HomeMy WebLinkAbout000185.tiff LINCOLN
NATIONAL
January 11, 1991
Dear Policyholder:
This is your Group Insurance Policy. It is divided into sections, enabling you to keep the policy current as changes
are made.
Policy pages which you receive in the future will be accompanied by a Group Insurance Amendment which will
tell you which policy pages are being replaced. The new policy pages should be filed in the proper section in the
policy. The Amendments and the replaced pages should be filed behind the divider labeled "Amendments" and
the changes noted on the divider.
Sincerely,
Elaine Schafer
Document Preparation Specialist
Group Division
Master Contract Section
185
LINCOLN
NATIONAL
Group Policy Number 50,158
POLICYHOLDER
WELD COUNTY
Greeley, Colorado
EMPLOYER (The POLICYHOLDER shown above, unless otherwise indicated here)
Subsidiaries and Affiliates whose employees are to be insured under the Policy.
NONE
DATE OF ISSUE: January 1, 1991. The INITIAL PREMIUM is due on the DATE OF ISSUE and RENEWAL PREMIUMS
are due monthly on the 1st day of each month.
POLICY ANNIVERSARIES occur annually on January 1, beginning January 1, 1992.
This policy is delivered in Colorado, and is governed by its laws. If any part(s) of this policy is contrary to such
laws, that part(s) is hereby amended to conform to such laws.
SUBJECT TO THE TERMS AND CONDITIONS CONTAINED IN THIS POLICY, The Lincoln National Life Insurance
Company, on approval by its Home Office of the application of Policyholder and on payment of premiums when
due, agrees that on and after the Date of Issue it will provide group insurance with respect to each Insured Indi-
vidual.
This policy, and the application made by Policyholder (a copy of which is attached), form the entire contract be-
tween the parties.
The Lincoln National Life Insurance Company has caused this policy to be executed this 11th day of January, 1991.
Edward R. Ricker,Assistant Secretary Ian M. Rolland, President
Group Insurance Policy--Term Insurance--Contributory--Nonparticipating
Examined y27
FORM 19000 -1- 050158
INDEX
Section 1 Schedule of Benefits and Description of Benefits
Section 2 Benefit Exclusions and Limitations
READ CAREFULLY, IT APPLIES TO ALL BENEFITS
Section 3 Other Coverage
Medicare
Coordination of Benefits
Third Party Reimbursement
and Subrogation
Section 4 Not Used
Section 5 Conversion/Continuation
Section 6 General Information
Section 7 Definitions
Section 8 Policyholder
Section 9 Lincoln National
Section 10 Records
r
FORM 19000-INDEX -2- 050158
SECTION 1 - BENEFITS
i A. SCHEDULE OF BENEFITS
EMPLOYEE
LIFE INSURANCE BENEFITS
The Amount of Insurance is equal to 100% of annual earnings rounded to the nearest $1,000, unless al-
ready an even $1,000. The minimum amount is $10,000 and the maximum amount is $100,000.
On becoming age 70, the Amount of Insurance based on 100% of the current annual earnings will re-
duce by 40% rounded to the next higher $1,000, unless already an even $1,000. The minimum amount
will be $6,000 and the maximum amount will be $60,000.
On becoming age 75, the Amount of Insurance based on 100% of the current annual earnings will re-
duce by 60% rounded to the next higher $500, unless already an even $500. The minimum amount will
be $4,000 and the maximum amount will be $40,000.
On becoming age 80, the Amount of Insurance based on 100% of the current annual earnings will re-
duce by 70% rounded to the next higher $500, unless already an even $500. The minimum amount will
be $3,000 and the maximum amount will be $30,000.
No Life Insurance Benefits are provided for Employees assigned to a temporary position..
ACCIDENTAL DEATH BENEFITS
The Full Amount of Insurance is equal to the Amount of Insurance provided under Life Insurance Benefits.
No Accidental Death Benefits are provided for Employees assigned to a temporary position..
EMPLOYEE AND DEPENDENT
HOME HEALTH CARE BENEFITS
Benefit Percentage 80%
Maximum Payment for a Single Visit $40
Maximum Number of Visits 100
Each visit by a representative of a home health care agency shall be considered as one home health care
visit: each four hours of home health care service by a representative shall be considered as one home
health care visit.
MAJOR MEDICAL BENEFITS
REFER TO UTILIZATION REVIEW
FOR AUTHORIZATION REQUIREMENTS
Maximum Benefit (Lifetime Aggregate) $ 2,000,000
Deductible $150
The Deductible applies Except where indicated with an asterisk (').
When the insured individuals of a family unit have satisfied two times the individual calendar year
deductible, no further deductible will be required of that family unit during that calendar year. Except
that, no more than $150 may be satisfied by any one insured individual.
FORM 19002 -3- 050158
If a single accident causes injuries to two or more insured individuals who are members of a family unit,
a single deductible will apply to all such members of that family unit for whom a benefit period is not
in effect for covered charges incurred during that calendar year and resulting from all such injuries. In
no event will a lesser amount be paid than would be payable if this single deductible did not apply.
Co-Payment
In those instances where a Co-Payment applies, the amount is indicated. A Co-Payment means the
share of the charges for services which the Insured Individual must pay.
Co-Payments do not apply towards the Deductible.
Benefit Percentage
Charges are paid at the benefit percentage shown below.
Non-
Preferred Preferred
Provider Provider
Inpatient Hospital Charges
Paid At 80% 80%
Skilled Nursing Facility Charges
Paid At 80% 80%
Inpatient Surgeon Charges
Paid At 80% 80%
Inpatient Doctor Visits
Paid At 80% 80%
Outpatient Doctor Visits
For Other Than In An
Emergency Room
Co-Pay $15
Paid At 100% * 80%
Outpatient Surgery Charges
Performed In The Doctor's Office
Co-Pay $15
Paid At 100% * 80%
Outpatient Surgery Charges
Performed In Other Than The
Doctor's Office
Paid At 80% 80%
Outpatient Emergency Room
Charges (Facility & Doctor)
Co-Pay $50
Paid At 100% * 80%
Outpatient Diagnostic X-Ray & Lab
Including Pre-Admission Testing
Paid At 100% * 80%
Outpatient Drugs
Per Prescription
Co-Pay $5 for Generic
$8 for Non-Generic
Paid At 100% * 80%
Physical Therapy &
Speech Therapy (1)
Co-Pay $15
Paid At 100% * 80%
FORM 19002 -4- 050158
Wellness Benefits (2)
Co-Pay $15 Benefit Not
Paid At 100% ' Available
Mental Illness, Substance
Abuse and Alcoholism (3)
Facility
Paid At 80% 80%
Doctor Charges
Co-Pay $30.00
Paid At 100% ' 50%
All Other Eligible Charges
Paid At 80% 80%
1. For Speech Therapy there will be a maximum of a 60 day period of treatment per disability.
2. Wellness benefits are payable
a. for physical exams and immunizations for the first two years of age and
b. for physical exams including pap smears and prostate exams up to $150 for any 12 month pe-
riod for individuals two years of age and older.
3. See special limits in this Schedule of Benefits. Payment will be made at 100% after a $30.00 co-
payment. However, this payment must equal or be better than 50% of the eligible charge.
After $5,000 of eligible charges payable at less than 100% are incurred by an insured individual, or
$10,000 of eligible charges payable at less than 100% are incurred by the insured members of a family
unit, during a calendar year, Major Medical Benefits pays 100% of eligible charges (other than those
for (i) mental illness, substance abuse and alcoholism and (ii) dental conditions) subsequently incurred
within the calendar year, provided such charges are not required to satisfy a deductible.
Maximum Covered Charge for Room and Board
Hospital Semi-Private Rate
Skilled Nursing Facility Semi-Private Rate
Benefit Period
A Benefit Period for an insured individual begins when the individual has incurred in a calendar year
covered charges which exceed the deductible amount.
A Benefit Period for an insured individual ends on the earliest of the following:
1. the last day of the calendar year in which it was established; or
2. the day coverage under this policy ends; or
3. the day the maximum benefit is paid.
Covered charges incurred each calendar year on or after October 1 for which benefits are not payable
because the deductible has not been met, will apply toward the next calendar year deductible.
