HomeMy WebLinkAboutStandard Security Life InsIsFand Group a dministration, Inc.
Corporate Offices
3 Toilsome Lane, East Hampton, New York 11937
Phone: (631) 324-2306 · Fax: (631) 324-7021
1-800-926-2306
October 18, 2001
Mr. John Cushman
Town of Southold
53095 Main Road
Southold. New York 1 t 971
Dear John.
Enclosed pleaSe find the fmal version of the stop loss contract for the 1-1-01 - 12-31-01
contract period.
Il'you have any questions, please do not hesitate to contact me./7 Sincer y4y.//
,3ffan DKaplan
!~resident
Eno.
STANDARD SECURITY LI~= iN~j~E COMiSAI~y OF NEW YORK
(a New York Stock Life and Health Insurance Company)
('~/Ve", "Us", "Our")
Home Office:
485 Madison Avenue
New York, New York '10022
POLICY NUMBER: CFE-6'13-NY
POLICYHOLDER ("You", "Your"):
POLICY PERIOD:
EFFECTIVE DATE:
',EXPIRATION DATE:
Town of Southold
January 1, 2001 through December 31, 2001
January ~1, 2001
December 31, 2001
~A!~[~IVERS,N'~Y DATE: January 1,2002, and on the same day each year after.
PR~. iUM DUE DATE: January 1, 2001, and on the same day each month.
STATE OF DELIVERY: New York
Thais pOlicy;is a ega contract We issue it in consideration of Your Application and Your payment of
prem urns when due.
Through this Policy, We agree to make payments in accordance with its pmwsions.
This Policy stays in force when premiums are paid on time. This Policy, however, can be canceled by
-You or by Us, as the Policy states~
In this, Policy, "You" and '~'our" refer to the Policyholder: and "We", "Us" and "Our" refer to Standard
Secudty Ufe Insurance Company of New York.
This Policy ~s issued in, and is governed by the laws of, the state of delivery, as indicated above.
The following pages, ApplicationS and riders are a part of this Policy.
Signed for Standard Secur~y Life Insurance Company of New York as of the Policy Effective Date.
Rachel Lipad David Kettig
President Secretary
EXCESS LOSS INSURANCE POLICY
Non-Participating
TABLE OF CONTENTS
SECTION I-SCHEDULE OF EXCESS LOSS INSURANCE .................................................................. 3
SECTION 2-DEFINITIONS ................................................................................................................... 5
SECTION 4-SPECIFIC EXCESS, LOSS INSURANCE ............................................................................. 9
SECTION 5-EXCLUSIONS AND LIMITATIONS ................................................................................... 10
SECTION 6-RENEWAL AND TERMINATION .......................................................................................
SECTION 7-PREMIUMS ....................................................................................................................... 13
SECTION 8-YOUR DUTIES .................................................................................................................. 14
SECTION 9-GENERAL PROVISIONS .................................................................................................. 15
GH 2001 2
SECTION 'I-SCHEDULE OF EXCESS LOSS INSURANCE
POUCYHOLDER: . Town of Southoid
ADDRESS:
ADMINISTRATOR:
ADDRESS:
53095 Main Road / Southold, NY 11937
Island GmupAdministration Inc.
3 Toilsome Lane, East Hampton, NY 11937
ALL AMOUNTS AND NUMBERS SHOWN IN THIS .SCHEDULE APPLY ONLY TQ THE POLICY
PERIOD iN EFFECT. A NEW SCHEDULE WILL BE ISSUED FOR EACH NEW POL CY PER OD
A. [X] AGGREGATE EXCESS LOSS INSURANCE:
1. BENEFITS COVERED: [X] Comprehensive
X Medical n/a_ Dental n/a_ Weekly Income
[n/a] Wraparound
n/a Vision X prescription Drugs
BENEFIT PERIOD/EXPENSE ELIGIBILITY CLAIM BASIS:
Eligible Expenses Incurred from January 1, 2001 through December 31, 2001; and
Eligible Expenses Paid from January 1, 2001 through December 31,2001.
If this Policy terminates prior to the Expiration Date, no AR.qre~ate Excess Loss Benefits will be payable.
