TransChoice® Plus Plan Option Designs

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TransChoice® Plus Policy Benefits
The TransChoice Plus, a group limited benefit hospital indemnity insurance, pays benefits to help cover basic medical expenses.

Base Plan Benefits Plan Pays
Daily In-Hospital Indemnity Benefit First Class - $400 per day (maximum of 30 days per confinement)

Express - $750 per day (maximum of 30 days per confinement)

Additional Benefits Plan Pays
Outpatient Physician Office Visit Indemnity Benefit First Class - $80 per visit up to 6 visits per calendar year per insured

Express - $80 per visit up to 6 visits per calendar year per insured

Outpatient Diagnostic X-Ray & Laboratory Indemnity Benefit First Class - $100 per day up to 3 days of testing per calendar year, per covered person

Express - $150 per day up to 4 days of testing per calendar year, per covered person

Surgical & Anesthesia Indemnity Benefit Pays benefit shown in Surgical Schedule based on type of surgery performed and plan selected.

First Class - $2,000 pays 20% of the Surgical Benefit for the administration of anesthesia.

Express - $3,000 pays 20% of the Surgical Benefit for the administration of anesthesia.

Off-the-Job Accidental Injury Benefit First Class - Pays actual charges incurred up to a maximum of $300 per covered accident (up to 5 covered accidents per covered person per calendar year)

Express - Pays actual charges incurred up to a maximum of $300 per covered accident (up to 5 covered accidents per covered person per calendar year)

Critical Illness Indemnity Benefits and Subsequent Critical Illness Indemnity Benefit All plans have this benefit
$10,000 lump-sum benefit for the initial diagnosis of a covered critical illness and also an additional lump-sum benefit of the same amount for a subsequent and separate covered critical illness.
Wellness Indemnity Benefit Express - $100 benefit per visit for physical exams or certain diagnostic tests. 1 visit per calendar year, per insured. Well child visits included - 4 visits per year for children 0-12 months and 2 visits per year for children 12-24 months.
Emergency Room Sickness Indemnity Visit Express - Pays $50 for each sickness visit for 2 visits per calendar year per insured
Intensive Care Indemnity Benefit Express - Pays $200 per day of confinement in an intensive care unit. Maximum 30 days per calendar year per insured
Ambulance Indemnity Benefit Express - Pays $100 per trip in an ambulance; maximum of 3 trips per insured per year with a lifetime maximum of 6 trips per insured
Additional Coverages Plan Pays
Group Term Life Insurance Policy with Accidental Death & Dismemberment (AD&D) Rider All plans have this benefit
Member: $5,000
Spouse: $2,500
Child: $2,500 (AD&D coverage is not available for dependent children)
Non Insurance Discount Programs
Prescription Drug Discount Card All plans have this benefit
By presenting a Caremark prescription drug discount card, provided by KBA, to one of Caremark's 55,000 participating providers
PPO Network - offered by KBA
www. MultiPlan.com
All plans have this benefit
Member and covered dependents will receive contracted savings from the normal fees charged by network physicians, hospitals, and outpatient x-ray and laboratory providers

** Group Term Life Policy with AD&D Rider is underwritten by Transamerica Life Insurance Company, Home Office, Cedar Rapids, IA. Policy Form Series CP100200 and CR101100.

Limitations and Exclusions

TransChoice Plus Policy
TransChoice Plus contains certain limitations and exclusions, which are listed below. It’s important to fully understand these limitations and exclusions and to properly explain them to clients. Doing so will avoid problems at claim time. Specifically, no benefits will be payable as the result of