MENTAL ILLNESS, SUBSTANCE ABUSE AND ALCOHOLISM LIMITATION
In no event will payment under this policy for treatment of mental illness, substance abuse or alcoholism
exceed:
Inpatient
1. 45 days of confinement as an inpatient in a hospital during any one calendar year; and
2. for treatment of mental illness only, 90 days of partial hospitalization in a hospital during any one
calendar year; and
FORM 19002 -5- 050158
3. 50% of the reasonable and customary charge for professional services provided while the patient is
confined in a hospital, up to a maximum payment of$1,000 during a calendar year.
Outpatient
1. 50% of the reasonable and customary charge for outpatient services provided by or under the direc-
tion of a legally qualified physician up to a maximum payment during any one calendar year of$1,000
for the treatment of mental illness, $500 for the treatment of alcoholism and $500 for the treatment of
substance abuse.
For the treatment of mental illness or alcoholism, the term hospital also means a comprehensive health
care corporation or any other public or private facility or portion thereof licensed, certified or approved by
the State in which it is located to provide treatment or rehabilitation services for mental illness or
alcoholism.
"Partial hospitalization" means continuous treatment for at least three hours but not more than twelve
hours in any twenty-four hour period.
The number of days for hospital confinement and partial hospitalization will be reduced as follows:
1. One day of hospital confinement will reduce the number of days for partial hospitalization by two days.
2. Two days of partial hospitalization will reduce the number of days for hospital confinement by one day.
REPLACEMENT OF ORGANS OR TISSUE
A. The following procedures are payable on the same basis as any other illness:
1. cornea transplants
2. artery or vein transplants
3. kidney transplants
4. joint replacements
r-, 5. heart valve replacements
6. implantable prosthetic lenses in connection with cataracts
7. prosthetic by-pass or replacement vessels
8. bone marrow transplants
B. The following procedures are payable on the same basis as any illness up to the lifetime maximum
of the policy or $100,000 whichever is less. This maximum applies for each type of procedure and to
all charges incurred as a result of the transplant(s):
1. heart transplants
2. heart and lung transplants
3. liver transplants
C. No other replacement of tissue or organs are covered by the policy.
NOTE: The maximum charge Lincoln National will consider eligible for any services or materials will be the
reasonable and customary charge for those services or materials. This will be based on available current
medical charge data and the level of benefit reimbursement purchased by the Policyholder.
PRE-EXISTING ILLNESS LIMITATION
Payment for charges incurred in connection with an illness starting prior to the insured individual's effec-
tive date of coverage is limited to a maximum of$1,000 unless the charges are incurred:
1. after a period of three months in a row ending after the effective date of coverage during which the
person has received no treatment with respect to the illness; or
2. after a period of twelve months in a row during which the person is continuously insured under this
policy.
EXCEPT THAT, if an insured individual has covered charges which would otherwise be excluded by this
Pre-Existing Illness Limitation, and if:
1. the individual is insured on the Date of Issue; and
FORM 19002 -6- 050158
2. the individual is insured on the immediately preceding date under any policy or plan which was re-
placed by this policy; and
r
3. such charges would have been paid under the policy or plan which was replaced by this policy:
THEN, Lincoln National will pay the lesser of the total amount that would be paid for the excluded charges
under:
1. The policy or plan replaced; or
2. This policy without the Pre-Existing Illness Limitation:
REDUCED BY the amount paid by the policy or plan replaced.
ELIGIBLE INDIVIDUALS
The individuals eligible for insurance under this policy are as follows:
1. employees who have completed the waiting period and who are actively working at least 32 hours
per week in the employ of the Employer (herein called employees within the eligible classes),
2. Employees assigned to a temporary position, and
3. dependents of those employees who are meeting the requirements of 1. or 2. above.
For Coverage Other Than Life Insurance Benefits and Accidental Death Benefits :
If an individual elects to be covered under a Health Maintenance Organization Plan (HMO), which is
qualified by the Department of Health and Human Services under the HMO Act of 1973, that individual
will not be eligible or insured under this portion of this policy. If the individual chooses the HMO and
later wants to be insured under this policy, the individual has the option to enroll under this policy each
November 16 through December 15. If the individual chooses to be covered under this policy after
having been covered under an HMO, coverage will be effective on January 1 without evidence of
insurability, provided the individual was insured by the HMO on the immediately preceding December
31.
No benefits are paid for retired employees and their dependents.
WAITING PERIOD
The waiting period is the period of time between the date of employment and the first day of the Calendar
Month next following one full pay period. Except that, for employees who are employed on the Date of Is-
sue, there is no waiting period.
The waiting period begins on the first day of continuous full-time employment with the employer.
CLASSIFICATION CHANGE DATE
A change in an employee's benefits caused by a change in his or her classification will be effective on the
first day of the Calendar Month next following one full pay period.
OCCUPATIONAL AND NON-OCCUPATIONAL BENEFITS
Life Insurance Benefits and Accidental Death Benefits are issued on an occupational and non-occupational
basis.
CONTRIBUTIONS TOWARD PREMIUM BY EMPLOYEE
Insurance for employees is non-contributory for Life Insurance Benefits and Accidental Death Benefits.
Medical Benefits are issued on a contributory basis.
Insurance for the dependents of an employee is contributory.
Insurance becomes effective as provided in Section 6.
r
FORM 19002 -7- 050158
B. DESCRIPTION OF BENEFITS
LIFE INSURANCE BENEFITS
1. Life Insurance Benefits
The Amount of Insurance will be paid for death of an insured employee from any cause.
2. Extension of Life Insurance Benefits
Life Insurance Benefits will be paid if:
a. an insured employee becomes totally disabled prior to age sixty; and
b. he or she remains totally disabled until death; and
c. he or she dies prior to age sixty; and
d. he or she dies within one year after the last date for which Life Insurance premium for him or her was
paid.
3. Waiver of Premium Benefit
Life Insurance Benefits will be continued without premium payment for one year from the date proof satis-
factory to Lincoln National has been received if:
a. an insured employee becomes totally disabled prior to age sixty; and
b. he or she remains totally disabled for at least nine months; and
c. such proof of total disability is furnished to Lincoln National after he or she has been totally disabled for
nine months; and
d. such proof is submitted to Lincoln National no later than twelve months after the end of premium pay-
ments for the employee.
Life Insurance Benefits will be continued without premiums for further periods of one year if:
a. the employee remains totally disabled; and
b. proof of such total disability is furnished to Lincoln National during the three-month period prior to each
anniversary of the date of the original proof.
All insurance under this Waiver of Premium Benefit will end on the earliest of:
a. the date the insured employee is no longer totally disabled;
b. the end of the last year for which proof was received by Lincoln National; or
c. the date the employee attains age sixty-five.
4. Payment
Payment of Life Insurance Benefits will normally be made in one lump sum. However, the insured employee,
prior to his or her death, may choose to have his or her Life Insurance Benefits paid
FORM 19002-L -8- 050158
in any other way approved by Lincoln National. If the employee, prior to his or her death, has not made an
election for payment other than in a lump sum, the beneficiary may elect the benefits to be paid in any other
way approved by Lincoln National.
5. Reduction Due to Conversion
An employee who has converted any part of his or her Life Insurance Benefits under this policy because he
or she ceased being an employee and who again becomes an insured employee at a later date will have his
or her Amount of Insurance reduced by the amount of the converted benefit in force until he or she submits
evidence of insurability to Lincoln National.
6. Assignability
An absolute assignment by an insured employee of all the incidents of ownership of his or her Life Insurance
will be permitted, but only if Lincoln National is given actual notice of it. Any such assignment will only take
effect for Lincoln National on the date it is received at the Home Office of Lincoln National. Collateral as-
signments, by whatever name called, will not be permitted.
7. Limit On Amount of Insurance
The total amount of Life Insurance Benefits paid will never exceed the Amount of Insurance shown on the
Schedule of Benefits. In no event will payment ever be made under more than one of the following:
a. Life Insurance Benefits;
b. Extension of Life Insurance Benefits;
c. Waiver of Premium Benefit; or
d. Any benefits resulting from the Conversion Section of this policy.
