HomeMy WebLinkAboutStop Loss Contract
I sCand qroup }ldministration, I ne.
Corporate Offices
3 Toilsome Lane, East Hampton, New York 11937
Phone: (631) 324-2306 or 1-800-926-2306
Fax: (631) 324-7021 or (631) 329-0152
June 22, 2006
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Mr. John Cushman
Town of South old
P.O. Box 1179
Southold NY 11971
Re: Stop/Loss Contract
Dear John,
Em;losed please find the final version ofthe 2006 Stop/Loss Contract for the Town of
Southold.
Standard Security increased your monthly specific premium 6% to $28.86. We have
attached for your convenience a spreadsheet outlining the premiums paid and the total
amount due along with a voucher.
If you have any questions, please do not hesitate to contact me.
Enclosure
C~J
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or
STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK
(a New York Stock Life and Health Insnrance Company)
Home Office:
485 Madison Avenne
New York, New York 10022
212-355-4141
POLICY NUMBER: JBM-122-NY-02
POLICYHOLDER: Town of South old
POLICY PERIOD: January 01, 2006 through December 31, 2006
EFFECTIVE DATE: January 01, 2006
EXPIRATION DATE: December 31, 2006
ANNIVERSARY DATE: January 01, 2007, and on the same day each year after.
PREMIUM DUE DATE: January 01, 2006, and on the same day each month.
STATE OF DELIVERY: New York
This Policy is a legal contract. We issue it in consideration of: (1) Your Application, (2) Your Disclosure
Statement, and (3) Your payment of premiums when due. This Policy, Your Application, Your Disclosure
Statement, and a copy of the Plan form the entire agreement between Us.
In issuing this Policy, We have relied upon the information (including, without limitation, information in
the Disclosure Statement, Your Application, and the Plan) provided to Us by: (I) You, (2) Your
Administrator, and (3) Your agent or broker. We have also relied on this information being both complete
and accurate. If the information was incomplete or incorrect, We shall have the immediate right: (I) to
modify the Policy to reflect the complete or correct information, or (2) to terminate the Policy upon
written notice.
We agree to make payments in accordance with the provisions of this Policy.
In this Policy, "You" and "Your" refer to the Policyholder, and "We", "Us", and "Our" refer to Standard
Security Life Insurance Company of New York.
This Policy is issued and governed by the laws of the state of delivery as indicated above.
Sigoed for Standard Security Life Insurance Company of New York as of the Effective Date.
P~l
Rachel Lipari
President
rG---r-o/
David Kettig
Secretary
EXCESS LOSS INSURANCE POLICY
Non-Participating
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TABLE OF CONTENTS
SECTION I-SCHEDULE OF EXCESS LOSS lNSURANCE
SECTION 2-DEFlNITIONS
SECTION 3 - AGGREGATE EXCESS LOSS lNSURANCE
SECTION 4-SPECIFIC EXCESS LOSS lNSURANCE
SECTION 5-EXCLUSIONS AND LIMITATIONS
SECTION 6- TERMINATION
SECTION 7-PREMIUMS
SECTION 8- YOUR DUTIES
SECTION 9-GENERAL PROVISIONS
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9
10
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SECTION I-SCHEDULE OF EXCESS LOSS iNSURANCE
(hereinafter referred to as the "Schedule")
POLICYHOLDER:
ADDRESS:
Town of South old
53095 Main Road
Southold, NY 11937
ADMlNISTRATOR:
ADDRESS:
Island Group Administrators
3 Toilsome Lane
East Hampton, NY 11937
ALL AMOUNTS AND NUMBERS SHOWN IN THIS SCHEDULE APPL Y ONLY TO THE POLICY
PERIOD IN EFFECT. A NEW SCHEDULE WILL BE ISSUED FOR EACH NEW POLICY PERIOD.
