 9

3. The date following a time period equal to the Covered Person's Coverage Period, with aminimum of thirty (30) days not to exceed a maximum of ninety (90) days;

4. The date the Covered Person becomes covered for any other medical insurance planproviding coverage for the same conditions causing the Total Disability; or

5. The date the Coverage Period Maximum Benefit amount has been reached.



HCCL STMM IND GA 10

PART IV - PREMIUMS

1. Unless the Pay In Advance option has been chosen, premium due dates for an Insuredwill be on the Effective Date and monthly thereafter. All insurance shall be charged fromand to the premium due date.

2. The monthly premium rates shown in the attached Schedule of Premiums are based onattained age of the Insured and any Dependent Spouse (as of the Insured’s EffectiveDate, and the number of Dependent Children (if any). Each premium shall be the sum ofthe premiums determined by applying the appropriate premium rates in the Schedule ofPremiums to the amounts of each form of insurance in force under this policy on thedate the premium is due.

3. If any change or clerical error affects premiums, an equitable adjustment in premiumsshall be made on the premium due date next following the date of the change or thediscovery of the error.

4. The first premium is due on or before the Effective Date, all other premiums shall bepayable to Us at Our Home Office when due or within the grace period.

5. If the Insured has not given written notice to Us that insurance is to be terminated priorto the premium due date, a grace period of thirty-one (31) days beginning from thepremium due date will be allowed for any premium after the first premium. If the Insuredfails to pay premium before the grace period expires all coverage shall lapse as of thepremium due date.

6. This policy does not share in the surplus earnings of the Company and no refund orassessment shall be made to any Insured, or Dependent of any excess or deficitearnings of the Company.



HCCL STMM IND GA 11

PART V – DESCRIPTION OF MEDICAL EXPENSES

Subject to the Deductible, Coinsurance and other limits set forth in PART IX – SCHEDULE OFBENEFITS, the Company will pay the following expenses incurred while this insurance is ineffect:1. Charges made by a Hospital for:

A. Daily room and board and nursing services not to exceed the average semi-private room rate. If a Hospital only has private rooms, benefits will be paid forthe average semi-private room rate for the area where the hospital is located;

B. Daily room and board and nursing services in Intensive Care Unit;C. Use of operating, treatment or recovery room;D. Services and supplies which are routinely provided by the Hospital to persons for

use while Inpatients;E. Emergency treatment of an Injury, even if Hospital confinement is not required;

andF. Emergency treatment of a Sickness; however, an additional $250 Deductible will

apply to emergency room charges unless the Covered Person is directlyadmitted to the Hospital as an Inpatient for further treatment of that Sickness.

2. For Surgery at an Outpatient surgical facility, including services and supplies.3. For charges made by a Doctor for professional services, including Surgery. Charges for

an assistant surgeon are covered up to 20% of the Usual and Customary charge of theprimary surgeon. (Standby availability will not be deemed to be a professional serviceand therefore is not covered).

4. For dressings, sutures, casts or other supplies which are Medically Necessary andadministered by or under the supervision of a Doctor, but excluding nebulizers, oxygentanks, diabetic supplies, other supplies for use or application at home, and all devices orsupplies for repeat use at home, except Durable Medical Equipment as herein defined.

5. For diagnostic testing using radiology, ultrasonographic or laboratory services(psychometric, intelligence, behavioral and educational testing are not included).

6. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs,

but not the replacement or repair thereof.7. For reconstructive surgery when the surgery is directly related to surgery which is

covered under this policy, including reconstructive breast surgery and prosthetic devicesincident to a Mastectomy. Coverage will also be extended to include surgery on a non-diseased breast to establish symmetry with the diseased breast. As used in this benefit:A. “Mastectomy” means the surgical removal of all or part of a breast as a result of

breast cancer.B. “Reconstructive breast surgery” means surgery performed as a result of a

mastectomy to reestablish symmetry between the two breasts and includesaugmentation mammoplasty, reductive mammoplasty, and mastopexy.

8. For radiation therapy or treatment and chemotherapy.9. For hemodialysis and the charges by the Hospital for processing and administration of

blood or blood components but not the cost of the actual blood or blood components.10. For oxygen and other gasses and their administration by or under the supervision of a

Doctor.11. For anesthetics and their administration by a Doctor, subject to a maximum of 20% of

the benefit payable for the primary surgeon.12. Extended Care Facility charges for room and board accommodations; if:

A. The Insured is an Inpatient in that facility on the certification of the attendingDoctor that the confinement is Medically Necessary;



HCCL STMM IND GA 12

B. The confinement commences immediately following a period of at least three (3)continuous days of Hospital confinement; and

C. That confinement is for the same covered Injury or Sickness that was treatedduring the Covered Person's confinement in the Hospital.

13. Treatment of a Covered Person by a Home Health Care Agency under a Home HealthCare Plan. Up to four (4) consecutive hours in a twenty-four (24) hour period of Home

Health Care services shall be considered as one Home Health Care visit. EligibleExpenses for Home Health Care are the Maximum Allowable Charges made for thefollowing:A. Part-time skilled nursing care;B. Physical therapy;C. Speech therapy;D. Medical supplies, drugs and medicines prescribed by a Doctor;E. Laboratory services by or on behalf of the Hospital but only to the extent benefits

for those services would have been paid under this policy had the CoveredPerson remained Hospitalized;

F. Occupational therapy; and

G. Respiratory therapy.However, benefits will not be paid for charges made by a Home Health Care Agency for:A. Any charges excluded under the Exclusions of this policy;B. Full-time nursing care at home;C. Meals delivered to the home;D. Homemaker services;E. Any services of an individual who ordinarily resides in the Insured’s home or is a

member of the Insured's immediate family; orF. Any transportation services.Benefits for Home Health Care are in lieu of any similar benefits provided under anyother provision of this policy.

14. Local Ambulance transport necessarily incurred in connection with Injury, and Local

Ambulance transport necessarily incurred in connection with Sickness resulting inInpatient hospitalization.