THE AMOUNT OF INSURANCE IS SHOWN ON THE SCHEDULE OF BENEFITS.
r
FORM 19002-L-1 -9- 050158
ACCIDENTAL DEATH BENEFITS
(Including DISMEMBERMENT AND LOSS
OF SIGHT BENEFITS)
1. Accidental Death Benefits
Benefits will be paid if an insured individual incurs any of the losses listed in the Table of Losses (Item 3.
below), if and only if:
a. The loss: i) results from an accidental bodily injury which occurred while the individual was insured; and
ii) was independent of all other causes; AND
b. The accidental bodily injury is evidenced by a visible bruise or wound (except in the case of: i) internal
injuries shown by autopsy; or ii) drowning); AND
c. The loss occurs no more than 90 days after the injury.
2. Exclusions
No Accidental Death Benefits will be paid for any loss which results directly or indirectly, wholly or partially,
from:
a. self-destruction or attempted self-destruction or intentionally self-inflicted injury, while sane or insane;
or
b. insurrection, riot, or war; or
c. the committing of, or the attempting to commit, an assault or felony; or
d. disease or disorder of the body or mind; or
e. medical or surgical treatment or diagnosis or preventive care; or
f. ptomaines or bacterial infection (except only in pyogenic infection occurring at the same time as, and
as a result of, a visible accidental wound); or
g. the voluntary or involuntary: i) taking of drugs (except drugs taken as prescribed by a doctor) or
poison; or ii) inhaling of gas.
3. Table of Losses
In the Event of Loss of: The Amount Payable will be:
Life The Full Amount of Insurance
Both Hands or Both Feet The Full Amount of Insurance
Sight of Both Eyes The Full Amount of Insurance
One Hand and One Foot The Full Amount of Insurance
One Hand and Sight of One Eye The Full Amount of Insurance
One Foot and Sight of One Eye The Full Amount of Insurance
One Hand One-Half The Full Amount of Insurance
One Foot One-Half The Full Amount of Insurance
Sight of One Eye One-Half The Full Amount of Insurance
With respect to hands or feet, loss" means permanent severance at or above the wrist or ankle joint. With
respect to eyesight, "loss" means the entire and permanent loss of sight.
FORM 19002-ADD -10- 050158
NOTE: IN ANY EVENT, THE FULL AMOUNT OF INSURANCE WILL BE PAID ONLY ONCE FOR ANY ONE AC-
CIDENT, NO MATTER HOW MANY OF THE ABOVE-LISTED LOSSES OCCUR AS THE RESULT OF THAT ACCI-
r- DENT.
THE FULL AMOUNT OF INSURANCE IS SHOWN ON THE SCHEDULE OF BENEFITS.
FORM 19002-ADD-1 -11- 050158
PREFERRED PROVIDER BENEFITS
This policy includes benefits under a Preferred Provider Arrangement. If treatment is received by one of the
Preferred Providers, the benefits provided by this policy with respect to the Benefit Percentage and Deductible
are greater than the benefits provided if treatment is received by a doctor which is not a Preferred Provider. SEE
THE SCHEDULE OF BENEFITS FOR DETAILS OF THE BENEFITS PAYABLE FOR TREATMENT RECEIVED BY A
PREFERRED PROVIDER. The insured individual still has the freedom to choose the doctor he or she wants to
provide the care.
r
FORM 19OOO-PPA -12- 050158
UTILIZATION REVIEW
Utilization Review is a program which reviews the setting, necessity and quality of health care. The Lincoln Na-
tional furnishes each individual with Utilization Review through Lincoln National Review. Lincoln National Re-
view's telephone number is 1-800-255-8749.
The requirements of Utilization Review shown below, apply if The Lincoln National is the primary insurance car-
rier. If The Lincoln National is the secondary carrier, only the Retrospective Review provision will apply.
The individual is responsible for making sure Lincoln National Review is contacted. Authorization from Lincoln
National Review is required for:
Inpatient Hospital Stays;
Outpatient Surgeries performed in other than the doctor's office;
Healthcare Services and Supplies.
Utilization Review is performed only for the purpose of reviewing the medical necessity of the above services for
the care and treatment of an illness. Authorization by Lincoln National Review does not guarantee that all
charges are covered under the policy. Charges submitted for payment are subject to all other terms and condi-
tions of the policy.
As part of the Utilization Review process, Lincoln National Review will also review for alternate methods of
medical care or treatment not otherwise listed as covered charges under the policy.
FAILURE TO CALL PENALTY: If the individual fails to call Lincoln National Review as required under
Certification/Pre-Certification below, a penalty of an additional $250 will apply. This penalty deductible is in ad-
dition to any other deductible under the policy.
CERTIFICATION/PRE-CERTIFICATION
1. Hospital Admissions:
The individual is responsible for making sure Lincoln National Review is notified of the hospital stay before
admission to a hospital as a bed patient. Lincoln National Review will review the doctor's recommendation
to determine whether a hospital stay is necessary or if the procedure can be safely performed on an outpa-
tient basis. If authorization for hospital admission is denied, no benefits will be paid for hospital charges.
2. Outpatient Surgery:
The individual is responsible for making sure Lincoln National Review is notified before outpatient surgery
is performed in other than a doctor's office. Lincoln National Review will review the doctor's recommended
course of treatment. Benefits will be paid only for authorized outpatient surgery. No benefits will be paid for
outpatient surgery not authorized.
FORM 19002-GEN-UR-A -13- 050158
3. Emergency/Urgent/Pregnancy Related/Hospital Admission:
For an emergency or urgent hospital admission (including all pregnancy related events), the individual is
responsible for making sure Lincoln National Review is notified within 48 hours after admission. For admis-
sion on a holiday, or after 5:00 p.m. on a Friday, or during a weekend, Lincoln National Review must be in-
formed of the admission on the next business day. Benefits will be paid for authorized days.
"Emergency hospital admission" means an admission for hospital confinement, which, if delayed would result
in a disability or death.
"Urgent hospital admission" means admission for a medical condition resulting from injury or illness which
is less severe than an emergency admission but requires care within a reasonably short time. This includes
pregnancy related events.
4. A second opinion may be required for inpatient admissions or outpatient services. Lincoln National Review
will inform the doctor if a second opinion is necessary. Lincoln National Review will direct the individual
requiring a second opinion to a doctor identified or approved by Lincoln National Review.
A "second opinion" means an evaluation of the need for inpatient admission or outpatient treatment by a
second doctor (or third doctor if the opinion of the doctors conflict), including the doctor's exam of the patient
and diagnostic testing.
A second opinion required by Lincoln National Review will be paid at 100% with no deductible. No ben-
efits will be paid for a second opinion not requested by Lincoln National Review.
If a second opinion is not obtained as required by Lincoln National Review, the benefit percentage will
be 50% for any charges associated with the inpatient admission or outpatient treatment.
No benefits will be paid for medically unnecessary services as determined by Lincoln National Review.
5. Healthcare Services and Supplies Review:
The individual is responsible for making sure Lincoln National Review is notified to obtain a plan of care
approval for the following healthcare services and supplies:
Speech Therapy
Rehabilitative Therapy
Home Health Care
Hospice Care
Skilled Nursing Care
FORM 19002-GEN-UR-1-A -14- 050158
Benefits will be paid only for authorized healthcare services and supplies. No benefits will be paid for
healthcare services and supplies not authorized.
CONCURRENT REVIEW
After admission to the hospital, Lincoln National Review will continue to evaluate the patient's progress. If after
consulting with the doctor, Lincoln National Review determines that continued confinement is no longer medically
necessary, the individual and the doctor will be advised. Benefits will be paid only for authorized days. No
benefits will be paid for hospital days not authorized.
Lincoln National Review will also evaluate the patient's progress under authorized Healthcare Services and
Supplies Review . If after consulting with the doctor, Lincoln National Review determines that continued treat-
ment is no longer medically necessary, the individual and the doctor will be advised. Benefits will be paid only
for authorized treatment and services. No benefits will be paid for treatment and services not authorized.
RETROSPECTIVE REVIEW
Lincoln National Review will evaluate the medical records of those individuals whose medical treatment or hos-
pital stay was not reviewed under Certification/Pre-Certification or Concurrent Review as described above.