A. ~ AGGREGATE EXCESS LOSS iNSURANCE:
1. BENEFITS COVERED:
X Medical N/A Dental
X Prescription Drug Card
N/A Weekly Income N/A Vision
2. POLICY BASIS/BENEFIT PERIOD:
Eligible Expenses Incurred from January 01. 2006 through December 31. 2006; and
Eligible Expenses Paid from January 01. 2006 through December 31. 2006
If this Policy terminates prior to the Expiration Date. no Ae:cree:ate Excess Loss Benefits
will be payable and premium paid will not be refundable.
3. iNITIAL AGGREGATE ATTACHMENT POiNT: $2.699.558.40
4. MINIMUM AGGREGATE ATTACHMENT POiNT: $2.564.580.48
5. BENEFIT PERCENTAGE PAYABLE iN ACCORDANCE WITH SECTION 3: 100%
6. MAXIMUM AGGREGATE BENEFIT (WHILE COVERED, AND WHILE THIS
POLICY IS iN FORCE): $1 million
7. AGGREGATE MONTHLY FACTOR(S): Single: N/A Family: N/A
Composite: $1.004.30
Coyered Units/emollment:
Single: _ Family: _
Composite: 224
8. AGGREGATE PREMIUM (Annually): $27.500
9. AGGREGATE LOSS LIMIT: $175.000
10. PAYMENT MODE: Annually
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B.1jg SPECIFICIINDIVIDUAL EXCESS LOSS INSURANCE:
I. BENEFITS COVERED: Medical and Rx Benefits Only
2. POLICY BASISIBENEFIT PERIOD:
Eligible Expenses Incurred from January 0 I. 2006 through December 31. 2006; and
Eligible Expenses Paid from January 01. 2006 through December 31.2006.
'fthis Policy terminates orior to the Exoiration Date. the Benefit Period will not extend oast
the date of termination. In addition. the deductible oer Covered Person will aoolv as if the
Policy were in force for the entire Policy Year.
3. DEDUCTffiLE PER COVERED PERSON: $175.000
4. BENEFIT PERCENTAGE PAYABLE IN EXCESS OF THE SPECIFIC
DEDUCTffiLE: 100%
5. MAXIMUM SPECIFIC BENEFIT PAYABLE MINUS THE SPECIFIC
DEDUCTffiLE (pER LIFETIME PER COVERED PERSON), WHILE THIS
POLICY IS IN FORCE: $825.000
6. SPECIFIC MONTHLY PREMIUM RATE:
Single: N/A Family: N/A Composite: $28.86
Covered Units/enrolhnent: Single: _ Family: _ Composite: 224
o OPTIONAL RIDERS ELECTED: None
Ijg WAIVER OF ACTIVELY AT WORK ELECTED: Yes
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_;__....-.~e_w._..''',
SECTION 2-DEFINITIONS
ADMINISTRATOR means an organization which has been retained by You and approved by Us to
provide claim and administrative services for You.
AGGREGA TE MONTHLY FACTOR means the amouot applicable to each Covered Person as shown in
the Schedule.
ANNUAL AGGREGATE ATTACHMENT POINT which is determined at the end of the Policy Year
and is an amouot equal to the product of the Aggregate Monthiy Factor times the number of Covered Units
for each applicable month during the Policy Year. The Annual Aggregate Attachment Point is stated in the
Schedule and is described in Section 3. This amouot is that portion of the Eligible Expenses not covered by
this Policy and entirely retained by You for the total Number of Covered Units in each Policy Year.
APPLICATION means the application for excess loss insurance submitted by You to Us in connection
with the issuance of this Policy.
BENEFIT PERCENT AGE PAYABLE means the factor that determines the amouot of the Maximum
Benefit payable to You as shown in the Schedule. Separate benefit percentages may apply to either the
Aggregate Excess Loss or to the Specific Excess Loss.
BENEFIT PERIOD means the period of time, as shown in the Schedule, during which a covered expense
must be Incurred, and/or Paid to be eligible for reimbursement uoder this Policy.
COVERED MONTH is determined from the Effective Date. Each new Covered Month will begin on the
date which corresponds with the Effective Date. If there is no such date in any applicable month, then the
last date of that month will be used.