15. Dental treatment and dental surgery necessary to restore or replace natural teeth lost ordamaged as a result of an Injury covered under this policy.

16. Medically Necessary rental of Durable Medical Equipment (limited to a standard basichospital bed and/or a standard basic wheelchair) up to the purchase prices, not includingexpenses for customization and only for the portion of the cost equivalent to theCoverage Period.

17. Physical Therapy if prescribed by a Doctor who is not affiliated with the Physical Therapypractice, necessarily incurred to continue recovery from a covered Injury or Sickness.

18. Ovarian Cancer – Coverage shall be provided for surveillance tests for women age thirty(35) or older at risk for ovarian cancer.

As used here:“At risk for ovarian cancer” means:A. Having a family history:

i. with one or more first or second degree relatives with ovarian cancer;ii. of clusters of women relatives with breast cancer;iii. of nonpolyposis colorectal cancer; or

B. Testing positive for BRCA1 or BRCA2 mutations."Surveillance tests” mean annual screening using:A. CA-125 serum tumor marker testing;



HCCL STMM IND GA 13

B. Transvaginal ultrasound; andC. Pelvic examination.

19. Mammography Screening - Coverage shall be provided for low dose radiologicscreening for the early detection of breast cancer based on the following:A. A baseline mammogram for a woman who is thirty-five (35) to forty (40) years of

age;

B. A mammogram for a woman who is forty (40) to forty-nine (49) years of age,every two years;

C. A mammogram each year for a woman who is at least fifty years (50) of age; andD. When ordered by a Doctor for a woman at risk.

20. Pap Smear – Coverage shall be provided for an annual pap smear. As used here, "papsmear" means an examination of the tissues of the cervix of the uterus for the purpose ofdetecting cancer when performed upon the recommendation of a medical Doctor, whichexamination may be made once a year or more often if recommended by a Doctor.

21. Prostate Screenings - Coverage shall be provided for an annual prostate specific antigentest for males who are:A. 45 years of age or older; orB. 40 years of age or older if ordered by a Doctor.

Prostate specific antigen test means a measurement in accordance with the standardsestablished by the American College of Pathologists.

22. Chlamydia Screening – Coverage shall be provided for one (1) annual chlamydiascreening test for a female who is not more than 29 years old. “Chlamydia screeningtest” means any laboratory test of the urogenital tract which specifically detects forinfection by one or more agents of chlamydia trachomatis. This test must be approvedfor such purposed by the FDA.

23 Osteoporosis - Coverage shall be provided for the prevention, diagnosis and treatmentof osteoporosis. Coverage will include reimbursement for scientifically proven bonemass measurement (bone density testing).

Pre-Certification Requirements

1. All hospitalizations, other Inpatient care, and Surgeries or Surgical Procedures must bePre-certified.

2. To comply with the Pre-certification requirements, the Covered Person must:A. Contact HCC Life at 1-800-447-0460 as soon as possible before the expense is

to be incurred; andB. Comply with the instructions of HCC Life and submit any information or

documents they require; andC. Notify all Doctors, Hospitals and other providers that this insurance contains Pre-

certification requirements and ask them to fully cooperate with HCC Life. 3. If the Covered Person complies with the Pre-certification requirements, and the

expenses are Pre-certified, the Company will pay Eligible Medical Expenses subject toall terms, conditions, provisions and exclusions described in this policy. If the Covered

Person does not comply with the Pre-certification requirements or if the expenses arenot Pre-certified:A. Eligible Medical Expenses will be reduced by 50%; andB. The Deductible will be subtracted from the remaining amount; andC. The Coinsurance will be applied.

4. Emergency Pre-certification: In the event of an emergency Hospital admission, Pre-certification must be made within 48 hours after the admission, or as soon as isreasonably possible.



HCCL STMM IND GA 14

5. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certifieddoes not guarantee either payment of benefits or the amount of benefits. Eligibility forand payment of benefits are subject to all the terms, conditions, provisions andexclusions herein.

6. Concurrent Review – For Inpatient stays of any kind, HCC Life will Pre-certify a limitednumber of days of confinement. Additional days of Inpatient confinement may later be

Pre-certified if a Covered Person receives prior approval.



HCCL STMM IND GA 15

PART VI – EXCLUSIONS

Charges for the following treatments and/or services and/or supplies and/or conditions areexcluded from coverage:1. Pre-existing Conditions – Charges resulting directly or indirectly from a condition for

which a Covered Person received medical treatment, diagnosis, care or advice within

the twelve (12) month period immediately preceding such person’s Effective Date areexcluded for the six (6) months of coverage hereunder. This exclusion does not applyto a newborn or newly adopted child who is added to coverage under this policy inaccordance with PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.

2. Outpatient Prescription Drugs, medications, vitamins, and mineral or food supplementsincluding pre-natal vitamins, or any over-the-counter medicines, whether or not orderedby a Doctor.

3. Routine pre-natal care, Pregnancy, childbirth, and postnatal care. (This exclusion doesnot apply to “Complications of Pregnancy” as defined.)

4. Alcoholism.5. Substance abuse.6. Charges which are not incurred by a Covered Person during his/her Coverage Period.

7. Treatment, services or supplies, which are not administered by or under thesupervision of a Doctor.

8. Treatment, services or supplies which are not Medically Necessary as defined.9. Treatment, services or supplies provided at no cost to the Covered Person.10. Charges which exceed Usual and Customary charge as defined.11. Telephone consultations or failure to keep a scheduled appointment.12. Consultations and/or treatment provided over the Internet.13. Surgeries, treatments, services or supplies which are deemed to be Experimental

Treatment.14. All charges Incurred while confined primarily to receive Custodial or Convalescence

Care.15. Weight modification or surgical treatment of obesity, including wiring of the teeth and all

forms of intestinal bypass surgery.16. Modifications of the physical body in order to improve the psychological, mental or

emotional well-being of the Covered Person, such as sex-change surgery.17. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except

for reconstructive surgery which is expressly covered under this policy.18. Any drug, treatment or procedure that either promotes or prevents conception including

but not limited to: artificial insemination, treatment for infertility or impotency,sterilization or reversal of sterilization.