3. INITIAL AGGREGATE ATTACHMENT POINT: $1,664,100.00
4. MINIMUM AGGREGATE ATTACHMENT POINT: $1,664,100.00
5 BENEFIT PERCENTAGE PAYABLE IN ACCORDANCE WITH SECTION 3. 100%
6. MAXIMUM AGGREGATE BENEFIT (WHILE COVERED, AND WHILE THIS POLICY IS IN
FORCE): $1,000,000
7. AGGREGATE MONTHLY FACTOR(S): Single: $645.00 Family: $645.00
Covered Units: 215
AGGREGATE ANNUAL PREMIUM: $15,000.00
PAYMENT MODE: Annual
GH 2001 3
SECTION 1 - SCHEDULE OF EXCESS LOSS INSURANCE (CONTINUED)
B. [ X] SPECIFIC/INDIVIDUAL EXCESS LOSS INSURANCE:
1. BENEFITS COVERED: Medical and Rx Only
2. BENEFIT PERIOD/EXPENSE ELIGIBILITY CLAIM BASIS:
Eligible Expenses Incurred from January 1,2001 through December 31, 2001; and
Eligible Exper~ses Pa['d from January 1, 2001 through December 31,2001.
Ir this P01iCy_t~f.r. qiir~:~tes prior [o Ille E~[qiratjerl D~at(;. [ho Benefit Period will ri()[ P. xlend past th(; date.TM oI
,orminatio. n: I,~ addi£ion. [ho dc~ql.uctible por C()verod Persor w a~olv as il II!e .P. olicy won? in force for th(;
:~.9l_ize Pnli(:y Yo~_r..
3. OEDUC3'IBLE PER COVERED PERSON: $150,000.00
4. ~F~T PERCENTAGE PAYABLE IN EXCESS OF THE SPECIFIC DEDUCTIBLE: 100%
5. ~ ~,~.'MUM SPECIFIC ~BENEFIT PAYABLE MINUS THE SPECIFIC DEDUCTIBLE (PER
~F~'IME PER COVERED PERSON), WHILE THIS POLICY IS IN FORCE: $850,000.00
SPECIFIC MONTHLY PREMIUM RATE:
Covered Units: 215
Single $18.31
Family $18.31
Single $ n/a
Two Party Sn/a
Family Sn/a
[ ] OPTIONAL RIDERS ELECTED: None
GH 200'l 4
SECTION 2-DEFINITIONS
ADMINISTRATOR means Your Plan Administrator who has bean retained by You and approved by Us
t0 provide claims and administrative services for You. The Administrator is not Our agent for any
purpose contemplated under this Policy.
AGGREGATE MONTHLY FACTOR which is specifically stated in the Schedule of Excess Loss
ir{~urance, is the amoUn~ apPliCabie to each Covered Person and/or their Covered Dependent.
ANNUAL AGGREGATE ATTACHMENT POINT which is deter, mined at the end of the Policy Y?r, is an
amou~ eq~taI'to the pJ'od~ of the Aggregate Monthly Factor times the Number of Coyered Units for the
'~applic~bte -~hanth~dt~dn~ ~h~ Pdlic~ Year, and is specifi(~ly stated~ in~ the Sch ~edu e ~ .E,~(cess Loss
Insurance. and is described in SocLion 3 of this Policy; and this ampu-~t is tha,t ~ord°n o{ the Eligible
Expenses nnt covered by this Policy arid (~ntirely retained bY YOU fcir th~0ta Nt~n~b~[of COvered Units
in o[~ch Po cYYoar
AYABLE as indicated in the Schedule of Excess Loss Insurance, is the
amount of the Maximum Benef~ payable to You. Separate benefit
pe.r(.'.entages rr),~y~apply to either the Aggregate Excess Loss or to the Specific ExCess Loss.
C~,~r,~ ~aqs~Sta~ndard Security Life Insurance Company of New York.
C~D 'I~OI~'~H ~%determined rrom the Effective Date of th's Po 'cy Each new Covered Month will
o(~Jl'rr.on ~Jb?.i,d~:,~v.h ch corr(,sponds w~th the Effective Date of th s Po cy If there is no such date in any
3pph,~51e m"b~.nLh. Ihen ti e asr ( ate of that month wilt be used.
C~E~0;N~!rpeans each individual or individuals included in a Covered Unit.