COVERED PERSON means an eligible employee or eligible dependent(s) .
COVERED UNIT includes an eligible employee, eligible employees and their dependents or such other
defined individuals as specifically agreed upon between You and Us.
DISCLOSURE STATEMENT means the disclosure statement submitted by You to Us in connection with
the issuance of this Policy.
ELIGIBLE EXPENSES means the reasonable and customary charges covered by the Plan and incurred by
a Covered Person while insured uoder the Plan for medically necessary treatment, services and/or supplies
prescribed by an attending physician.
EFFECTIVE DATE means the date the coverage begins as stated in the Schedule.
EXPERIMENTAL or INVESTIGATIVE means care, procedures, treatments, or technology that are not
widely recognized and accepted as effective, safe and appropriate for the injury or illness by the medical
profession in the U.S., that are in research or Investigative stage, or conducted for research or similar
purposes; or 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 similar term.
In determining any of the criteria stated above We will rely on recognized medical sources such as, but not
limited to the American Medical Association, the Couocil of Technology Assistance Program and the
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Council on Medical Special Services, the National Institute of Health, Medicare, the Food and Drug
Administration; and other accepted medical authorities and sources.
INCURRED means the date on which an Eligible Expense was rendered to a Covered Person.
INITIAL AGGREGATE ATTACHMENT POINT means the annual aggregate attachment point as
calculated on the Effective Date based upon the number of Covered Units at that time multiplied by the
corresponding attachment factors and multiplied by twelve.
LATE ENROLLEE means any individual who makes a written application for coverage under the Plan
more than a specified number of days (as indicated in the Plan) after first becoming eligible for coverage
under the Plan.
LOSS OR LOSSES mean amounts Paid, in accordance with the Policy BasislBenefit Period shown on the
Schedule, by You or the Administrator on Your behalf for benefits under the Plan, in settlement of claims
for benefits under the Plan; or in satisfaction of judgments for benefits under the Plan.
LOSS OR LOSSES, HOWEVER, DOES NOT INCLUDE:
I. any payment which does not strictly comply with the provisions of the Plan; or
2. 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
3. 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 the part of You, Your Administrator or Your
agent or broker; or
4. salaries paid to Your employees as well as Your claim and administrative expenses; or
5. litigation costs and expenses.
MAXIMUM AGGREGATE BENEFIT means the amount stated in the Schedule.
MAXIMUM SPECIFIC BENEFIT means the amount stated in the Schedule.
MINIMUM AGGREGATE ATTACHMENT POINT means an amount equal to 95% of the product of
the Initial Enrollment of the first Covered Month of the Policy multiplied by the corresponding Aggregate
Monthly Factor multiplied by twelve.
MONTHLY AGGREGATE ATTACHMENT POINT means an amount equal to the product of the total
Number of Covered Units per Covered Month of a Policy Year multiplied by the corresponding Aggregate
Monthly Factor.
NUMBER OF COVERED UNITS means the total Covered Units existing in anyone Covered Month and
will be determined on a monthly basis in accordance with the defmition of Covered Units; and the eligibility
requirements of the Plan.
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PAID (Payment) means that a claim has been adjudicated by the Administrator and the funds are actually
disbursed by the Plan prior to the end of the Benefit Period. Payment of a claim must be unconditional and
directly made to a Covered Person or their health care provider(s). Payment will be deemed made on the
date that both You or Your Administrator directly tenders payment by mailing (or by other form of delivery)
a draft or check; and the account upon which the payment is drawn contains, and continues to contain,
sufficient funds to permit the check or draft to be honored by the institution upon which it is drawn.
PLAN means the employee benefit plan You provide Your eligible employees and their eligible
dependents, as defined in this Policy, which has been received and accepted by Us. Plan does not include
life insurance, accidental death and dismemberment insurance, long and short-term disability insurance
coverages, or fully insured major medical insurance coverages.
POLICY YEAR means the specified period oftirne during which the coverage provided under this Policy
is in effect, as stated in the Schedule.