19. Any drug, treatment or procedure that either promotes, enhances or corrects impotencyor sexual dysfunction.

20. Abortions, except in connection with covered Complications of Pregnancy or if the lifeof the expectant mother would be at risk.

21. Dental treatment, except for dental treatment that is expressly covered under thispolicy.

22. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visualtherapy, and any examination or fitting related to these devices, and all vision andhearing tests and examinations.

23. Eye surgery, such as radial keratotomy, when the primary purpose is to correctnearsightedness, farsightedness or astigmatism.

24. Treatment for cataracts.25. Treatment of the temporomandibular joint.



HCCL STMM IND GA 16

26. Injuries resulting from participation in any form of skydiving, scuba diving, organizedauto racing, bungee jumping, hang or ultra light gliding, parasailing, sail planing, flyingin an aircraft (other than as a passenger on a commercial airline), rodeo contests or asa result of participating in any professional, semi-professional or other non-recreationalsports including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes,snowmobiling or go-carting.

27. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate ororganized competitive sports.

28. Injury resulting from being intoxicated or under the influence of any narcotic unlessadministered on the advice of a physician.

29. Willfully self-inflicted Injury or Sickness.30. Immunizations and Routine Physical Exams.31. Services received for any condition caused by a Covered Person’s commission of or

attempt to commit a felony or to which a contributing cause was the Covered Personbeing engaged in an illegal occupation.

32. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep ormusic therapy, holistic care of any nature, massage and kinestherapy.

33. Any services performed or supplies provided by a member of the Insured’s Immediate

Family.34. Orthoptics and visual eye training.35. Services or supplies which are not included as Eligible Expenses as described herein.36. Care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription

devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstableor unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses ortoenails.

37. Care and treatment for hair loss including wigs, hair transplants or any drug thatpromises hair growth, whether or not prescribed by a Doctor.

38. Treatment of sleep disorders.39. Hypnotherapy when used to treat conditions that are not recognized as Mental or

Nervous Disorders by the American Psychiatric Association, and biofeedback, and non-

medical self-care or self-help programs.40. Any services or supplies in connection with cigarette smoking cessation.41. Exercise programs, whether or not prescribed or recommended by a Doctor.42. Treatment required as a result of complications or consequences of a treatment or

condition not covered under this policy.43. Charges for travel or accommodations, except as expressly provided for local

ambulance.44. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or

radioactive material(s).45. Organ or Tissue Transplants or related services.46. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea,

sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic

conditions of skin, nevus.47. Services received or supplies purchased outside the United States, its territories or

possessions, or Canada.48. Treatment for or related to any congenital condition, except as it relates to a newborn

or adopted child added as a Covered Person to this policy.49. Spinal manipulation or adjustment.50. Sclerotherapy for veins of the extremities.



HCCL STMM IND GA 17

51. Except in an emergency, expenses during the first 6 months after the Effective Date ofcoverage for a Covered Person for the following (subject to all other coverageprovisions, including but not limited to the Pre-existing Condition exclusion):

A. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosisof carcinoma;

B. Tonsillectomy;

C. Adenoidectomy;D. Repair of deviated nasal septum or any type of surgery involving the sinus;E. Myringotomy;F. Tympanotomy;G. Herniorraphy; orH. Cholecystectomy.

52. Chronic fatigue or pain disorders.53. Treatment or diagnosis of allergies, except for emergency treatment of allergic

reactions.54. Treatment, medication or hormones to stimulate growth, or treatment of learning

disorders, disabilities, developmental delays or deficiencies, including therapy.55. Kidney or end stage renal disease.

56. Joint replacement or other treatment of joints, spine, bones or connective tissueincluding tendons, ligaments and cartilage, unless related to a covered Injury.

57. Expenses resulting from a declared or undeclared war, or from voluntary participationin a riot or insurrection.

58. Expenses incurred by a Covered Person while on active duty in the armed forces.Upon written notice to Us of entry into such active duty, the unused premium will bereturned to the Covered Person on a pro-rated basis.



HCCL STMM IND GA 18

PART VII - CLAIM PROVISIONS

Notice of Claim: Written notice of claim must be given within 31 days after a covered lossbegins or as soon as is reasonably possible. The notice must be given to HCC Life. Noticeshould include information that identifies the claimant and the policy.

Claim Forms: When HCC Life receives notice of claim, forms for filing proof of loss will be sentto the claimant. If claim forms are not supplied within 10 working days, a claimant can giveproof as follows:1. In writing;2. Setting forth the nature and extent of the loss; and3. Within the time stated in the Proof of Loss provision.

Proof of Loss: Written proof of loss must be given to HCC Life within 90 days after the lossbegins. We will not deny nor reduce any claim if it was not reasonably possible to give proof ofloss in the time required. In any event, proof must be given to HCC Life within one year after itis due unless the Insured is legally incapable of doing so.

Time of Payment of Claim: Benefits for loss covered by this policy will be paid or denied assoon as We receive proper written proof of such loss. Payment or notice of denial will be madeno later than fifteen (15) working days after receipt of Proof of Loss. If a claim is denied, We willgive written notice stating the reasons for the denial and the information necessary to processthe claim. We will pay the claim within 15 working days of receipt of the necessary information.If a claim is not paid and notice of denial not given, We will pay interest at 18% per year on anyunpaid claim amount.

Payment of Claims: All benefits will be paid to the Insured, if living, unless an Assignment ofBenefits has been requested by the Insured. Any other benefits due and unpaid at the Insured’sdeath will be paid to the Insured’s estate. If a benefit is to be paid to the Insured’s estate, or toan Insured or beneficiary who is not competent to give a valid release, the Company may pay

up to $1,000.00 of such benefit to one of the Insured’s relatives who is deemed by the Companyto be justly entitled to it. Such payment, made in good faith, fully discharges the Company tothe extent of the payment.