  • In the event of suicide, the Company’s liability may be limited to only the return of premiums paid. In Missouri, suicide is no defense to payment of benefits unless the Company can show the insured intended suicide when he/she applied/enrolled for coverage.;
  • any intentionally self-inflicted injury or sickness;
  • rest care or rehabilitative care and treatment (unless provided as a benefit on the Schedule of Benefits);
  • immunization shots and routine examinations such as physical examinations, mammograms, pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings unless the Wellness Benefit is included;
  • routine newborn care (unless covered under the Wellness Indemnity Benefit);
  • the treatment of mental illness; functional or organic nervous disorder, regardless of cause (unless the daily Inpatient Mental and Nervous Benefit is shown on the Schedule of Benefits); alcohol abuse; and drug use, unless such drugs were taken on the advice of a physician and taken as prescribed (unless the daily inpatient Drug and Alcohol Benefit is shown on the Schedule of Benefits);
  • participation in a riot, civil commotion, civil disobedience or unlawful assembly;
  • committing, attempting to commit or taking part in a felony, or assault, or engaging in an illegal occupation;
  • participation in an organized contest of speed, parachuting, parasailing, bungee jumping or hang gliding;
  • air travel, except as a fare-paying passenger on a commercial airline on a regularly scheduled route, or as a passenger for transportation only and not as a pilot or crew member;
  • any accident caused by the participation in any activity or event, including the operation of a vehicle, while under the influence of a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated (intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred);
  • any procedure or treatment to change physical characteristics to those of the opposite sex and other treatment related to sex change;
  • the reversal of tubal ligation or vasectomy;
  • artificial insemination, in vitro fertilization and test tube fertilization, including any related testing, medications or physician’s services,
    unless required by law;
  • any loss incurred while on active duty status in the armed forces (if the insured notifies Transamerica of such active duty, Transamerica will refund any premiums paid for any period for which no coverage is provided as a result of this exception);
  • accidents or sicknesses arising out of and in the course of any occupation for compensation, wage, or profit OR expenses which are payable under Occupational Disease Law or similar law, whether or not application for such benefits has been made;
  • air or ground ambulance transportation (unless the Ambulance Benefit has been included);
  • routine eye examinations or fitting of eye glasses;
  • hearing aids or fitting of hearing aids;
  • dental examinations or dental care other than expenses resulting from an accident;
  • care or treatment of an accident or sickness not specifically provided for in the plan;
  • with respect to the Off-the-Job Accidental Injury Benefit only, charges that the insured is not legally required to pay, or charges which would not have been made if this coverage had not existed; or
  • treatment of an accident or sickness made necessary by or arising from war, declared or undeclared, or any act of war.

Termination — Your insurance will cease on the earliest of:

  1. The last day of the payroll deduction period during which You cease to be eligible for coverage;
  2. The end of the last period for which premium payment has been made to Us;
  3. The date the Policy terminates; or
  4. The last day of the payroll deduction period during which You terminate employment.

The insurance on a Dependent will cease on the earliest of:

  1. The date Your coverage terminates;
  2. The end of the last period for which premium payment has been made to Us;
  3. The date the Dependent no longer meets the definition of Dependent; or
  4. The date the Policy is modified so as to exclude Dependent coverage.

We will have the right to terminate the coverage of any Covered Person who submits a fraudulent claim under the Policy.

Extension of Benefits — Whenever termination of coverage under this section occurs due to termination of Your employment or membership, such termination will be without prejudice to any Hospital Confinement which commenced while coverage was in force, with respect to Daily In-Hospital Indemnity Benefits; or any covered treatment or service for which benefits would be provided and which commenced while coverage was in force; provided, however, that the Covered Person is and continues to be Hospital Confined or Disabled.

Such Extension of Benefits will continue for up to the earlier of 30 days; or The date on which the Covered Person is no longer Disabled.

Group Term Life Insurance Policy with AD&D Rider
Exclusions – Group Term Life Insurance Policy
Suicide Exclusion: We will not pay a death benefit if an insured dies by suicide, while sane or insane, within two years of the date his or her insurance starts. If the insured or his or her spouse die by suicide, we will refund the premiums paid for the insurance. If a dependent child dies by suicide, we will refund the premiums paid for the dependent children’s insurance only if there are no surviving insured dependent children. If any death benefit is increased, this suicide exclusion starts anew, but will apply only to the amount of the increase.

Exclusions – AD&D Rider
We will not pay any benefits if the loss, directly or indirectly, results from any of the following, even if the means or cause of the loss is accidental:

  • In the event of suicide, the Company’s liability may be limited to only the return of premiums paid. In Missouri, suicide is no defense to payment of benefits unless the Company can show the insured intended suicide when he/she applied/enrolled for coverage;
  • commission of or attempt to commit an assault or felony;
  • sickness or mental illness, disease of any kind, or medical or surgical treatment for any sickness, illness or disease;
  • injuries received while under the influence of alcohol, a controlled substance or other drugs as defined by the laws of the state where the accident occurs, except as prescribed by a doctor;
  • any poison or gas voluntarily taken, administered, absorbed or inhaled (except in the course of employment);
  • flight in any kind of aircraft, except as a fare paying passenger on a regularly scheduled commercial aircraft;
  • any bacterial or viral infection;
  • declared or undeclared war, or any act of war; and
  • taking part in an insurrection.

This Rider stops on the member’s 70th Birthday.