If Lincoln National Review is unable to authorize any portion of the stay or treatment, the doctor will be contacted
to provide additional information.
Benefits will be paid only for those days or treatment which would have been authorized. No benefits will be paid
for any days or treatment not medically necessary.
APPEAL PROCESS
The individual, doctor, hospital or responsible party may request an appeal when authorization is denied by
contacting the Lincoln National Review Medical Director. The appeal may be submitted in writing or by telephone
as soon as possible but within 60 days after the denial.
r- SPECIAL CARE CONSULTING
Special Care Consulting is a service by Lincoln National Review to arrange for care at home or other alternate
methods of medical care or treatment not otherwise covered under the policy instead of hospital confinement.
Benefits will be paid for these charges when an individual:
1. is discharged from the hospital sooner than would have been possible without Special Care Consulting; or
2. would otherwise have been required to be confined as a bed patient in a hospital.
FORM 19002-GEN-UR-2-A -15- 050158
MAJOR MEDICAL BENEFITS
Benefits will be paid if an insured individual has covered charges during his or her Benefit Period.
Benefit Period
A Benefit Period begins and ends as shown on the Schedule of Benefits.
Determination of Benefits
Benefits to be paid will be determined by multiplying the benefit percentage times the amount of covered charges
in a Benefit Period which exceed the Deductible.
Maximum Benefit
Payment will never be more than the Maximum Benefit for all of an insured individual's illnesses, even though
the person may not have been continuously insured.
The Maximum Benefit will be renewed when an insured individual submits evidence of insurability to Lincoln
National at his or her own expense. This renewed Maximum Benefit will apply to all charges made after the date
such increase is effective.
COVERED CHARGES
1. Room and Board and routine nursing for confinement in a hospital as shown on the Schedule of Benefits.
2. Room and Board and routine nursing for confinement in a skilled nursing facility as shown on the
Schedule of Benefits.
3. Intensive Nursing Care for each day of confinement in a hospital as follows:
a. for those hospitals which make a separate charge for Intensive Nursing Care, the hospital's specific
charge for Intensive Nursing Care is covered;
b. for those hospitals which make a combined charge for Room and Board and Intensive Nursing Care,
that part of the combined charge which is in excess of the hospital's prevailing semi-private Room
and Board rate will be the covered charge for Intensive Nursing Care.
4. Medical services and supplies furnished by the hospital.
5. Anesthetics and their administration.
6. Medical treatment given by or in the presence of a doctor if such treatment is within the scope of his or
her license.
7. Services of a licensed physiotherapist.
FORM 19002-MM-A -16- 050158
8. Charges by a doctor or speech therapist for speech therapy due to an illness (other than a functional
nervous disorder), or due to surgery on account of an illness, up to a 60 day period of treatment per
disability. If the speech therapy is due to a congenital anomaly, surgery to correct the anomaly must
have been performed prior to the therapy. There must be continuing measurable progress demonstrated
at regular intervals.
9. X-ray exams (other than dental), lab tests and other diagnostic services.
10. X-ray and radiation therapy.
11. Charges for the repair of natural teeth (including their replacement) which are a result of and within 24
months of an accidental bodily injury which occurs while the person is insured.
12. Transportation within the United States and Canada of the insured individual by professional ambulance
service, railroad, or scheduled airline to, but not returning from a hospital or sanitarium. These charges
will be covered if the insured individual's illness cannot be adequately treated in the locale where the
illness occurs.
13. Medical supplies as follows:
a. drugs which require a written prescription of a doctor and which must be dispensed by a licensed
pharmacist or doctor;
b. blood and other fluids to be injected into the circulatory system;
c. artificial limbs and eyes for loss of natural limbs and eyes which occurred while insured;
d. lens, each eye (contact or frames) immediately following and because of cataract surgery only;
e. casts, splints, trusses, braces, crutches and surgical dressings;
f. purchase or rental of hospital-type equipment for kidney dialysis for the personal and exclusive use
of the patient. The total purchase price to be eligible will be on a monthly pro-rata basis during the
first 24 months of ownership but only so long as a dialysis treatment continues to be medically re-
quired. Lincoln National also will consider as eligible all charges for supplies, materials and repairs
necessary for the proper operation of such equipment and also reasonable and necessary expenses
for the training of a person to operate and maintain the equipment for the sole benefit of the
patient;
g. purchase or rental of durable medical equipment for other than kidney dialysis. Lincoln National's
payment will be based on an amount equal to the generally accepted cost of durable medical
equipment that provides the necessary level of care at the lowest cost. In determining Lincoln Na-
tional's liability, we will be guided by nationally established standards of the rental or purchase of
such equipment. However, charges for repair or maintenance of durable medical equipment are
not covered.
FORM 19002-MM-1-06-A -17- 050158
14. For a child born with cleft lip and or cleft palate charges for medically necessary care and treatment
which includes:
a. oral and facial surgery, surgical management and follow-up care by plastic surgeons and oral
surgeons;
b. prosthetic treatment such as obturators, speech appliances and feeding appliances;
c. orthodontic treatment;
d. prosthodontic treatment;
e. habilitative speech therapy;
L. otolaryngology treatment;
g. audiological assessments and treatment.
SPECIAL CARE CONSULTING
This policy also provides benefits for approved charges for Special Care Consulting. Special Care Consulting
is a service to arrange for care at home or other alternate methods of medical care or treatment not covered.
Benefits may be provided when an insured individual:
a. is discharged from the hospital sooner than would have been possible without Special Care
Consulting; or
b. would otherwise have been required to be confined as a bed patient in a hospital.
The Special Care Consulting must be in writing and approved by Lincoln National in advance.
CHANGE IN INSURANCE CLASSIFICATION
NOT AS A RESULT OF AMENDMENT OF POLICY
If the insured individual's insurance classification changes and results in an increase in the Maximum Ben-
efit, such increase will not apply to any illness which exists on the date of such change. The increase will
not apply to those illnesses until a three-month period has elapsed during which the insured individual has
not received any treatment for the existing illness.
FORM 19002-MM-2-06-A -18- 050158
HOME HEALTH CARE BENEFITS
Benefits will be paid, if authorized by Lincoln National Review, if an insured individual has covered charges
for Home Health Care. The amount paid will be the fee charged, but not more than the Maximum Amount for
a single visit. Benefits will not be paid for more than the maximum number of visits in any one calendar year.
Covered charges are those which meet all three of the following requirements:
1. They are medically necessary for the care of an insured individual who is totally disabled and:
a. the insured individual is under the direct care of a doctor;
b. the plan of treatment for the Home Health Care is established in writing by the attending doctor
prior to the start of such treatment;
c. the plan of treatment for Home Health Care is certified by the attending doctor at least once
each month, and
d. the insured individual is examined by the attending doctor once each 60 days.
2. They are for services provided by a home health agency.
A "home health agency" means an agency which meets the following requirements:
a. its primary services are those listed in 3. below;
b. it is federally certified as a home health agency; and
c. it is licensed, if licensing is required.
3. They are for one or more of the following, unless the charge is a covered charge under Major
Medical Benefits:
a. part-time or intermittent professional nursing care by a registered nurse (R.N.) or a qualified
therapist;
b. part-time or intermittent home health aide services under the supervision of a registered nurse
(R.N.) or a qualified therapist;
c. occupational therapy and physical therapy performed by a licensed therapist;
d. speech therapy and audiology performed by a licensed speech therapist or audiologist;
e. respiratory and inhalation therapy;
f. medical social services. Medical social services are services aimed at assisting the insured
or the family in dealing with the insured's medical condition. The services must be recom-
mended by the attending doctor and must be performed by an individual with a baccalaureate
degree in social work, psychology or counseling or the documented equivalent in education,
training and experience;
FORM 19002-HHC-06-A -19- 050158
g. nutrition counseling by a nutritionist or dietitian;
h. medical supplies;
i. prosthesis and orthopedic appliances;
j. rental or purchase of durable medical equipment;
k. drugs, medicines, or insulin; and
I. special meals.
Exclusions
No Home Health Care Benefits will be paid for:
1. General housekeeping services; or
2. Services for custodial care; or
3. Services not authorized by Lincoln National Review.
THE BENEFIT PERCENTAGE, THE MAXIMUM AMOUNT FOR A SINGLE VISIT AND THE MAXIMUM NUMBER
OF VISITS ARE ALL SHOWN ON THE SCHEDULE OF BENEFITS.