Physical Examination: At our expense, we may have a person claiming benefits examined asoften as reasonably necessary while the claim is pending.

Legal Action: No legal action may be brought to recover on this policy before 60 days afterwritten proof of loss has been furnished as required by this policy. No such action may bebrought after three years from the time written proof of loss is required to be furnished.



HCCL STMM IND GA 19

PART VIII – GENERAL PROVISIONS

Time Limit on Certain Defenses: The validity of this policy shall not be contested, except fornon-payment of premiums. No statement made by any Covered Person relating to hisinsurability, except a fraudulent misstatement, shall be used to contest the validity of anyinsurance with respect to which that statement was made, unless it is contained in a writteninstrument signed by him, and such statement is material to the risk assumed by the Companyand a copy of such instrument is or has been furnished to him or to his beneficiary.

Misstatement of Age: If the age of any Covered Person is incorrectly stated, we will make a fairadjustment of the premiums, benefits or both; such adjustment shall be made within 10 workingdays of discovering the error. The adjustment will be based on the premiums and benefits thatwould have been payable had we known the correct information. If based on the correct age,this policy would not have been issued or would have terminated earlier, the Company’s liabilityshall be a refund any premiums paid.

Not in Lieu of Workers’ Compensation: This policy is not in lieu of and does not affectrequirements for coverage under Workers’ Compensation laws.

Pronouns: Whenever a personal pronoun in the masculine gender is used, it will be deemed toinclude the feminine also, unless the context clearly indicates to the contrary.

Entire Contract: This policy, riders, endorsements and all applications copies of which areattached hereto, shall constitute the entire contract between the parties. All statements made bythe policyholder and any other covered persons shall be deemed representations and notwarranties.

Authority, Amendment and Alteration: None of the terms of this policy may be modified, exceptby an agreement in writing signed by the President, a Vice President or the Secretary of theCompany. The authority for this purpose cannot be delegated. This policy may be amended orchanged at any time, subject to the laws of the jurisdiction in which it is delivered. No agent orperson, other than as stated above, shall have the authority to change this policy or otherwisewaive any requirements or provisions of this policy. No change in this policy shall be validunless mutually agreed to in writing and evidenced by endorsement on this policy or by anamendment to this policy signed by Us and the Policyholder.

Non-Renewability of Insurance: Insurance for an Insured and his Eligible Dependents, if any,does not renew and shall terminate at the end of the Coverage Period selected by the Insuredand approved by Us, unless earlier terminated as provided in this policy.

Conformity with Law: If any provision of this policy is contrary to any law to which it is subject,this provision is hereby amended to conform thereto.


http://slidepdf.com/reader/full/health-insurance-infomationpdf 25/39HCCL STMM IND GA 20

PART IX – SCHEDULE OF BENEFITS

INSURED INFORMATION:

POLICY NUMBER:

POLICYHOLDER:

EFFECTIVE DATE:

COVERAGE PERIOD:

ELIGIBILE DEPENDENTS COVERED

COVERAGE AND BENEFIT AMOUNTS:Deductible per Covered Person per

Coverage Period. Maximum of 3

Deductibles per family per CoveragePeriod.

$250 per visit additional Deductible willbe applied to charges for use ofemergency room in the event ofSickness unless the Covered Person isdirectly admitted as an Inpatient forfurther treatment.

Coinsurance - per Coverage Period of the first $5,000 of EligibleExpenses after the Deductible paid by

the Company, then 100% of EligibleExpenses to the Overall Maximum Limit.

Urgent Care Center $50 co-payment, for each visit, afterwhich Coinsurance will apply. Notsubject to Deductible

Hospital Room and Board Average Semi-private room rate,including nursing services; for Hospitalswith only private rooms, the averagesemi-private room rate for the areawhere the hospital is located; forIntensive Care Unit, the Usual andCustomary charges.

Local Ambulance Injury: Usual and Customary charges toa Maximum of $250 per trip, whenrelated to a covered Injury.Sickness: Usual and Customarycharges to a maximum of $250 per trip,when covered Sickness results inhospitalization as Inpatient

Physical Therapy $50 Maximum per visit per day


2 / 1 / 2 0 1 6

6 M o n t h s

$ 7 , 5 0 0

5 0 %



HCCL STMM 101 21

Mental and Nervous DisordersOutpatient TreatmentInpatient Treatment

Maximum 10 visits per Coverage PeriodMaximum 31 days per Coverage Period

Home Health Care 1 visit per day maximum40 visits maximum per Coverage Period

Extended Care Facility $150 daily rate maximum60 day maximum

All Other Eligible Medical Expenses Usual and Customary charges

Penalty for Failure to Pre-certify 50% of Eligible Medical Expenses

Coverage Period - Overall Maximum Limit $ 2 , 0 0 0 , 0 0 0



HCC Life Insurance CompanyShort Term Medical Insurance Application

For use in GA

Please submit completed enrollment forms withpayment to:

HCC Life Insurance Company251 N. Illinois Street, Suite 600

Indianapolis, IN 46204

• Please complete this enrollment form entirely. Failure toprovide complete information may delay processing.

• You may elect the $5,000 and $7,500 deductible options byapplying online or contacting us.

Personal Details Please provide the following details for all individuals to be covered.

Name (First and Last) Date of Birth Gender Contact Information

Primary Male Female

Address

Spouse Male Female

City State Zip

Child 1 Male Female

Phone Number

Child 2 Male Female

E-mail Address

PlanOptions

Please check the boxes corresponding to yourelections for a policy period deductible andcoinsurance.

PaymentOption

Monthly – 6 month plan

Deductible $250 $500 $1,000 $2,500 Single Payment (please specify end date)

Coinsurance 80% of $5,000 50% of $5,000 Specify End Date ________________

Requested Effective Date _____ / _____ / __________ Number of days (max 180)_________

Eligibility Questions Please answer the questions below as they apply to all family members applying for coverage.