SPECIFIC DEDUCTIBLE AMOUNT means the amount shown in the Schedule.
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SECTION 3 - AGGREGATE EXCESS LOSS INSURANCE
If at the end of a Policy Year, Losses exceed the Annual Aggregate Attachment Point or the Minimum
Aggregate Attachment Point shown in the Schedule, We will pay You an amount equal to:
I. the amount by which Losses Paid during the Policy Year exceed the applicable Annual Aggregate
Attachment Point or the Minimum Attachment Point, whicheyer is greater. multiplied by.
2. the Benefit Percentage Payable and shown in the Schedule, subiect to
3. the Maximum Aggregate Benefit as shown in the Schedule.
Payment of Policy benefits is:
I. subject to all terms, conditions, limitations and exclusions in this Policy, and
2. contingent upon Our receipt of satisfactory proof of Loss (including, without limitation, an on-site
audit), and Your request for reimbursement.
Losses Paid under this Section 3 during any Policy Year will be determined according to the Policy
Basis/Benefit Period, 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 ofthis Policy.
If this Policy terminates prior to the Expiration Date as shown in the Schedule no Aegreeate Excess Loss
Benefits will be payable.
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SECTION 4-SPECIFIC EXCESS LOSS INSURANCE
If during the Policy Year, or any fraction of a Policy Year, Losses for any Covered Person exceed the
Specific Deductible Amount shown in the applicable Schedule, We will pay a benefit for such Covered
Person in an amount equal to:
I. the amount by which Losses Paid during the Policy Year exceed the Specific Deductible Amount as
shown in the Schedule multiplied by:
2. the Benefit Percentage Payable, subject to
3. the Maximum Specific Benefit as shown in the Schedule.
Payment of Policy benefits is:
I. subject to all terms, conditions, limitations and exclusions in the Policy and the Plan, 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 Policy Basis/Benefit
Period.
Payment will not include any amounts paid or payable by Us to You for Aggregate Excess Loss
Insurance according to the terms in Section 3 of this Policy.
If this Policv terminates prior to the Exoiration Date. the Benefit Period will not extend Past the date of
termination. In addition. the deductible per Covered Person will applv as if the Policv were in force for the
entire Policv Year.
SL-2001
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SECTION 5-EXCLUSIONS AND LIMITATIONS
Our liability under this Policv will not be increased if the Plan provides more liberal exclusions and
limitations orovisions.
In addition to the exclusions and limitations provided under the Plan, this Policy will not cover any of the
following (unless such exclusion or limitation is specifically waived by rider or endorsement):
1. Deductibles, co-payment amounts, or any other charges which are not payable under the terms of the
Plan or charges which are payable by the Plan, or to You from any other source.
2. Charges for Experimental or Investigative services, treatments or supplies; or drugs which have not
been approved by the Food and Drug Administration.
3. Any conditions 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. Claims for a Covered Person who, on the date that coverage under this Policy would otherwise
begin, is an employee who is not actively at work at his or her normal job or is a retired employee or
dependent of an employee who is unable to perform the normal activities of a person of like age or
sex.
No benefits will be provided for any charges Incurred until the day after the date that such Covered
Person if an employee returns to active work on a full-time basis or if a retired employee or
eligible dependent of an employee is able to perform the normal activities of a person of like age
and sex.
5. Charges resulting from any extra or non-contractual damages or legal fees and expenses for the
defense thereof, or any fmes or statutory penalties.
6. Any procedure or treatment to change physical characteristics to those of the opposite sex, or any
other treatment or studies related to a sex change or treatment of sexual disorders.
7. 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.
8. Services or expenses for charges Incurred as a result of suicide or attempted suicide, whether sane or
insane; or intentional self-inflicted injury or illness.
9. Injury or illness which occurs due to a Covered Person's commission of, or attempt to commit a
criminal act or while a Covered Person is engaged in an illegal activity.