~( .~. ~IT }n,c[udes an amp oyee an amp oyee with dependents, such other defined individuals,
~[~b~C~j~ly eg~d upon between You and Us.
EEiGJ~. ~N,S~ means ,the reasonable and customary charges incurred by a Covered Person,
wh~. er tl~ Plan, for medically necessary treatment, services and/or supplies prescribed by
F_XP~. ~ ~L~G[BIEI,TY CLAIMS BASIS/BENEFIT PERIOD as shown in the Schedu e of Excess Loss
l~,.JU~, ,s:~e p~e~d of timff dunng wh ch a covered expense must be Incurred, and/or Pa d to be
eligibli~ [fOr.r~i~bursement under this Policy.
ExPE. RiMENTAL or'INVESTIGATIVE means care, procedures, treatments, or technology:
1. that is notwidely recognized and accepted as effective, safe and appropriate for the injury or illness
b~ the mad ce profess on n the U S
2. that is in research or investigative stage, or conducted for research or similar purposes: or
3. for which the patient has been asked to give, or has signed, a release or other document, indicating
that the treatment is Experimental or Investigative or other term of similar import.
In determining any of the three (3) criteria, We will rely on recognized medical sources such as, but not
lin-~ited to, the Amedcen Medical Association, including the Council of Technology Assistance Program
and the Council on Medical Special Services; the National Institute of Health; Medicare: the Food and
Drug Administration, and other accepted medical authorities and sources.
GH2~ 5
INCURRED means the date on which an Eligible Expense was rendered to a Covered Person.
INITIAL ATTACHMENT POINT means the annual attachment point as calculated on the effective date
of coverage based upon the number of Covered UnitS at that time multiplied by the corresponding
9ttachment factors multiplied by twelve.
iNSURED means You esthe Policyholder named in this Policy.
LATE ENROLLEE means any individual who makes a written application for coverage under the Plan
more than thirty-one (3~l)~,days after first becoming eligible for coverage under the Plan.
LOSS me?ns amoun,ts actual!y Paid, in accordance with the Expense Eligibility Claims Basis shown on
[he, Sclled~le'of Less LOss Insurance, by You or the Plan Administrator on Your behalf:
1. For benefitS under the Plan:
In. settlement ~f claims for benefits under the Plan: or
3. In satisfaction of judgments for benefits under the Plan.
LOSS, HOWEVER, DOES NOT INCLUDE:
1. Any payment which does not stdctly comply with the pmvis~ons of the Plan; or
Any payment for which there is any other insurance~ reinsurance or plan established pursuant to
federal, state or local law or any other indemnity against loss which would, except for the existence
of this Policy, indemnify the Insured; or
Extra-contractual damages of any nature, compensatory damages, exemplary and punitive damages
or liabilities of any kind whatsoever, including but not limited to those resulting from negligence,
intentional wrongs, fraud, bad faith or strict liability on Your part or Your agent; or
4. Salaries paid to Your employees as well as Your claim and administrative expenses: or
5. Litigation costs and expenses.
Benefits under the Plan will be considered Paid as of the date of issue of a draft or check in payment of
benefKs to, or on behalf of a Covered Person.
MAXIMUM AGGREGATE BENEFIT is the amount stated in the Schedule of Excess Loss Insurance.
MAXIMUM SPECIFIC BENEFIT is the amount stated in the Schedule of Excess Loss Insurance.
MINIMUM AGGREGATE ATTACHMENT POINT is an amount equal to 85 percent of the product of the
Initial Enrollment of the first Covered Month of the Policy multiplied by the corresponding Aggre~gate
MonthJy Factor multiplied by twelve.
MONTHLY AGGREGATE ATTACHMENT POINT is an amount equal to the product of the total Number
of Coveted Un~ts per Covered Month of a Pohcy Year mult~plred by the corresponding Aggregate Monthly
Factor.
GH 2001 6
NUMBER OF COVERED UNITS means the total Covered Units existing in any one Covered Month and
will be determined on a monthly basis in accordance with:
1. The definition of Covered Units; and
2. The eligibility requirements of the Plan.
OFFICER means Our President, a Vice-President or the Corporate Secretary.
PAID means drafts or checks that are issued on an account that is funded.