1. Will any applicant have other health insurance in force on the policy effective date or be eligible forMedicaid?

Yes No

2. Are you or any applicant:a. Now pregnant, an expectant father, in process of adoption, or undergoing infertility treatment?b. Over 300 pounds if male or over 250 pounds if female?

Yes No

3. Within the last 5 years has any applicant been diagnosed, treated, or taken medication for any of thefollowing: cancer or tumor, stroke, heart disease including heart attack, chest pain or had heartsurgery, COPD (chronic obstructive pulmonary disease) or emphysema, Crohn's disease, liverdisorder, degenerative disc disease or herniation/bulge, rheumatoid arthritis, kidney disorder,diabetes, degenerative joint disease of the knee, alcohol abuse or chemical dependency, or anyneurological disorder?

Yes No

4. Within the last 5 years has any applicant been diagnosed or treated by a physician or medicalpractitioner for Acquired Immune Deficiency Syndrome (AIDS) or tested positive for HumanImmunodeficiency Virus (HIV)?

Yes No

5. If you are not a US Citizen, do you expect to legally reside in the US for the duration of the policy? Yes No

US citizen

If you have answered “Yes” to questions 1 through 4 or “No” to question 5 above, coverage cannot be issued.Thank you for your interest.

For product information or assistance withthis enrollment form, please contact:

HCCL STMM APP1 GA (04/11)

D a m o n t a H e n r y 5 / 4 / 1 9 7 9 X

G A 3 0 0 1 6 C o v i n g t o n

2 7 5 M o u n t a i n L a n e

( 3 1 3 ) 2 5 8 - 9 6 1 3

d o n n i e s m i t h 3 8 3 @ y a h o o . c o m

X

1 2

X

2 0 1 6

X

X

X

X

X

X

e H e a l t h I n s u r a n c e S e r v i c e s , I n c . 8 0 0 - 9 7 7 - 8 8 6 0 S u p e r v i s o r @ e h e a l t h i n s u r a n c e . c o m

$ 7 5 0 0



RateCalculation

Use the rate table corresponding to your choice of planoption and coinsurance level to complete applicantrates below, then follow the calculation instructions.

MonthlyPayments

Single Up-front Payment

A Applicant’s Rate A A

B Spouse’s Rate B B

C Per child _________ x # ______ = C C

D A + B + C = D D

E Zip Code Factor E E

FD x E = Monthly / DailyPremium Total(round to the nearest penny)

F F

GNumber of to beCovered

n/a G

H F x G = n/a H

IAdministrative Fee** Fee is $5 on each monthly

a ment after the first a ment.

I I

J Total DueMonthly: F + I=Daily: H + I =

J J

AuthorizationI hereby request coverage under a policy underwritten by HCC Life Insurance Company. I understand this insurance contains a Pre-existing Condiexclusion, a Pre-certification Penalty and other restrictions and exclusions. I agree that coverage will not become effective for me or any dependent whmedical status, prior to the effective date, has changed and therefore results in a “yes” answer to any of the medical questions on this application. Imedical status changes in this way, coverage will be declined for all individuals included on this application. I understand that if I have elected the MonPayment option, my credit card will be charged each month on the due date of the premium for 6 months. I understand that I may terminate the schedpayments by notifying HCC Life in writing at least one business day prior to the next scheduled payment date. I understand that this coverage isrenewable or extendable. I understand that the information contained herein is a summary of the coverage offered in the policy and that I may obta

complete copy of the policy upon request to HCC Life. I understand that HCC Life, as underwriter of the plan, is solely liable for the coverage and beneprovided under the insurance. I understand and agree that the insurance agent/broker, if any, assisting with this application is a representative oapplicant. If signed by a representative of the applicant, the undersigned represents his/her capacity to so act. If signed as guardian or proxy ofapplicant, the undersigned represents his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the appliratifies the authority of the signer to so act and bind the applicant. Fraud Warning: Any person who knowingly and with intent to injure, defraud, or decany insurance company or other person submits an insurance application or statement of claim containing any materially false, incomplete or misleadinformation may be committing a crime and may be subject to civil or criminal penalties.

Applicant Signature Date Spouse Signature Date

Signed by HCC Life Appointed Agent: Plan Administrator Use Only:

PBC 612.110.04.12 Code:

RIGHT TO EXAMINE POLICY FOR 10 DAYS: If your application is submitted and accepted and a policy issued, you mayreturn it to us within 10 days after you receive it if you are not satisfied for any reason. All premiums, including all feeswill be refunded and Your coverage will be void.

HCCL STMM APP1 GA

Payment Information

Please provide complete payment informatiEnrollment forms without payment cannot processed.

Check/Money Order (Single Up-Front Payment O

MasterCard VISA Discover American Express

Credit Card Number Exp Da

Name on Card

Phone #

Billing Address (including city, state and zip)

Check or Money Orders should be made payable, in dollars, to HCC Life Insurance Company. If paying by ccard, I authorize HCC Life to debit my Discover, VIMasterCard or American Express account for the amospecified in the Rate Calculation section. If I have selectmonthly plan, I hereby request and authorize HCC Lifdebit my Credit Card account for the proper installmamounts on the due dates of the installments.

authorization will remain in effect for the duration of Coverage Period elected or until revoked by me in writCoverage purchased by credit card is subject to validaand acceptance by the credit card company.

Cardholder Signature Date

9 / 2 0 1

1 / 3 1 /

4 0 . 4 6

0

0 0

4 0 . 4 6

0

1 . 0 1 7 0

$ 4 1 . 1 5

$ 4 6 . 1 5

X

D a m o n t a M H e n r y

( 3 1 3 ) 2 5 8 - 9 6 1 3

x x x x x x x x x x x x 4 2 0 8

C o v i n g t o n , G A 3 0 0 1 6 2 7 5 M o u n t a i n L a n e

S i g n e d E l e c t r o n i c a l l y

S i g n e d E l e c t r o n i c a l l y 1 / 3 1 / 2 0 1 6

2 3 7 2 3

M o n t h s

$ 5 . 0 0



HCC LIFE INSURANCE COMPANY (the Company)

225 TownPark Drive, Suite 350


HCCL STMM OOC GA Page 1

SHORT TERM MEDICAL INSURANCE POLICYOUTLINE OF COVERAGE

THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE

ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR

PEOPLE WITH MEDICARE AVAILABLE FROM THE COMPANY.