FORM 19002-HHC-1-06-A -20- 050158
HOSPICE BENEFITS
Major Medical Benefits will be paid for benefits for services and supplies provided under active management
through a Hospice, regardless of the location or facility in which the services are furnished, if authorized by
or approved by Lincoln National Review. Certification is required once every 30 days to verify that an insured
individual's condition continues to require a hospice setting.
COVERED CHARGES
1. room and board for confinement in a hospice;
2. services and supplies furnished by the hospice while the individual is confined;
3. home hospice care. A maximum payment of$5,000 will be paid in any one benefit period. A daily rate
of$55 will be paid for any combination of the following services:
a. professional nursing services provided by or under the supervision of a registered nurse (R.N.);
b. home health aide services under the supervision of a registered nurse (R.N.) or specialized
rehabilitative therapist;
c. physical therapy;
d. occupational therapy;
e. speech therapy and audiology;
f. respiratory and inhalation therapy;
g. nutrition counseling by a nutritionist or dietitian;
h. medical social services provided by an individual who possesses a baccalaureate degree in social
work, psychology or counseling or the documented equivalent in a combination of education, train-
ing and experience, provided upon the recommendation of a doctor. Such services are aimed at
assisting the insured or the family in dealing with a specific medical condition;
i. family counseling related to the individual's terminal condition;
j. respite care;
4. crisis care. Benefits will be paid for up to 30 days of inpatient care in a Hospice or for continuous home
care, for pain control or for acute intervention and chronic symptom management;
5. counseling services provided by a licensed social worker or licensed pastoral counselor;
6. medical supplies, including drugs and biologicals;
7. prostheses and orthopedic appliances;
8. rental or purchase of durable medical equipment;
FORM 19002-MM-H-06 -21- 050158
9. bereavement support services for the individual's family unit during the three month period following the
death of the individual, limited to a maximum payment of$500.
LIMITATIONS
Hospice Benefits will only be paid if the individual's attending doctor certifies that the individual is:
1. is terminally ill; and
2. is expected to die within six months.
However, if death does not occur within 365 days, benefits may continue for up to 3 additional months.
EXCLUSIONS
No benefits will be paid for the following:
1. services or supplies for personal comfort or convenience, including homemaking services, except in
crisis periods or in association with respite care;
2. food services or meals other than dietary counseling;
3. services related to well-baby care;
4. services provided by volunteers.
DEFINITIONS
"Hospice" means an agency that provides counseling and medical services and may provide room and board
to a terminally ill individual. Hospice must meet all of the following conditions;
1. have obtained any required state or governmental Certificate of Need approval;
2. provide service 24 hours a day, 7 days a week;
3. be under the direct supervision of a doctor;
4. have a nurse coordinator who is a registered nurse (R.N.);
5. have a licensed social service coordinator;
6. be an agency whose primary purpose is to provide Hospice services;
7. have a full-time administrator;
8. maintain written records of services provided to the individual; and
9. be licensed to provide hospice care, if licensing is required.
FORM 19002-MM-H-1-06 -22- 050158
"Benefit period" means a period of 3 months, during which hospice services are provided on a regular basis.
"Family unit" means the individual's immediate family, the primary care giver, and individuals with significant
personal ties.
"Respite care" means hospice services provided in the individual's home or in the Hospice facility to tem-
porarily relieve the family or other care providers from the daily demands of the care for the individual.
"Homemaking services" include:
1. general household activities including the preparation of means and routine household care; and
2. teaching the individual or family techniques that promote self-care, good nutrition and independent liv-
ing.
FORM 19002-MM-H-2-06 -23- 050158
SECTION 2 - BENEFIT EXCLUSIONS AND LIMITATIONS
A. THE FOLLOWING EXCLUSIONS AND LIMITATIONS APPLY TO ALL BENEFITS OTHER THAN LIFE INSURANCE:
No benefits are provided for:
1. Any accidental bodily injury which arises out of or in the course of any employment with any employer
or for which the individual is entitled to benefits under any worker's compensation law or occupational
disease law, or receives any settlement from a worker's compensation carrier, unless it is shown in the
Schedule of Benefits that the coverage provided by a benefit is issued on both an occupational and
non-occupational basis.
2. Any illness for which the individual is entitled to benefits under any worker's compensation or occupa-
tional disease law, or receives any settlement from a worker's compensation carrier, unless it is shown
in the Schedule of Benefits that the coverage provided by a benefit is issued on both an occupational
and non-occupational basis.
3. Losses which are due to war or any act of war, whether declared or undeclared.
4. Charges incurred or disability claimed while an insured individual is not under the direct care of a doctor.
B. IN ADDITION, FOR MEDICAL INSURANCE THE FOLLOWING CHARGES ARE NOT COVERED:
1. Charges which are not necessary to the care or treatment of an illness. EXCEPT THAT, Lincoln National
will pay for surgical charges in connection with sterilization. Lincoln National will not pay for the cost
of reversal of sterilization.
2. Charges which would not have been made if no insurance existed.
3. Charges which the insured individual is not legally obliged to pay.
4. Charges which are in excess of the reasonable and customary charges for services and materials.
5. Charges for treatment by a doctor which is not within the scope of his or her license.
6. Charges for which benefits are not provided in this policy.
7. Charges for care, treatment, services or supplies that are experimental or investigational in nature and
which have not been approved by the Food and Drug Administration.
8. Charges for dental services or supplies for treatment of the teeth, gums or alveolar processes if Dental
Benefits are not included in this policy. Except that, Lincoln National will pay for:
a. hospital charges if the insured individual is a bed patient; or
b. any dental charges covered under Major Medical and/or Additional Accident Benefits.
FORM 19003-B -24- 050158
9. Charges for the purchase of hearing aids, if Hearing Aid Benefits are not included in this policy.
10. Charges for the treatment of refractive errors, including but not limited to, eye exams, radial keratotomy
procedures and other forms of surgery.
11. Charges for eye glasses or contact lenses or the fitting of them, if Vision Benefits are not included in this
policy. Except that, Lincoln National will pay for charges covered under Major Medical Benefits for
cataract surgery.
12. Charges for any treatment for cosmetic purposes or for cosmetic surgery. Except that, Lincoln National
will pay for cosmetic treatment or surgery:
a. due solely to an accidental bodily injury which occurred while the individual was insured under this
policy; or
b. due solely to surgical removal of all or a part of the breast tissue as a result of an illness; or
c. due solely to a birth defect of an individual who was insured under this policy on the date of his or
her birth.
13. Charges for services of a person who usually lives in the same household as the insured individual, or
who is a member of his or her immediate family or the family of his or her spouse.
14. Charges for services or supplies furnished by an agency of the United States Government or a foreign
government agency, unless excluding them is prohibited by law.
15. Charges due to a pre-existing illness, except as shown in the Schedule of Benefits.
16. Charges related to changing the sex of an individual.
17. Charges for occupational therapy, by any name called.
18. Charges for cognitive therapy, by any name called.
19. Charges for vocational rehabilitation, by any name called.
20. Charges for professional services for treatment which involves manual manipulation (with or without the
application of treatment modalities such as, but not limited to diathermy, ultrasound, heat and cold) of
the spinal skeletal system and/or surrounding tissue to restore proper articulation of joints, alignment
of bones or nerve functions which are in excess of:
a. a payment of$10.00 for each visit;
b. one visit on any one day; or
c. 50 visits during any one calendar year.
FORM 19003-1-8-06 -25- 050158
Except that, this limitation does not apply if such services are rendered:
a. during general anesthesia;
b. during a cutting operation; or
c. while the patient is confined in a hospital.
21. Charges for diagnosis or treatment of temporomandibular joint dysfunction, by any name called. EX-
CEPT, this limitation does not apply to such charges which result in payments not exceeding a total of
$1,000.00 in an individual's lifetime, subject to the deductible and benefit percentage shown on the
Schedule of Benefits.
22. Charges due to tissue transplants, organ transplants or replacement of tissue or organs, whether natural
or artificial replacement materials or devices are used; and all charges due to complications arising from
such procedures or treatment unless such charges are specifically provided for on the Schedule of
Benefits.