PLAN means the Employee Benefit Plan You provide under a written Plan of Benefits for eligible
emproyees and their eligible ~lependents. as defined in this Policy.
POLICY YEAR means the specified period of time during which the coverage provided under this Policy
is in effect~ as sho~vn in the Schedule of Excess Loss Insurance.
RISK CORRIDOR means the percentage amoun[~ which can vary between 15 percent and 50 percent,
selected b~/Y'od~ as the additional percentage of Plan benefits that will be funded by You.
SPECIFIC DEDUCTIBLE AMOUNT is the amount shown inthe Schedule of Excess Loss Insurance.
GH2~I 7
SECTION 3 - AGGREGATE EXCESS LOSS INSURANCE
If at the end of each Policy Year, Losses, as explained below, exceed the Annual Aggregate Attachment
Point or the Minimum Aggregate Attachment Point showr~ in the applicable Schedule of Aggregate
Excess Loss Insurance, We will' pay You an amount-equal to:
1. The amount by which Losses exceed the applicable Annual Aggregate Attachment Point or the
Minimum Attachment Point, whichever is greater, multiplied by,
2, The Benefit Percentage Payable and shown in the Policy Schedule, subiect to
3. The Maximum Aggregate Benefit as shown in the Policy Schedule.
Our prompt payment of Policy benefits is:
1 subject to all terms, conditions, limitations and exclusions in this Policy, and
2. contingent upon Our receipt of satisfactory proof of loss, and Your request for reimbursement, and
3. losses during any Policy Year will be determined according to the Expense Eligibility Basis, and will
not include any amount paid or payable by Us to You for the applicable Policy Year for Specific
Excess Loss Insurance according to the terms in Section 4 of this Policy.
If this Policy terminates prior to the Expiration Date of the applicable Schedule of Excess Loss
Insurance, no Aggregate Excess Loss Benefits will be payable.
In addition:
We can change the Aggregate factors upon any of the following provided that We notify You at least
thirty-one (31) days before We make the change:
1. The effective date of any change in benefits under Your Plan.
2. Any Policy Anniversary when the last two (2) months of claims in the preceding Policy Pedod vary by
more than twenty-five (25) percent of the average monthly paid claims for the prior ten (10) months.
3. Any Premium Due Date when there is a twenty-five (25) percent or more change in the number of
Covered Persons dudng a Policy Pedod.
GH 2001 8
SECTION 4-SPECIFIC EXCESS LOSS INSURANCE
If during Your Policy Year, or any fraction of a Policy Year, Losses for any Covered Person, as explained
be ow, exceed the Specif-m DeductibleAmount shown in the applicable Schedule of Specific Excess Loss
Insurance, We will pay You the Specific Benefit for any one Covered Person in any Policy Period in an
amount equal to:
1. The amount by which Losses exceed the Specific Deductible Amount multiplied by:
2. The Benefit Percentage Payable and
3. Subject to the Maximum Specific Benefit.
Our prompt payment o1: Policy Benefits is:
1. subject to all terms, condit oas, m tat oes and exclusions in the Policy, and
2. contingent upon our receipt of satisfactory proof of loss and Your request for reimbursement, and
3. determined, for any Covered Person during the Policy Year, according to the Expense Eligibility
Basis, and will not include any amounts paid or payable by Us to You for Aggregate Excess Loss
Insurance acco~'ding to the terms in Section 3 of this Policy.
If this Policy terminates prior to the Expiration Date, the Benefit Period will not extend past the date of
termination. In~ addition, the deductible per Covered Person will apply as if the Policy were in force for
the entire Policy Year.
In addition:
The Company can change the Specific rates upon any of the following, provided that We notify You at
least thirty-one (31) days before We make the change:
1. The effective date of any change in benefits under Your Plan.
2. Any Policy Anniversary, when the last two (2) months of claims in the preceding Policy Period vary
by more than twenty-five (25) percent of the average monthly paid claims for the prior ten (10)
months.
3. Any premium due date, when there is a twenty-five (25) percent or more change in the number of
Covered Persons during a Policy Pedod.
GH 2001 9
SECTION 5-EXCLUSIONS AND LIMITATIONS
Our liability under this Policy will not be increased if Your Plan provides more liberal Exclusions and
Limitations Provisions.