NOTE: NO CONTINUOUS COVERAGE. The Policy provides coverage for a short term duration only.It is not renewable.

This outline of coverage provides a brief description of the important features of the Policy. This is not theinsurance contract. The Policy sets forth all the limits and conditions of coverage as well as the rights andobligations of both You and the Company. It is important that You READ THE POLICY CAREFULLY.

BENEFITS: After the Deductible, Coinsurance and Co-payment, if any, have been satisfied, the Company,will pay benefits for covered expenses. Benefits are subject to the Overall Maximum Limit and any othermaximum benefit shown below and in the Policy.

Coverage Period:Coverage and Benefit Amounts:

Deductible per Coverage Period. Maximum of 3 Deductiblesper family per Coverage Period.$250 per visit additional Deductible will be applied tocharges for use of emergency room unless directlyadmitted as an inpatient.

Coinsurance per Coverage Period of the first $5,000 of eligible expenses after theDeductible paid by the Company, then 100% up to theOverall Maximum Limit.

Urgent Care Center $50 co-payment per visit, after which Coinsurance willapply. Not subject to Deductible

Hospital Room and Board Average Semi-private room rate, including nursingservices; for Hospitals with only private rooms, theaverage semi-private room rate for the area where thehospital is located; for Intensive Care Unit, the Usual andCustomary charges.

Local Ambulance Injury: Usual and Customary charges to a Maximum of$250 per trip, when related to a covered injury.Sickness: Usual and Customary charges to a maximum of$250per trip, when covered sickness results inhospitalization as inpatient

Physical Therapy $50Maximum per visit per day

Mental and Nervous DisordersOutpatient TreatmentInpatient Treatment

Maximum 10 visits per Coverage PeriodMaximum 31 days per Coverage Period

Home Health Care 1 visit per day maximum40 visits maximum per Coverage PeriodExtended Care Facility $150 daily rate maximum

60 day maximumAll Other Eligible Medical Expenses Usual and Customary charges

Penalty for Failure to Pre-certify 50% of eligible medical expenses

Coverage Period - Overall Maximum Limit

PREMIUM INFORMATION

$ 2 , 0 0 0 , 0 0 0

5 0 %

$ 7 , 5 0 0







Premium Payment Mode: ___________ TOTAL PREMIUM AMOUNT: $________________M o n t h l y 4 6 . 1 5







Covered expenses: Subject to the Deductible, Coinsurance, Co-pay and other limits stated in the Scheduleshown above and in the Policy, the following expenses incurred while this coverage is in effect will be coveredunder the Policy. The full details of your insurance are set forth in the Policy.• Charges made by a hospital for daily room and board not to exceed the average semi-private room

rate, this includes miscellaneous service and supplies routinely provided while an inpatient.Emergency treatment for an Injury or a Sickness are also covered, an additional Deductible of $250

is required for treatment of an emergency Sickness unless the person is directly admitted to thehospital.

• Surgery at an outpatient surgical facility, including services and supplies.• For charges made by a Doctor for professional services, including Surgery; assistant surgeon are

covered up to 20% of the Usual and Customary charge of the primary surgeon• For dressings, sutures, casts or other supplies• For diagnostic testing using radiology, ultrasonographic or laboratory services.• For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs.• For reconstructive surgery when the surgery is directly related to surgery which is covered under the

policy, including reconstructive breast surgery and prosthetic devices incident to a mastectomy.• For radiation therapy or treatment and chemotherapy.• For hemodialysis and the charges by the Hospital for processing and administration of blood or blood

components but not the cost of the actual blood or blood components.• For oxygen and other gasses and their administration.• For anesthetics and their administration by a Doctor, subject to a maximum of 20% of the benefit payable

for the primary surgeon.• Extended Care Facility charges for room and board accommodations, subject to the conditions stated in

the policy.• Services by a home health care agency under a home health care plan, subject to the conditions stated

in the policy.• Local Ambulance, subject to the conditions stated in the policy.• Dental treatment and dental surgery, subject to the conditions stated in the policy.• Medically necessary rental of durable medical equipment.• Physical therapy to continue recovery from a covered injury or sickness.• Ovarian cancer surveillance tests as stated in the policy.• Mammography screening - low dose radiologic screening for the early detection of breast cancer as

stated in the policy.• An annual pap smear for detecting cancer as stated in the policy.• An annual prostate specific antigen test for males as stated in the policy.• An annual chlamydia screening test for a female who is not more than 29 years old as stated in the

policy.• Treatment of osteoporosis, including reimbursement for scientifically proven bone mass

measurement (bone density testing).

Pre-Certification RequirementsAll hospitalizations, other inpatient care, and surgeries or surgical procedures must be pre-certified. Tocomply with the pre-certification requirements:• Contact HCC Life at 1-800-477-0460 as soon as possible before the expense is to be incurred; and• Comply with the instructions of HCC Life and submit any information or documents they require; andNotify all doctors, hospitals and other providers that this insurance contains pre-certification requirementsand ask them to fully cooperate with Us.







Exclusions: The policy does not cover the following:• Pre-existing Conditions – conditions for which medical treatment, diagnosis, care or advice was received

within the twelve (12) month period immediately preceding the effective date are excluded for the first sixmonths of coverage under the policy. Does not apply to a newborn or newly adopted child.