23. Charges for treatment of infertility, by any name called.
For purposes of this policy, "treatment of infertility" means the use of methods which do not correct the
inability to conceive, but create the conditions for the individual to conceive by stimulating the individ-
ual's natural reproductive system or by implantation. Methods used to correct the inability to conceive
are not subject to this limitation.
24. Charges for outpatient physical therapy are limited to a maximum payment of$1,000 per calendar year.
Physical therapy is a treatment program which:
a. uses procedures which are not experimental or investigational and are generally accepted by the
physical therapy profession to assist in diagnosis, prognosis and treatment of acute or prolonged
movement dysfunction of anatomic or physiologic origin;
b. is performed by a licensed physical therapist; and
c. is provided upon referral by a doctor.
25. Charges for rehabilitation services which are pre-authorized by Lincoln National Review will be paid on
the same basis as any other illness provided the treatment program:
a. consists of more than one form of therapy;
b. is furnished to restore a physically disabled insured individual to useful activity.
Continuing measurable progress must be demonstrated at regular intervals.
FORM 19003-2-C -26- 050158
26. Charges for skilled nursing care. Except that charges which are pre-authorized by Lincoln National Re-
view will be paid:
a. on the same basis as any other illness;
b. up to a maximum of 90 days per calendar year,
provided acute care is required and the services:
a. are under the direction of a doctor;
b. require the skills of qualified technical or professional health personnel;
c. achieve the medically desired result;
d. are in lieu of hospitalization.
If an insured individual is confined in a skilled nursing facility, such facility must be:
a. licensed and operated in accordance with the law of the jurisdiction in which treatment is received;
and
b. Medicare approved.
27. Charges for screening by low-dose mammography are limited to the following:
a. a baseline mammogram for women 35 years of age through age 39;
b. screening not less than once every two years for women 40 years of age through age 49 but at least
once a year for women with risk factors to breast cancer as determined by a physician;
c. annual screening for women 50 years of age through age 64;
d. maximum payment per mammography screening is $60.
C. CHARGE FOR SERVICE OR PURCHASE
The charge for service or purchase will be deemed to have been incurred on the date the service is per-
formed or the date the purchase occurs.
D. RETURN OF OVER PAYMENT
Payment made for charges must be returned to Lincoln National if it is found that such charges were paid in
error.
FORM 19003-3-06-A -27- 050158
SECTION 3 - OTHER COVERAGE
A. MEDICARE BENEFITS
Active employees age 65 and over and their dependent spouses age 65 and over who are insured under this
policy are entitled to benefits under this policy on the same basis as active employees and their dependent
spouses under age 65. This policy will pay as the Primary Plan to Medicare as described in the Coordination of
Benefits Section Below.
For employers with 100 or more employees, this Policy will be the primary plan for totally disabled employees
and totally disabled dependents who are insured under this policy while entitled to Medicare disability benefits.
For all insured individuals entitled to Medicare, other than those shown above, the Coordination of Benefits Sec-
tion shown below will not apply. Benefits paid under this policy will be reduced by the amount of any benefits
or compensation to which the Insured Individual is entitled under Medicare. An insured individual is deemed to
be entitled to all Medicare benefits for which he or she is or has been eligible. The benefits paid under this policy
will be reduced whether or not the insured individual has received or made application for such Medicare Bene-
fits.
B. COORDINATION OF BENEFITS
BENEFITS SUBJECT TO THIS PROVISION
All medical expense benefits provided under this policy, are subject to this provision. Medical expense benefits
do not include Weekly Income Benefits.
EFFECT ON BENEFITS
Coordination of Benefits (COB) means that the benefits provided by this policy will be coordinated with the ben-
efits provided by any other Plans covering the Insured Individual for whom claim is made. If this policy is a
Secondary Plan, the benefits payable under this policy may be reduced, so that an insured individual's total
payment from all Plans will not exceed 100% of his or her total Eligible Expenses.
"Primary Plan" means the Plan which pays benefits or provides services first under the Order of Benefit Deter-
mination Rules below. The Primary Plan does not reduce its benefits because of duplicate coverage.
"Secondary Plan" means any Plan which provides coverage for the Individual for whom claim is made and which
is not a Primary Plan.
ELIGIBLE EXPENSES
"Eligible Expenses" means any necessary, reasonable and customary item of expense which is covered, in whole
or in part, under one or more Plans covering the individual for whom claim is made.
FORM 19004-89 -28- 050158
If a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered
as both an Eligible Expense and a benefit paid.
r-.
The difference between the cost of a private hospital room and the cost of a semi-private hospital room is not
considered an Eligible Expense under the above definition unless the private room is medically necessary.
CLAIM DETERMINATION PERIOD
"Claim Determination Period" is the period of time during which Eligible Expenses are compared with total ben-
efits payable to determine how much each Plan will pay.
The Claim Determination Period is a calendar year.
PLANS CONSIDERED FOR COB
A "Plan" is any arrangement which provides coverage for the Individual for whom claim is made. A "Plan" does
not include individual policies other than individual No-Fault auto insurance, by whatever name called.
COB applies to the following Plans:
1. Group insurance;
2. Other arrangements, whether insured or uninsured, covering individuals in a group. COB will not apply
to plans which provide coverage for accidents for students, including athletic injuries;
3. Plans designed to pay a fixed-dollar benefit per day while the individual is hospital confined, but which,
at the time of claim, allow the individual to elect an alternate benefit;
4. Plans designed to pay a fixed-dollar benefit per day while the insured individual is hospital confined.
COB will be applied only to the portion of the daily benefit which exceeds $100.00 per day;
5. Blue Cross and Blue Shield plans on a group basis;
6. Plans of other hospital or medical service organizations on a group basis;
7. Group practice plans;
8. Group pre-payment plans;
9. Coverage under Federal Government plans or programs, including Medicare;
10. Coverage required or provided by law. COB will not apply to state programs which provide benefits for
individuals unable to pay for their care.
11. Group auto insurance;
12. Individual no-fault auto insurance, by whatever name called.
Note: This Policy is always a Secondary Plan to benefits provided under any mandatory No-Fault Auto
Insurance Act in the state in which the Insured Individual resides.
FORM 19004-1-87-06 -29- 050158
If a "No-Fault" policy provides coverages in excess of the minimum required by state law this plan will coordinate
benefits with those coverages in effect.
The benefits of this plan will not be available to you to the extent of minimum benefits required by the "No-Fault"
Law for injuries suffered by you while operating or riding in a motor vehicle owned by you if said vehicle is in
operation on the public highways of this State and such vehicle is not covered by No-Fault Automobile Insurance
as required by Law. This denial of benefits does not apply to any other person injured in a motor vehicle accident
if the injured person is a non-owner operator, passenger or pedestrian and such other person is not covered by
No-Fault Automobile Insurance.
ORDER OF BENEFIT DETERMINATION
A. Any Plan which does not have a COB or similar provision will pay its benefit first.
B. All Plans which have a COB or similar provision will pay benefits in the order determined by the following
rules:
1. A Plan which covers the individual as an employee/member will be considered before a Plan which
covers the individual as a dependent.
2. For dependent children, the Plan which pays first is determined by the parents' birthdays. The Plan
which covers the parent whose month and day of birth occurs earlier in the calendar year will be con-
sidered first. If both parents have the same birthday, the Plan covering the parent for the longest period
of time will be considered first. NOTE: If a Plan which is being considered for COB does not have a
birthday rule for dependent children, then the COB rules in the other Plan will be used and this rule will
not apply.
NOTE: The following exception applies.
EXCEPT THAT, when the natural parents of a dependent child are divorced or legally separated, the following
rules apply:
a. If the parent with custody of the child has not remarried, the benefits of a Plan which covers the child
as a dependent of the parent with custody of the child will be considered first.
b. If the parent with custody of the child has remarried, the benefits of a Plan which covers the child
as a dependent of the parent with custody of the child will be considered first. The benefits of a Plan
which covers the child as a dependent of the step-parent will be considered second. The benefits
of a Plan which covers the child as a dependent of the parent without custody will be considered
third.
c. Except that, if there is a court decree which establishes financial responsibility for the medical.
dental or other health care expenses of the child, a. and b. above will not apply, and the Plan which
covers the parent with such financial responsibility will be considered before the benefits of any
other Plan which covers the child as a dependent.
