Enrollment Kit

TransChoice® Advance Plan Designs

Please review plan descriptions below prior to calling for more information.

PRODUCT DETAILS
First Class
Express

Daily In-Hospital Indemnity
Pays each day a covered person is confined to a hospital (but not an emergency room. outpatient stay or stay in an observation unit) as the result of a covered accident or sickness.

$400.00
$750.00
Maximum
31 Days per confinement
Intensive Care Indemnity Benefit Rider (Rider Form Series CRCICUOO)

Pays each day a covered person is confined to an intensive care unit as the result of a covered accident or sickness.

None
$200.00
30 Days
Ambulance Indemnity Benefit Rider (Rider Form Series CRAMB400)

Pays each day a covered person receives ambulance transportation as the result of a covered accident or sickness. Transportation must be provided by a licensed ambulance company within 96 hours of a covered accident or onset of sickness. Air ambulance pays 3 times the amount shown.

None
$100.00
Maximum
3 days per calendar year
6 days per lifetime
Emergency Room Sickness Indemnity Benefit Rider
(Rider Form Series CRERS400)

Pays each day a covered person receives treatment in the emergency room for a sickness. This rider does not pay benefits for emergency room treatments as a result of an accident.

None
$50.00
Calendar Year Maximum
2 Days
Critical Illness Indemnity Benefit Rider (Rider Form Series CRC/0400)

Pays once when the insured is diagnosed with a critical illness (invasive cancer, heart attack, stroke, end stage renal failure, or major organ failure). A subsequent benefit is payable when the insured is diagnosed with a different critical illness 60 or more days after the first diagnosis.

Employee
$10000.00
Employee
$10000.00
Dependents 50%
Dependents 50%

Wellness Indemnity Benefit Rider (Rider Form Series CRHWELOO)

Pays each day a covered person undergoes a health screening test as defined in the policy.

None
1$100
Calendar Year Maximum (ages 2+)
(ages 12 to 24 months)
(ages birth to 12 months)
1 Day(s)
2 Day
4 Day

Off-the-Job Accidental Injury Indemnity Benefit Rider
(Rider Form Series CRACINOO)

Pays each day a covered person receives treatment for a covered accident. Treatment must be provided by a physician within 96 hours of the accident

$300.00
$300.00
Maximum
1 day per accident/5 days per calendar year

Outpatient Diagnostic Laboratory Test Indemnity Benefit Rider
(Rider Form Series CRLAB400)

Pays each day a covered person undergoes an outpatient laboratory test performed for the purpose of diagnosis for a covered accident or sickness. Does not include tests covered under any other rider.

$20.00
$30.00
Calendar Year Maximum
5 Days
5 Days

Outpatient Select Diagnostic Test Indemnity Benefit Rider
(Rider Form Series CRSDT400)

Pays each day a covered person undergoes an outpatient X-ray, ultrasound. Electroencephalogram (EEG). or sleep study for the purpose of diagnosis for a covered accident or sickness.

$100
$200
Calendar Year Maximum
3 Days
3 Days
Outpatient Advanced Studies Diagnostic Test Indemnity Benefit Rider
(Rider Form Series CRASD400)

Pays each day a covered person undergoes an outpatient Computer Tomography (CD Scan, Magnetic Resonance Imaging (MRI), Myelogram, Positron Emission Tomography (PET), Angiogram. Arteriogram, or Thallium Stress Test for the purpose of diagnosis for a covered accident or sickness.

$400.00
$800.00
Calendar Year Maximum
2 Day(s)
2 Day(s)
Outpatient Physician Office Visit Indemnity Benefit Rider
(Rider Form Series CROPV400)

Pays each day a covered person receives outpatient treatment in a physician’s office or at an urgent care facility as the result of a covered accident or sickness.

$80.00
$80.00
Calendar Year Maximum
6 Days
6 Days

Surgical and Anesthesia Indemnity Benefit Rider (Rider Form Series CRSRGPOO)

Pays each day a covered person undergoes surgery, as follows:

Inpatient Surgery
Calendar Year Maximum
$1400.00
1 Day
$2400.00
1 Day
Outpatient surgery
Calendar Year Maximum
$700.00
1 Day
$1200.00
1 Day
Outpatient Minor surgery
Calendar Year Maximum
$140.00
1 Day
$240.00
1 Day
If anesthesia is administered,
pays an additional
20%
20%
Group Term Life Insurance with Accidental Death & Dismemberment
(Policy Form Series CP100200 and CC100400l
Pays a death benefit when a covered person dies:
Employee
$10,000
$10,000
Spouse
$5,000
$5,000
Children
(AD&D is not available to dependent children)
$2,500
$2,500
Non-Insurance Benefits:
PPO Network Offered by KBA
Included
Included
Employee Discount Card
Offered by New Benefits Ltd.
Included
Included

 

Limitations and Exclusions

TransChoice Advance
Confinement for the same or related condition within 30 days of discharge will be treated as a continuation of the prior confinement. Successive confinements separated by more than 30 days will be treated as a new and separate confinement.