• Outpatient prescription drugs, medications, vitamins, and mineral or food supplements.• Routine pre-natal care, pregnancy, childbirth, and postnatal care, except complications of pregnancy.• Alcoholism or substance abuse.• Charges which are not incurred during the Coverage Period.• Treatment, services or supplies, which are not administered by or under the supervision of a doctor.• Treatment, services or supplies which are not medically necessary or are deemed to be experimental

treatment as defined in the policy.• Treatment, services or supplies provided at no cost.• Charges which exceed Usual and Customary charge as defined.• Telephone consultations or failure to keep a scheduled appointment or provided over the Internet.• charges incurred while confined primarily to receive custodial or convalescence care.• Weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of

intestinal bypass surgery.• Modifications of the physical body in order to improve the psychological, mental or emotional well-being,

such as sex-change surgery.• Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons.• Artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.• Treatments that either promotes, enhances or corrects impotency or sexual dysfunction.• Abortions, except in connection with covered complications of pregnancy or if the life of the expectant

mother would be at risk.• Dental treatment, except as expressly covered under the policy.• Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any

examination or fitting related to these devices; eye surgery, such as radial keratotomy; treatment forcataracts.

• Treatment of TMJ.• Injuries from participation in any form of skydiving, scuba diving, organized auto racing, bungee jumping,

hang or ultra light gliding, parasailing, sail planing, flying in an aircraft (other than as a passenger on a

commercial airline), rodeo contests or participating in any professional, semi-professional or other non-recreational sports including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes,snowmobiling or go-carting.

• Injuries from participation in interscholastic, intercollegiate or organized competitive sports.• Injury resulting from being intoxicated or under the influence of any narcotic unless administered on the

advice of a physician.• Willfully self-inflicted injury or sickness.• Immunizations and Routine Physical Exams.• Services received for any condition caused by commission of or attempt to commit a felony or to which a

contributing cause was being engaged in an illegal occupation.• Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy,

holistic care of any nature, massage and kinestherapy.• Any services performed or supplies provided by a member of the immediate family.•

Orthoptics and visual eye training.• Services or supplies which are not included as eligible expenses in the policy.• Care, treatment or supplies for the feet.• Care and treatment for hair loss.







• Treatment of sleep disorders.• Hypnotherapy, biofeedback, and non-medical self-care or self-help programs; cigarette smoking

cessation or exercise programs.• Treatment as a result of complications or consequences of a treatment or a condition not covered.• Charges for travel or accommodations.• Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive

material(s).• Organ or tissue transplants or related services.• Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst,

unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.• Services received or supplies purchased outside the U.S. its territories or possessions, or Canada.• Treatment for or related to any congenital condition, except for a newborn or adopted child.• Spinal manipulation or adjustment.• Sclerotherapy for veins of the extremities.• Except in an emergency, expenses during the first 6 months after the effective date of coverage for

the following (subject to all other coverage provisions, including but not limited to the pre-existingcondition exclusion): total or partial hysterectomy, tonsillectomy, adenoidectomy, repair of deviatednasal septum or any type of sinus surgery, myringotomy; tympanotomy; herniorraphy, orcholecystectomy.

• Chronic fatigue or pain disorders.• Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.• Treatment, medication or hormones to stimulate growth, or treatment of learning disorders,

disabilities, developmental delays or deficiencies, including therapy.• Kidney or end stage renal disease.• Joint replacement or other treatment of joints, spine, bones or connective tissue, tendons, ligaments

and cartilage.• Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or

insurrection.• Expenses incurred while on active duty in the armed forces.



HCCL NPP revised 9/07- 1 -

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BEUSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICALINFORMATION IS IMPORTANT TO US.

Our Privacy Promise

We will keep your medical information private. We will also give you this notice aboutour privacy practices, our legal duties and your rights concerning your medicalinformation. We will follow the privacy practices that we describe in this notice while it isin effect. This notice took effect April 14, 2003, and will remain in effect until it ischanged or replaced.

We reserve the right to change our privacy practices and the terms of this notice at anytime, as long as the law allows. We reserve the right to make these changes effectivefor all medical information that we keep, including medical information we created orreceived before we made the changes. Before we make a significant change in ourprivacy practices, we will change this notice accordingly and send the new notice to youprior to the effective date of the change.

You may request a copy of this notice at any time or view a copy on our Web site atwww.hcclife.com.

Uses and Disclosures of Medical Information

Treatment, Payment, Health Care OperationsWe may use and disclose your medical information for purposes of treatment, paymentand health care operations. For example:

Treatment: We may disclose your medical information to a physician or other healthcare professional so they can treat you.

Payment: We may use and/or disclose your medical information for these and otherrelated activities:

•

To pay claims from physicians, hospitals and other health care professionalsfor covered services you received.

• To determine your eligibility for benefits.• To coordinate those benefits.

• To determine medical necessity.• To obtain premiums.• To issue explanations of benefits to the named insured.




We may also disclose your medical information to a health care professional orentity that is bound by the federal Privacy Rules so they can obtain payment orengage in payment activities.

Health Care Operations: We may use and/or disclose your medical information in

the normal course of our health care operations. This includes:• Determining our risk and premiums for your health plan.• Quality assessment and improvement activities.• Reviewing the qualifications of health care professionals; evaluating

practitioner and provider performance; conducting training programs; andaccreditation, certification, licensing and credentialing activities.

• Medical review, legal services and auditing, including fraud and abusedetection and compliance programs.

• Business planning and development.

• Business management and general administrative activities, includingmanagement activities relating to privacy, customer service, internal

grievances and creating de-identified information or a limited data set.

We may disclose your medical information to another entity, which has a relationshipwith you and is also bound by the federal Privacy Rules, for its health careoperations relating to quality assessment and improvement activities, reviewing thecompetence or qualifications of health care professionals, or detecting or preventinghealth care fraud and abuse.

Your AuthorizationYou may give us written authorization to use your medical information or to disclose it toanyone for any purpose. You may revoke your authorization in writing at any time.

However, this will not affect any uses and disclosures we made while your authorizationwas in effect. Without your written authorization, we will not use or disclose yourmedical information for any reason except those described in this notice.

Your Family and Friends We may disclose your medical information to a family member, friend or other person tothe extent necessary for them to assist with your health care, or with payment for yourhealth care. We may also use or disclose your medical information to notify (or helpnotify, including identifying and locating) a family member, a personal representative orother person responsible for your care of your location, general condition or death.