10. Legal expenses of any kind or description, including legal expenses related to or Incurred for the
confmement 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 performed to correct functional disorders or congenital
anomalies; or due to accidental injury occurring while that individual is a Covered Person.M
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12. Expenses for hearing aids.
13. Treatment for obesity and/or eating disorders.
14. Expenses for artificial insemination, invitro fertilization, gamete or zygote intrafallopian transfer, or
reversal of voluntary sterilization.
15. Transplants of non-human, mechanical or artificial organs or tissue.
16. Expenses arising out of, caused by, contributed to or in consequence of war, declared or undeclared,
civil war, hostilities, or invasion.
17. Expenses for any COBRA continuee or retiree whose continuation of coverage was not offered in a
timely manner or according to COBRA regulations.
18. Expenses incurred as a result of any lost savings or discounts offered by a facility or provider due to
untimely payment of the bill by You or Your Administrator.
19. Expenses for which benefits are not payable under the Plan because of an exclusion for expenses
incurred due to a pre-existing condition as defined in the Plan.
8L-2001
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(6/01)
SECTION 6- TERMINATION
This Policy and all Policy benefits will terminate upon the earliest of;
I. on any premium due date, if the premium due on that date is not paid in full by the end of the Grace
Period;
2. the premium due date following Our receipt of Your written notice to cancel or terminate this
Policy;
3. on any premium due date We specify if We give You at least thirty-one days advance written notice.
to cancel or terminate this Policy;
4. the end of the Policy Year as shown in the Schedule;
5. the date of termination ofthe Plan or the Policy;
6. the date that You suspend active business operations or become insolvent or a bankruptcy action is
commenced (whether voluntary or involuntary) or You are in liquidation or receivership;
7. the date that You do not pay claims or make funds available to pay claims as required by the Plan;
or
8. the date on which Your employees are covered under another employee benefit plan or fully insured
medical program.
In addition, this Policy shall automatically terminate upon the cancellation of the agreement between You
and the Administrator, unless We have, prior to such cancellation, agreed in writing to Your designation of a
successor Administrator.
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SECTION 7-PREMIUMS
PAYMENT OF PREMIUMS
No coverage under this Policy shall be in effect until the first premium for the Policy is paid. For coverage
to remain in effect, each subsequent premium must be paid on or before its due date. You are responsible
for paying premiums when they become due. Premium due dates are determined from the Effective Date.
Each premium due date is the same day of each month corresponding with the Effective Date. If there is no
such date in any applicable month, the last day of that month shall be used.
GRACE PERIOD
We will allow a thirty-one day Grace Period for the payment of each premium due after the payment of the
first premium. During this Grace Period, this coverage shall remain in effect. If any premium is not paid
within this thirty-one day period, coverage under this Policy will automatically terminate without further
notice. Such termination will be effective as of the premium due date immediately following the end of the
last period for which the minimum monthly premium has been paid.
PREMIUM RATE CHANGE
We have the right to modify Aggregate Monthly Factor(s) or Specific Monthly Premium Rates on any of the
following dates:
I. the effective date of any change in benefits or other amendment to the Plan; or
2. the date that You acquire or dispose of any subsidiary, affiliated company, corporate division or
assets relating thereto; or
3. any Anniversary Date as shown on the cover page of this Policy; or
4. any premium due date, when there is a ten percent or more change in the number of Covered
Persons during a Policy Period; or
s. at such time as We determine that the last two months of claims in the preceding Policy Period vary
by more than ten percent from the average monthly paid claims for the prior ten months.
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SECTION 8-YOUR DUTIES
You shall be responsible for the investigating, auditing, calculating, and paying of all claims, and the
defense of any legal action instituted against You.
You shall maintain and make available to Us, at all times, such information and records as We may
reasonably require evidencing Your proof of payment of amounts which qualify for coverage under this
Policy.
You shall maintain a record of any and all amounts paid in excess of payments required by the Plan.