FORM 19004-2-87-06 -30- 050158
3. A Plan which covers the individual as an active employee/member, or as the dependent of an active
employee/member, will be considered before a Plan which covers the individual as a laid-off or retired
employee/member. NOTE: If a Plan which is being considered for COB does not have a provision re-
garding laid-off or retired employees/members, then this rule will not apply.
4. If the above rules do not establish an Order of Benefit Determination (such as when two Plans cover the
individual as an employee/member), the Plan which has covered the individual for the longest contin-
uous period of time will be considered first.
OPERATION OF COB
In order to make this COB provision work properly:
1. Upon request, the Insured Individual is required to furnish to Lincoln National complete information
concerning all Plans which cover the individual for whom claim is made.
2. As permitted by law, Lincoln National may, without the Insured Individual's consent:
a. Obtain information from all Plans which may cover the individual; and
b. Release to such other Plans any information it has with respect to any individual.
3. If payments which should have been made by Lincoln National have been made under any other Plans,
Lincoln National may reimburse such other Plans to the extent necessary to make this provision work.
Any such payment will be a benefit paid under This Policy.
4. If Lincoln National has paid benefits which result in payment in excess of the amount necessary under
This Policy to make this provision work, Lincoln National has the right to recover such excess payment
from:
a. any person;
b. any other insurance company; or
c. any other organization
to or for or with respect to whom such payments were made.
FORM 19004-3-87-06 -31- 050158
THIRD PARTY REIMBURSEMENT AND SUBROGATION
This provision applies when a third party or its insurer is liable as a result of the negligence or intentional act of
the third party for a loss for which medical benefits or dental benefits are payable under this policy. If a third party
or its insurer is liable for past, present, or future medical or dental charges, the following rules will apply.
Reimbursement
1. If the third party makes payment before Lincoln National pays, no benefits will be paid under this policy
to the extent of the third party's payment.
2. If the third party does not make payment before Lincoln National pays:
a. Lincoln National will pay any benefits due under this policy;
b. when payment is later made by the third party, Lincoln National is entitled to be repaid first; the in-
sured individual or legal representative is obligated to return the payment to Lincoln National less
reasonable prorated expenses, such as lawyer's fees and court costs, the insured individual incurs
in seeking the third party payment.
c. the insured individual's obligation to repay Lincoln National will be binding upon the insured indi-
vidual or legal representative regardless of whether:
1) the payment received from the third party, or its insurer, is the result of a court judgment, ar-
bitration award, compromise settlement, or any other arrangement; or
2) the third party or its insurer admits liability; or
3) the medical or dental expenses or loss of income are itemized in the third party payment; or
4) the insured individual has been paid by the third party for all losses sustained or alleged.
Subrogation
Before payment is made by the third party, Lincoln National has the right of subrogation to attempt to recover the
amount of Lincoln National's payment. This includes the right to file or intervene in a lawsuit. Lincoln National
will give the insured individual or representative prior written notice of Lincoln National's intent to file suit. The
insured individual must cooperate in full with Lincoln National's effort to seek recovery from the third party. The
insured individual must do nothing to hinder Lincoln National's attempt to recover from the third party or to re-
solve the claim with the third party unless Lincoln National gives prior written consent. Lincoln National's re-
covery from the third party will be limited to the lesser of:
1. the amount Lincoln National paid in benefits under this policy as a result of the medical or dental
charges, or
2. the amount recovered from the third party.
Lincoln National's recovery will apply whether or not payment has been made by the third party for all of the in-
. sured individual's losses.
FORM 19004-4 -32- 050158
SECTION 5 - CONVERSION
A. LIFE INSURANCE CONVERSION
1. If an employee's group term life insurance ends due to the end of his or her employment or the end of
his or her membership in the eligible classes, he or she may convert such insurance to an individual
policy of life insurance. Evidence of Insurability will not be required.
The form of the life policy may be any then offered by Lincoln National, except term insurance, at the
individual's then attained age and for the amount for which he or she applies. At the individual's option,
the amount of such policy will be equal to or less than the amount of his or her group term life insurance
under this policy.
The premium for such policy will be at Lincoln National's rate then in effect for:
a. the form and amount of the policy;
b. the class of risk to which the individual then belongs; and
c. the individual's attained age on the effective date of the policy.
2. If an individual's group term life insurance ends because this policy ends or is amended to end Life In-
surance Benefits, he or she may convert such insurance to an individual policy of life insurance. The
form and premium will be as in 1. above, but the amount of insurance may not exceed the lesser of:
a. the amount of the group term life insurance the individual has under this policy less the amount of
any life insurance for which he or she is or becomes eligible under any Group policy which replaces,
within 31 days, his or her insurance that just ended under this policy; or
b. $2,000.
3. The individual policy of life insurance:
a. will only be issued if application is made and the first premium is paid to Lincoln National within 31
days after the date on which the insured individual's group term life insurance under this policy
ends;
b. will take effect at the end of this 31 day application period; and
c. will be issued without Disability or other added benefits.
4. If benefits are paid under the Waiver of Premium Benefit or Extension of Life Insurance Benefits pro-
visions of this policy, any policy issued under this Section will be void. The individual policy must be
returned to Lincoln National for a refund of premium, and no claims under it will be paid.
5. If an insured individual dies during the 31-day application period, Lincoln National will pay the maximum
amount of insurance which the individual might have converted . The death
FORM 19006 -33- 050158
claim will be paid under the group policy and not the individual policy. Any premiums paid for the indi-
vidual policy will be refunded.
6. The total amount of Life Insurance Benefits paid will never exceed the Amount of Insurance shown on
the Schedule of Benefits. In no event will payment ever be made under more than one of the following:
a. Life Insurance Benefits;
b. Extension of Life Insurance Benefits;
c. Waiver of Premium Benefit; or
d. Any benefits resulting from this Conversion Section of this policy.
B. MEDICAL INSURANCE CONVERSION
1. An individual whose medical insurance terminates for any reason other than failure to pay contributions
agreed upon may convert to medical insurance Conversion Coverage.
The benefits provided by the individual policy will be in accordance with the applicable state laws.
2. The individual policy may insure the following individuals if they were insured under this policy on the
date their insurance ends:
a. the employee and his or her dependents;
b. the spouse of a deceased employee and that spouse's dependents;
c. the dependents of a deceased employee if the employee is not survived by a spouse;
d. a dependent child whose insurance ends because of his or her age or marriage;
e. the former spouse of an employee, when the ending of the marriage ends the spouse's insurance
under this policy. Also, dependents of this former spouse, if their insurance ends solely because
of the end of the marriage.
3. The individual must apply and pay the first premium for the individual medical policy to Lincoln National
within 31 days from the time his or her insurance ends under this policy.
EXCEPT THAT:
If the Policyholder does not give an insured individual written notice within the first 16 days from the
date of the end of his or her group medical insurance, the conversion period will extend more than
31 days. It may extend for up to 15 days after such notice is given, but not more than 91 days after
the end of the individual's group medical insurance. If no notice is given, the period will extend for
no more than 91 days from the date of the end of the individual's group medical insurance.
4. The individual policy will take effect on the day after the individual's group insurance ends.
5. The premium for the individual policy will be Lincoln National's scheduled premium based on the age
of the applicant.
FORM 19006-1-06-A -34- 050158
6. This Section does not extend an individual's medical insurance under this policy beyond the date such
insurance would otherwise end.
7. An individual whose medical insurance ends because this policy ends will not be entitled to convert to
an individual medical policy.
•
FORM 19006-2-06 -35- 050158
Note: This policy includes medical continuation provisions required under Federal and State Law. Except that,
an Insured Individual may elect only one of the continuation provisions for which he or she is eligible.
CONTINUATION OF BENEFITS REQUIRED UNDER FEDERAL LAW
1. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that certain employers offer
continued coverage for employees and their dependents whose medical insurance would end due to a
qualifying event.
An insured individual must be allowed to continue the same medical insurance which was in force at the time
of a qualifying event. All policy provisions applicable to the medical insurance elected still apply under
continuation.