This Policy will not cover any of the following:
Deductibles, co-payment amounts, or any other charges which am not payable under the terms of
the Plan or' charges which are payable by Your Plan, or to You from any other source.
2. Charges for:
a) Experimental or Investigative services, treatments or supplies; or
b) Drugs which have not been approved by the Food and Drug Administration.
3. Any coeditions for which benefits of any kind are paid or payable, by judgment or settlement, under
any Worker's Compensation or Occupational Law; even if the Covered Person fails to claim his or
her rights to such benefits.
4. A. Claims for a Covered Person who, on the date that coverage under this Policy would
otherwise begin,
a) is not actively at work at his or her normal job, or his or her usual place of business; or
b) is a retired employee or dependent of a covered employee, and is unable to perform the normal
activities of a person of like age or sex.
B. No benefits will be provided for any charges incurred until the day after the date
that such Covered Person:
a) returns to active work on a full-time basis; or
b) or a retired employee or dependent of a covered employee, is able to perform the normal
activities of a person of like age and sex.
Charges resulting from any extra or non-contractual damages; or legal fees and expenses for the
defense thereof; or fines or statutory penalties.
Any procedure or treatment to change physical characteristics to those of the opposite sex; and any
other treatment or studies related to a sex change or treatment of sexual disorders.
Any services furnished by an institution which is primarily a rest home, a place for the aged, a
nursing home, a convalescent home, a place for custodial care~ or any other place of like character.
GH 2001 10
8. Services or expenses for charges Incurred as a result of:
a) Suicide or a[tempted suicide, whether sane or insane: or
b) Intentional self-inflicted injury or illness.
9. Injury or illness which occurs due to a Covered Person's commission of, or attempt to commit: an
assault, battery, felony, actor aggression, insurrection, rebellion, or participation in a dot.
10. Legal expenses of any kind or description, including legal expenses related to or Incurred for the
confinement of a Covered Person or any compulsory process to adopt, abstain from, or cease to
continue a particular mode of treatment, care or therapy.
11. Services done for cosmetic purposes, unless:
a) performed to correct functional disorders or congenital anomalies: or
b) due to acc[dental injury occurring while that individual is a Covered Person.
12. Expenses for Hearing aids: or
13. Expenses for Tempammandibular joint (TM J) treatment; or
14. Treatment for obesity, eating disorders; or
15. Expenses for artificial insemination, in vitro fertilization, gamete or zygote intrafallopian transfer and
reversal of voluntary sterilization; or
16. Transplants of non-humen, mechanical or artificial organs.
17. Expenses adsieg out of, caused by, centdbuted to or in consequence of: War, declared or
undeclare~; Civil War; Hostilities; or Invasion.
GH2001 11
SECTION 6-RENEWAL AND TERMINATION
RENEWAL
At the end of a Policy Year, a subsequent Policy Year may be agreed by You and Us. The Schedule of
Excess Loss Insurance in Secti0~n I will be amended to show the coverage and terms in effect during
each subsequent Policy Year.
TERMINATION
This Policy and all benefits will terminate upon the earliest of:
1. The end of the Grace Period if any premium remains unpaid at the end of the Graco Period;
2. The premium due date following Our receipt of Your written notice to cancel or terminate this Policy
at the end or,he Grace P.edod;
3. The end of the P01iby Year, as shown in the Schedule of Excess Loss Insurance unless We mutually
agree with You as to rene~val termS:
4. The date of terminatian of the Plan or the Policy;
5. The date that You suspend active business operations or are placed in bankruptcy or receivemhip; or
6. The date that You do not pay claims or make funds available to pay claims as required by the Plan.
In addition to ~he Termination pmvisioes of this Section, this Policy shall automatically terminate upon
the cancellation of the agreement between You and the Plan Administrator, unless We have, pdor to
such cancellation, agreed in writing to Your designation of a successor Administrator.
GH 2001 12
SECTION 7-PREMIUMS
PAYMENT OF PREMIUMS
No coverage under this Policy shall be in effect until the first months premium for the Policy is paid. For
coverage to mrna n in effect, each subsequent monthly premium must be paid on or before its due date.