Before we disclose your medical information to that person, we will give you a chance toobject to us doing so. If you are not available, or if you are incapacitated or in anemergency situation, we will disclose your medical information based on ourprofessional judgment of what would be in your best interest.

Your Employer or Organization Sponsoring Your Group Health Plan We may disclose summary information about you to your employer or plan sponsor fortwo reasons. One is to get premium bids for the health insurance coverage offered




through your group health plan. The second is to decide whether to modify, amend orterminate your group health plan. The summary information we may disclosesummarizes claims history, claims expenses or types of claims members of your grouphealth plan have filed. The summary information will not include demographicinformation about the people in the group health plan, but your employer or plan

sponsor may be able to identify you or others from the summary information.

Underwriting We may receive your medical information for underwriting, premium rating or otheractivities necessary to create, renew or replace a contract of health insurance or healthbenefits. We will not use or further disclose this medical information for any otherpurpose (except as required by law) unless the contract of health insurance or healthbenefits is placed with us, in which case we will use and disclose your medicalinformation as described in this notice.

Disaster Relief

We may use or disclose your medical information to a public or private entity authorizedby law or by its charter to assist in disaster relief efforts.

Public BenefitWe may use or disclose your medical information as authorized by law for the followingpurposes that are in the public interest or benefit:

• As required by law.• For public health activities, including disease and vital statistics reporting, child

abuse reporting, FDA oversight, and to employers regarding work-related illnessor injury.

• To report adult abuse, neglect or domestic violence.•

To health oversight agencies.• In response to court and administrative orders and other lawful processes.• To law enforcement officials in response to subpoenas and other lawful

processes concerning crime victims, suspicious deaths, crimes on our premises,reporting crimes in emergencies and to identify or locate a suspect or otherperson.

• To coroners, medical examiners and funeral directors.• To organ procurement organizations.• To avert a serious threat to health or safety.• In connection with certain research activities.• To the military and to federal officials for lawful intelligence, counterintelligence

and national security activities.• To correctional institutions regarding inmates.• As authorized by state workers’ compensation laws.




Health-Related ServicesWe may use your medical information to contact you about health-related benefits andservices, or about treatment alternatives. We may disclose your medical information toa business associate to assist us in these activities.

MarketingWe may use or disclose your medical information to encourage you to purchase or usea product or service by face-to-face communication, or to provide you with promotionalgifts of nominal value.

Individual Rights

Access

You have the right to inspect or get copies of your medical information, with someexceptions. You may request that we provide copies in a format other than photocopies.We will use the format you request unless it is not practical to do so. To get yourmedical information, you must make a request in writing. If you request copies, we willcharge you $0.50 for each page and for staff time to copy your medical information. Wealso will charge for postage if you want us to mail the copies to you. If you requestanother format, we will charge a cost-based fee for providing your medical informationin that format. Contact us using the information listed at the end of this notice for a fullexplanation of our fees.

Disclosure Accounting You have the right to request, in writing, to receive a list of instances in which we (or ourbusiness associates) disclosed your medical information for purposes other thantreatment, payment and health care operations, or as authorized by you, or for certainother activities allowed by law, on or after April 14, 2003. We will provide you with thedate on which we made each disclosure, the name of the person or entity to which wedisclosed your medical information, a description of the medical information wedisclosed and the reason for the disclosure. If you request this accounting more thanonce in a 12-month period, we may charge you a reasonable, cost-based fee for eachadditional request. Contact us using the information listed at the end of this notice for afull explanation of our fees.

Restriction You have the right to request, in writing, that we place additional restrictions on our useor disclosure of your medical information. We are not required to agree to theseadditional restrictions, but if we do, we will abide by our agreement (except in anemergency). Any agreement to additional restrictions must be in writing signed by aperson authorized to make such an agreement for us. We will not be bound unless ouragreement is in writing.




Confidential Communications You have the right to request, in writing, that we communicate with you about yourmedical information by other means, or to other locations. You must state that you couldbe in danger if we do not communicate to you in confidence. We must accommodateyour request if it is reasonable, if it specifies the other means or location, and if it

permits us to continue to collect premiums and pay claims under your health plan. Thisincludes sending explanations of benefits to the named insured of your health plan. Wewill not be bound to your confidential communications request unless our agreement isin writing.

Even though you requested that we communicate with you about your health care inconfidence, an explanation of benefits issued to the named insured for health care thatthe named insured (or others covered by the health plan) received might containsufficient information, such as deductible and out-of-pocket amounts, to reveal that youobtained health care for which we paid.

AmendmentYou have the right to request, in writing, that we amend your medical information. Yourrequest must explain why we should amend the information. We may deny your requestif we did not create the information you want amended and the person or entity that didcreate it is available, or we may deny your request for certain other reasons. If we denyyour request, we will send you a written explanation.

You may respond with a statement of disagreement that we will add to the informationyou wanted to amend. If we accept your request to amend the information, we will makereasonable efforts to inform others of the amendment, including people you name, andto include the changes in any future disclosures of that information.

Electronic NoticeIf you are viewing this notice on our Web site or by electronic mail (e-mail), you mayrequest this notice in written form by using the information listed at the end of thisnotice.

Questions and Complaints

If you want more information about our privacy practices, or if you have questions orconcerns, please contact us using the information below.

If you think that we may have violated your privacy rights, or you disagree with adecision we made about your privacy rights, you may tell us using the contactinformation listed below. You also may submit a written complaint to the U.S.Department of Health and Human Services. We will provide you with that address uponrequest.



We support your right to the privacy of your medical information. We will not retaliate inany way if you choose to file a complaint with us or with the U.S. Department of Healthand Human Services.

Contact Information

HCC LifeBradley T. Long, Privacy Officer225 TownPark Drive, Suite 350Kennesaw, GA 30144

(800) 447-0460 (telephone)(770) 973-9854 (fax)

Health Insurance Infomation.pdf

Documents