You shall prepare and submit to Us the following:
1. a monthly report of the total claims paid during the month,
2. a monthly report of the total number of Covered Units under the Plan during the month,
3. any other report as required by Us, and
4. any notice of claim as required under this Policy.
You shall maintain records reasonably required by Us and shall furnish to Us upon Our request, all pertinent
data with respect to Covered Persons.
You shall immediately notify us if You acquire or dispose of any subsidiary, affiliated company, corporate
division or assets relating thereto.
You shall immediately notify Us of the date that You suspend active business operations or become
insolvent or a bankruptcy action is commenced (whether voluntary or involuntary) or You are in liquidation
or receivership.
You shall immediately notify Us if the Plan is amended or terminated.
If You do not give Us notice of amendment of the Plan Our liability is limited to the lesser of the benefits
payable: a) under the Plan as revised; or b) as if the Plan had not been amended.
You may retain an Administrator as Your agent to perform any or all of the duties listed in this Section. We
are not liable under this Policy for any charges or expenses that may be incurred by You and/or Your
Administrator for the performance of these duties.
You and the Plan acknowledge that:
1. The Administrator is not Our agent.
2. Payments by or notices from Us to the Administrator are deemed received by You upon receipt
by the Administrator. Payments from You to the Administrator are not deemed received by Us.
We act only as a provider of excess loss'insurance coverage to the Plan. We do not act as a
fiduciary. We do not assume any duty to perform any of the functions or provide any of the
reports required by the Employee Retirement Income Security Act of 1974 (ERISA), as amended.
3. We must approve a change in Administrator prior to its occurrence.
SL-2001
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(6101)
SECTION 9-GENERAL PROVISIONS
ENTIRE CONTRACT
This Policy, Your Application, Your Disclosure Statement and a copy of the Plan constitute the entire
contract between the parties.
No change in the Plan, made after the Effective Date, shall have any effect on benefits payable under this
Policy, unless a copy of such change has been submitted to and approved in writing by one of Our officers
or Our authorized representative.
This Policy does not create any right or legal relationship whatsoever between Us and a Covered Person or
beneficiaries under the pian. 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 the Plan. Our only liability under this Policy is to You. Only one of Our
officers may change this Policy. No change shall be valid unless the change is agreed to by Our President,
Vice President or Secretary in writing.
OTHER INSURANCE
The insurance coverage provided by this Policy shall be excess over any other valid group health, excess
insurance, or group indemnity coverage unless such other coverage is specifically issued to be in excess of
the insurance provided by this Policy.
NOTICE
For the purpose of any notice required under this Policy, notice to the Administrator is notice to You, and
conversely, notice to You is notice to the Administrator.
EXAMINATION OF RECORDS
Your books and records, and the books and records of all of Your agents and representatives pertaining to
the Plan and/or insurance provided by this Policy shall be available to Us and Our representatives during
Your regular business hours for inspection and audit.
AMENDMENTS TO THE PLAN
Amendments to the Plan are not covered under this Policy unless We have approved the proposed change in
writing; and You have agreed to pay any additional premium or to accept a higher Aggregate MontWy
Factor(s) as a result of the Plan change.
CLERICAL ERROR
Clerical error will not invalidate insurance otherwise in effect nor continue insurance validly terminated. A
clerical error does not include intentional acts or the failure to comply with the Plan or this Policy. If an
error is discovered, an equitable adjustment in premium will be made. If a premium and/or factor(s)
adjustment involves the return of unearned premium, the amount of the return will be limited to the
premium for the twelve month period which precedes the date that We receive proof that such an adjustment
should be made.
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(6101)
CONFORMITY 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 earnings.
NOTICE OF POTENTIAL CLAIM
You shall give Us a written notice of any potential claim within thirty days of the date You become aware of
the existence of facts which would reasonably suggest the possibility that expenses covered under the Plan
will be Incurred for which benefits may be payable under this Policy, and is equivalent to or exceeds fifty
percent of the Specific Deductible Amount.
This notice shall include:
1. name of the Covered Person;
2. date of accident or onset of sickness;
3. nature of injury or sickness; and
4. estimated total cost of claim.