You are responsible for paying premiums when they become due. Premium due dates are de[ermined
from the Effective Date of thYs Policy. Each premium due date is the same day of each month
corresponding w/th the Effective Date of this Policy. If there is no such date in any applicable month, the
last day of that month shalt be used.
GRACE, PERIOD
A ~pe~i0d of th Ay-one (31) days from the premium due date is allowed for the payment of each premium
du~ ~f~.,~r~the. pa~yment of the first prem um During the Grace Period, th s covera e shall rem n
eff~ect-if~'; r&~i ' s ~ ' . g a' in
rt'- ' '" ~" "y P,- urn_ . .n~ pa~d when due, coverage under th~s Po cy w~ll automat ca I term n~te at
.~.erto ~,me ~race ~enoa~ You are liable for the pre rata part of the unpaid premium ~'or an
dating Wti~dh fliis~Policy remaineU in effect, y penod
PREMIUM RATE CHANGE
Subje~ t~ se~ing YOU written notice thirty-one (31) days prior to the date on which a remium
foli'~v~t~g dates:
The date that'the Plan is amended: or
1. The date~that the Plan is amended; or
2. The date ,that You add or delete any subsidiary or affiliated company or corporate division; or
3. Any anniversary date of the Effective Date of the' Policy.
GH 2001
13
'SECTION 8-YOUR DUTIES
The parties agree that You have ~e following duties and obligations:
1. You will be responsible for:
a) The investigation, auditing, calculating, and paying of all claims:
b) The defense of any claim made, or suit brought or proceeding instituted against You; and
c) The preparation of periodic reports required by Us.
2. You shall maintain and make aVailable to Us, at all t~mes, such information and records that as We
may r~asonabl¥ require for proof'of payment 9fthe amounts by You which qualify You for coverage
under .Aggregate Excess Loss Insurance and/or Specific Excess Loss Insurance provided by this
Policy; These payments w~ll, be ceunted toward~the Specific Deductible and the Attachment Point
fo~' the Aggregate Benefit.
3. You.shal] maintain a record of any and all amounts paid in excess of payments required by the~lan.
4. You shall prepare and submit to Us on a monthly basis the following:
a) A report of thetotal claims paid during the menth and;
b) A report of the total number of employees and dependent units ceverad under the Plan during
the month.
5. You shall maintain records reasonably required by Us and shall furnish to Us upon Our request, all
pertinent data with respect to Covered Persons.
6. You shall immediately notify Us if the Plan is amended or terminated.
The parties also agree that You may retain a Plan Administrator as Your. agent, to perform any or all oT
the duties listed in this Section; and, further agree that We are not liable under this Policy for any
chartJes or expenses that may be Incurred by You and/or Your Administrator for the performance of
these duties.
GH 2001 14-
SECTION 9-GENERAL PROVISIONS
ENTIRE CONTRACT
.This'Policy, Your application, a copy of which is attached, and a copy of Your Plan constitute the entire
contract between~the parties. Statements made ,by You i[3 tiie Application and Disclosure Statement are
mpresentat~oes and not warranties. No Cha~qge in the Plan, made after the Policy Effective Date, shall
have any effect on benefits payable under this Policy, unless a copy of such change has been submitted
~ and approved in wdting by one of Our Off[eem.
Only one of Our Officers may change this Policy or extend the time for payment of any premium. No
.;such cha[~cje~ shall be valid unless the chaegeis sfgned by one of O~r Officers in writing.
O:~ER INSURANCE
The insurance coverage provided by this Policy shall be excess over any other valid group health,
~cess.insurance, or group indemnity coverage unless such other coverage is specifically issued to be in
cess of~the ~nsui'ance provided by this Policy.
PARTIES TO THE POLICY
The parties t(3 thts Policy are You and Us. This Policy does not create any dght or legal relationship
whatsOever between Us and a Covered Person or beneficiaries under Your Plan. We shall not have any
responsibility or, obligation under this Policy to directly reimburse any Covered Person, or provider of
professional or medical services for any benefits which are provided under the terms of Your Plan. Our
only liability under this Policy is to You.
NOTICE
For the purpose of any notice required from Us under the applicable provisions 9[ this Policy, notice to
the Administrator is notice to You, and conversely, notice to You is notice to the Admioistrator.