No benefits under this contract will be payable as the result of the following:

  • suicide or attempted suicide, whether while sane or insane.
  • intentionally self-inflicted injury.
  • rest care or rehabilitative care and treatment.
  • immunization shots and routine examinations such as: physical examinations, mammograms, Pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings (unless Wellness Indemnity Benefit Rider is included)
  • any pregnancy of a dependent child including confinement rendered to her child after birth.
  • routine newborn care (unless Wellness Indemnity Benefit Rider is included).
  • a covered person’s abortion, except for medically necessary abortions performed to save the mother’s life.
  • treatment of mental or emotional disorder (unless Inpatient Mental and Nervous Disorder Indemnity Benefit Rider is included).
  • treatment of alcoholism or drug addiction (unless Inpatient Drug and Alcohol Addiction Indemnity Benefit Rider is included).
  • participation in a felony, riot, or insurrection.
  • 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).
  • dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly.
  • sex change, reversal of tubal ligation or reversal of vasectomy.
  • artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician’s services, unless required by law.
  • committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation.
  • traveling in or descending from any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial airline (other than a charter airline) on a regularly scheduled passenger trip.
  • any loss incurred on active duty status in the armed forces. {If you notify us of such active duty, we will refund any premiums paid for any period for which no coverage is provided as a result of this exception.)
  • an accident or sickness arising out of or in the course of any occupation for
    compensation, wage or profit or for which benefits my be payable under an
    Occupational Disease Law or similar law, whether or not application for such benefits has been made.
  • involvement in any war or act of war, whether declared or undeclared.

Termination of Insurance
The insurance terminates on the earliest of:

  • the insured’s death.
  • the premium due date when we fail to receive a premium, subject to the grace period.
  • the date of written notice to cancel coverage.
  • the date the policy terminates.
  • the date the insured ceases to be eligible for coverage.

Dependent coverage ends on the earliest of:

  • the date the insured’s coverage terminates for any of the reasons above.
  • the date the dependent no longer meets the definition of a dependent.
  • the premium due date when we fail to receive a premium, subject to the grace period.
  • the date of written notice to cancel coverage.
  • the date the policy is modified so as to exclude dependent coverage.

The insurance company has the right to terminate the coverage of any insured who submits a fraudulent claim. Termination will not impact any claim which begins before the date of termination.

Critical Illness Indemnity Benefit Rider:
Invasive Cancer does not include: Carcinoma in Situ; pre-malignant conditions or conditions with malignant potential; prostatic cancers which are histologically described as TNM Classification T1 (including T1 (a) or T1 (b), or of other equivalent or lesser classification; any malignancy associated with the diagnosis of HIV; or Skin Cancer.

Skin Cancer does not include malignant melanoma or mycosis fungoides.

Stroke does not include cerebral symptoms due to: Transient lschemic Attack (TIA); reversible neurological deficit; migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye, optic nerve or vestibular functions.

The Subsequent Critical Illness Benefit is not payable for Skin Cancer or carcinoma In Situ.

Off-the-Job Accidental Injury Indemnity Benefit Rider:
Does not cover injuries which are caused by an accident that occurs while in the course of any legal or illegal occupation, activity, or employment for pay, benefit or profit.

Surgical and Anesthesia Indemnity Benefit Rider:
As an exception to the dental care or treatment exclusion above, we will pay the following dental or oral surgery procedures under this rider:

  • excision of impacted third molars.
  • closed or open reduction of fractures or dislocation of the jaw.

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

The AD&D rider terminates on the employee’s 70th birthday.

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

  • suicide or intentionally self-inflicted injury, while sane or insane.
  • 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.
  • taking part in an insurrection.

If more than one covered loss is sustained as a result of the same accidental bodily injury, payment shall be made for only the one loss for which the largest amount is payable.

 


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