Your failure to furnish written notice of a potential claim within thirty days shall not invalidate or reduce the
claim if it was not reasonably possible to give such notice within such time; provided that written notice is
furnished to Us as soon as reasonably possible.
CLAIMS
We shall have the sole authority to payor deny claims which exceed any Aggregate Attachment Point or
Specific Deductible Amount. Claims shall be administered by Us or Our authorized representative. Claims
must be submitted within thirty days after You have paid Eligible Expenses on behalf of any Covered
Person. We are not obligated to reimburse a claim submitted after such period. However, We will
reimburse such claim in the event You show that timely submission was not possible, and You made the
submission as soon as possible.
In no event will We reimburse claims submitted more than one year after proof of the claim was
otherwise due. 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 Our immediate attention.
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LEGAL ACTION
No legal action to recover any benefits may be brought until sixty days after tbe date tbat written claim for
benefits has been given to Us. No legal action may be brought more tban three years after tbe Incurred date
of tbe Loss for which benefits are claimed.
RENEWAL
At tbe end of a Policy Year, a subsequent Policy Year may be agreed to by You and Us. The Schedule in
Section I will be amended to show tbe coverage and terms in effect during each subsequent Policy Year.
SUBROGATION
You shall pursue any and all valid claims against third parties arising out of any occurrence resulting in a
Loss payment under the Plan in accordance witb applicable law. You shall account for any amounts
recovered. Should You fail to pursue any valid claims against third parties for good cause and We tben
become liable to make payment to You under tbe terms and conditions of tbe Policy, tben We shall be
subrogated to all of Your rights to the proceeds of a tbird party settlement or satisfied judgment; but only to
tbe extent tbat said settlement or judgment specifically allocates a portion tbereof to Eligible Expenses
Incurred by a Covered Person prior to tbe date of settlement or judgment. You shall take such action,
furnish such information and assistance, and execute such papers as We may require to facilitate
enforcement of Our rights, and shall take no action prejudicing Our rights and interests under this Policy.
Any amounts that We recover shall be used to pay Our expenses of collection; and reimbursement for any
amount that We may have paid or become liable to pay, to You under the terms of tbis Policy. All
remaining amounts shall be paid to You.
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 right to be enrolled
under tbe Plan, such exclusion shall not apply.
REINSTATEMENT
We may agree at Our sole option and witbout prejudice to Our rights under this Policy to reinstate
coverage as of the effective date of cancellation, on receipt and approval of written application for
reinstatement and any and all otber material and/or information as We may request, including but not
limited to all outstanding premiums plus interest due from the effective date of reinstatement at a rate of
not less than 1.5% per month compounded monthly. No insurance shall be reinstated until We confirm
such reinstatement to You in writing and any premiums have been paid.
LIABILITY AND INDEMNIFICATION
Except as specifically provided in any rider or endorsement, attached to and forming part oftbe Policy,
We have no obligation to any third party. Our liability under tbis Policy is limited to reimbursing You for
payments You make on behalf of Covered Persons for expenses covered under the Plan. You hold Us
harmless for damages, of any kind, which are not caused by Our own acts or omissions. We are not
responsible for any liability You assume under any contract of agreement other tban tbe Plan.
SL-2001
17
(6/01)
JB MURPHY ASSOCIATES LLC
Friday, February 03, 2006
Mr. Alan Kaplan
Island Group Administrators
3 Toilsome Lane
East Hampton, NY 11937
Re: Town of SouthoId Renewal! Southold. NY 11937
Dear Alan:
JB Murphy Associates, LLC is pleased to offer you, on behalf of Standard Security Life
Insurance Company of New York, the following renewal for Specific and Aggregate stop
loss coverage:
Contract Period:
TPA:
January 01, 2006 through December 31, 2006
Island Group Administrators
Commission:
12.50% (I)
Enrollment (Est.)