EXAMINATION OF RECORDS
Your books and records, an(3 the books and records of all of Your agents and representatives pertaihieg
to the Plan and/or insurance provided by this Policy shall be open to Us and Our representatives dudeg
Your regular business hours for inspection and audit,
AMENDMENTS TO THE PLAN
Amendments to Your Plan are not covered under this Policy unless:
1. We have approved the proposed change in wdting; and
2. You have agreed to pay any additional premium or to accept a higher Aggregate Monthly Factor(s)
as a result of the Plan change.
CLERICAL ERROR
Clerical error will not invalidate insurance othenNise in effect nor continue insurance validly terminated. If
an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment
involves the return of unearned premium, the amount of the return will be limited to the premium for the
GH 2001 15
twelve 112) month pedod which precedes the date that We receive proof that such an adjustment should
- be made.
coN'IFi~i~MITY WITH STATE STATUTES
If any prOVision of this Policy or its Effective Date conflicts with any applicable law, the provision will be
deemed to conform with the minimum requirements of such law.
'~ASSIGNMENT
Your interest under this Policy is not assignable and any attempt to assign Your interest shall be null and
void.
NON-PARTICIPATING
You are not entitled to share in Our surplus eamiegs.
CLAIMS
We shall have the sole authority to pay or deny claims which exceed any Aggregate Attachment Point or
Specific Deductible Amount. Claims shall be administered by Us or Our authorized representative.
Claims mast be submitted within thirty (30) days after You have paid Eligible Expenses on behalf of any
Covered Person. All benefits will be paid to You as they become payable under this Policy.
Any objection, notice of legal action, or complaint, which is received on a claim processed by You or
Your Administrator and on which it reasonably appears that benefits will be payable under this Policy,
shall be brought to the immediate attention of Our Banefits/Clalm Department.
NOTICE OF CLAIM
You shall give Us a written preliminary notice of any claim, for which benefits may be payable under this
Policy, that is equivalent to or exceeds fifty 50 percent of the Specific Deductible Amount. Your failure
to famish written notice within thirty (30) days shall not invalidate or reduce the claim if it was not
reasonably possible to give such notice within such time; provided that wdtten notice is famished to Us
as sbon as reaSOnably possible.
LEGAL ACTION
No legal action to recover any benefits may be brought until sixty (60) days after the date that written
claim for benefits has been given to Us. No legal action may be brought more than three (3) yearn after
the incurred date of the Loss for which benefits are claimed.
GH 200t 16
SUBROGATION
You shall pursue any and all valid claims against third parties adsing out of any occurrence resulting rna
Loss payment under the Plan; and You shall account for any amounts recovered. Should You fail to
pursue any valid claims against third parties for good cause and We then become liable to make
;payment to You under the terms and conditions of the Policy, then We shall be subrogated to all of Your
~ights to the proceeds of a thin:l party settlement or satisfied judgment; but only to the extent that said
~settlement or judgment specifically allocates a portio~ thereof to Eligible Expenses Incurred by a
Covered Person prior to the date of settlement Or judgment. You shall take such action, furnish such
~nformation and assistance and execute such papers as We may require to facili~tate enforcement of Our
Tights, and shall take no action prejudicing Our rights and interests-underi" this POlicy.
~einY a~our~ts that We, recever shall be used t~ pay.' (~) Oqr e~pen~es of c~llection; and (2)
mbursem ,en~~ for. any a~n, Ount; that- We- may ~h~a.~. [~d or beCom~liabl~tO pay, to You, Under the terms
0fthis Policy. Ali remair~ngam~u'ntS Sh~
LATE ENROLLEE RULE
We will not accept liability under any Excess Loss Insurance for persons who apply for coverage under
[he Plan r~ore than thirty;one (31) days after the date on which such persons become initially eligible,
until such persons have submitted satisfactory evidence of insurability and have been appmvff..d, ~
writing, for COverage by Us.
MEDICARE
This Policy does not provide benefits for any Loss for which payment has been made or would have
been made, if application has been made or eligibility maintained, under Part A or Part B of Medicare on
behalf of a Covered Person. However, if a Covered Person is eligible for Medicare but has a ri~j~[ to be
enrol~er the Plan, such exclusiOn shall not apply.
GH 2001 17