Total:
224
(I) Standard Security Life Insurance Company of New York may pay the
selling broker or third party administrator compensation for the promotion and
sale of the products and services offered in this proposal. In addition to our
standard compensation arrangements, we may make additional cash and!or non-
cash payments or reimbursements to selling brokers in recognition of their
marketing and distribution activities, persistency levels and volume of business.
We encourage brokers and their clients to discuss what commissions or other
compensation may be paid in connection with the purchase of products and
services from Standard Security Life Insurance Company of New York
140 West 22nd Street - 5th Floor - New York, New York -10011
(212) 584-9125 Phone (212) 584-9116 Fax
Specific Coveral!e
Deductible:
Contract Basis:
Lifetime Maximum:
Coverage:
Composite Rate PEPM:
Est. Annual Premium:
Al!l!rel!ate Coveral!e
Attachment Point Factor:
Contract Basis:
Lifetime Maximum:
Coverage:
Annual Premium:
JB MURPHY ASSOCIATES LLC
Current
Renewal
Option #1
$175,000
12/12
$1 million
Med & Rx
$27.23
$73,194.24
$175,000
12/12
$1 million
Med & Rx
$28.86
$77,575.68
$200,000
12/12
$1 million
Med & Rx
$22.64
$60,856.32
$1,004.30
12/12
$1 million
Med & Rx
$27,500
$1,004.30
12/12
$1 million
Med & Rx
$27,500
$1,029.41
12/12
$1 million
Med &Rx
$27,500
Underwritinl! ReQuirements/ Considerations:
The above proposal, including the rates, factors, and the applicability of the deductible
levels to all covered persons, shall not be binding until our receipt and favorable review
of the following:
1) Copy ofthe group's complete plan document with any plan amendments.
2) Updated claims information, throul!h 12-31-05, on all claims in excess of
$75,000 over the past twelve months and those likely to exceed $75,000
during the next twelve months, with diagnosis, prognosis and pending claims.
We will need an updated shock claims report prior to a final determination
as to a waiver of the Activelv- at-Work provision and we reserve the rillht to
set lasers
In the meantime we would like updated information (Case management
notes, updated prognosis and diagnosis, future treatment plan and related
costs, updated amount of paid claims, amount of pending claims,
"lifetime" claims, etc) on the following individuals:
A. Michael Fouchet: (Liver Cancer / $125,746.43 in paid claims from 01/01/05 through
11/28/05).
B. Jovce Wilkins: (prognosis??? / $116,235.68 in paid claims from 01/01/05 through
11/28/05).
140 West 22nd Street - 5th Floor - New York, New York -10011
(212) 584-9125 Phone (212) 584-9116 Fax
JB MURPHY ASSOCIATES LLC
3) Updated claim report tracking claims on a "lifetime" basis. Of particular
concern will be claimants who have exceeded $250,000 on a cumulative basis.
Is this currently being tracked by the TP A and / or client?
4) Are there any pending claims that have not been processed due to any sort of
delay (re-negotiation of discounts, audits, possible disclosure issues, COB
investigations, Eligibility Disputes, etc.)?
5) Are there any claims currently being re-priced by IGA from prior
contract periods (2003, 2004)?
6) Signed application and disclosure statement.
7) Current census as of 0 1-0 1-06.
8) Individuals who are Medicare Eligible (vs. Medicare Primary) and why.
For instance, are there any individuals with end-stage-renal disease who are
not yet Medicare primary?
9) Any individuals on Social Security Disability or Medicaid?
10) Are there any disabled "adult" dependent children over the plan's "limiting
age" (23 or 25) covered under this plan?
II) Individuals who are on maintenance drugs (Le. cyclophosphamide and
prednisone for Factor VIII, etc.) and have incurred drug charges over $5,000.
12) Listing of any claims subject to third-party liability / subrogation.
13) Does this group have anyone currently on an organ transplant list or being
considered for any organ transplant?
Sincerely,
Brian A. Murphy
140 West 22nd Street 0 5th Floor 0 New York, New York 010011
(212) 584-9125 Phone (212) 584-9116 Fax