The insured individual must elect continuation during an election period and pay the required premium. The
individual's medical insurance must have ended due to one of the following qualifying events:
a. a reduction in hours;
b. end of employment with the employer for any reason other than gross misconduct;
c. death of the employee;
d. divorce or legal separation from the employee;
e. entitlement of the employee to Medicare; or
f. loss of dependent status by an insured employee's child.
Items c. through f. may be second qualifying events if a dependent is already on continuation as a result of
the employee's reduction in hours or termination of employment.
An individual who is totally disabled may extend continuation coverage if:
a. it has been determined the individual is totally disabled for Social Security purposes; and
b. the individual notifies the plan administrator within 60 days of the date the determination is made by the
Social Security Administration.
Continuation does not apply to any individual covered under any other employer-sponsored group health plan
either as an employee or dependent or to any individual entitled to Medicare. Except that an individual with
a pre-existing condition which is limited or excluded under any other employer-sponsored group health plan
may continue coverage.
2. Notification Requirements and Election Period
In the case of an employee's reduction in hours, end of employment, death or entitlement to Medicare the
employer must notify the plan administrator named in the Summary Plan Description.
FORM COBRA-B-90 -36- 050158
The employee or dependent must notify the plan administrator within 60 days when medical insurance would
end for a dependent due to divorce, legal separation, or loss of dependent status for an insured employee's
child.
Within 14 days of receiving notification of the qualifying event, the plan administrator must notify the em-
ployee or dependent of his or her right to elect continuation.
The insured individual must elect continuation by the later of:
a. 60 days after the individual's medical insurance ends; or
b. 60 days after the individual receives notification from the plan administrator of his or her right of con-
tinuation.
3. End of Continuation
Continuation will end on the earliest of the following dates:
a. 18 months from the date continuation began for individuals whose coverage ended because of the em-
ployee's reduction in hours or end of employment;
b. 29 months from the date continuation began for individuals whose coverage was extended due to total
disability;
c. 36 months from the date continuation began for individuals whose coverage ended because of the death
of the employee, divorce or legal separation from the employee, loss of dependent status for a covered
employee's child, or the employee's entitlement to Medicare;
d. 36 months from the date of the original qualifying event if a second qualifying event occurs;
e. the end of the period for which premium is paid if the individual fails to make a premium payment on the
date specified by the employer;
f. the date the individual becomes covered under any other employer-sponsored group health plan:
g. the date the individual becomes entitled to Medicare; or
h. the date the group health plan ends.
If continuation coverage terminates because the maximum period of continuation is reached, the plan ad-
ministrator will notify the individual of any right to conversion coverage within 180 days prior to the end of
continuation.
FORM COBRA-1-90 -37- 050158
SECTION 6 - GENERAL INFORMATION
A. INDIVIDUALS ELIGIBLE
The individuals eligible for insurance are shown on the Schedule of Benefits.
Each employee must fill out and sign an enrollment card approved by Lincoln National.
B. INSURANCE BENEFITS
Benefits for each insured individual will be determined from information in the Benefits Section of this policy.
Any change in the amount of an individual's insurance caused by a change in classification will be effective
on the Classification Change Date shown on the Schedule of Benefits, EXCEPT THAT:
1. If the insured employee is not actively at work on a full-time basis on the date his or her insurance or
his or her dependents' insurance would increase due to a change in classification, such increase will
not be effective until the employee returns to active, full-time work; and
2. The amount of insurance for a dependent will not be increased while the dependent is confined in a
hospital or skilled nursing facility. Such increase will only become effective on the day after his or her
final discharge from the hospital or skilled nursing facility.
C. EFFECTIVE DATES OF INSURANCE
An individual's insurance will be effective as follows:
1. EMPLOYEES
If the Schedule of Benefits shows that employee insurance is noncontributory, an employee's insurance
will be effective on the day he or she becomes eligible.
If the Schedule of Benefits shows that employee insurance is contributory, each employee who both
applies for insurance on a form approved by Lincoln National, and agrees in writing to pay the required
contributions, will become insured as follows:
a. if the employee applies within 31 days of the date he or she first becomes eligible, he or she will
be insured on the later of:
1) the date he or she applies; or
2) the date he or she becomes eligible.
FORM 19007 -38- 050158
b. if the employee applies after:
1) 31 days from the date he or she first becomes eligible; or
2) he or she previously elected to end his or her insurance,
he or she must then furnish evidence of insurability, at his or her own expense, to Lincoln National
before he or she may be considered for insurance. If Lincoln National approves insurance for that
employee, he or she will become insured on the date of Lincoln National's approval.
2. DEPENDENTS
If the Schedule of Benefits shows that dependent insurance is noncontributory, a dependent's insurance
will be effective on the date he or she becomes eligible. The employee must be insured in order for his
or her dependents to be insured.
If the Schedule of Benefits shows that dependent insurance is contributory, the employee who both ap-
plies for dependent insurance on a form approved by Lincoln National and agrees in writing to pay the
required contributions for dependents will become insured for his or her dependents as follows:
a. if the employee applies within 31 days after the date he or she became eligible for dependents' in-
surance, his or her dependents will be insured on the later of:
1) the date the employee applies for dependents' insurance; or
2) the date the employee becomes insured.
b. if the employee applies after:
1) 31 days from the date he or she became eligible for dependents' insurance; or
2) he or she previously elected to end the insurance for his or her dependents while continuing to
have dependent(s) eligible;
his or her dependent(s) will not be considered for insurance until the employee furnishes to Lincoln
National evidence of insurability, at his or her own expense, for each dependent he or she wants to en-
roll. Insurance for those dependents must be approved by Lincoln National, and will only become ef-
fective on the date of Lincoln National's approval.
If an employee is insured, coverage for a newborn child will be effective on the date the child is born.
The insurance will end 31 days after the child's birth unless the employee enrolls the child and pays any
premium due before the end of the 31 days.
EXCEPT THAT:
a. if an insured employee is married and has a spouse and children who are insured under another
group plan but not under the policy, coverage for any newborn will not be provided under the policy
unless the employee enrolls the child. If the child is enrolled and premiums are paid within 31 days
of birth, insurance will be effective on the later of:
1) the date the child is born; or
2) the date of the written request for coverage.
b. with respect to the first newborn child,-if an employee is married and the spouse is insured under
another group plan but not under the policy, the employee and spouse must
FORM 19007-1-06 -39- 050158
choose which plan will insure the first newborn child. If insurance is elected under this plan, the
child will be insured from birth. Such insurance will end 31 days after the child's birth unless the
employee enrolls the child and pays any premium due before the end of the 31 days.
If the child is not enrolled and premiums are not paid within 31 days of birth, evidence of insurability
must be provided.
A newly acquired dependent will be automatically insured if the employee is already insured for de-
pendent insurance.
3. EMPLOYEES AND DEPENDENTS
a. If an individual is not eligible because:
1) the employee is not actively working for the Employer; and/or
2) the dependent is confined in a hospital or skilled nursing facility,
the employee will not become insured until the day he or she returns to full-time active work;
the dependent will not become insured if the employee is not insured, or if the dependent is confined
in a hospital or skilled nursing facility.
b. once an individual is required to submit evidence of insurability in order to become insured under
this policy, and does not submit it, that individual will continue to be subject to such requirement
regardless of:
1) changes in this policy;
2) changes in employment;
3) changes in eligibility.
^ D. NOTICE AND PROOF OF CLAIM
1. NOTICE - 20 DAYS
a. Written notice of claim must be given to Lincoln National within 20 days of the date of any:
1) loss of weekly income; and/or
2) expenses incurred.
b. If notice is not given within 20 days, a claim will not be denied or reduced if notice was given as soon
as was reasonably possible.
c. When Lincoln National receives notice of claim, forms for filing proof of claim will be furnished to the
insured individual. If these forms are not furnished to the insured individual within 15 days from the
time notice is received by Lincoln National, the insured individual will have met the proof of loss
requirements if written proof of loss is submitted within the time required.
FORM 19007-2-06 -40- 050158
2. PROOF - 90 DAYS
a. Proof of claim for hospital confinement must be given to Lincoln National within 90 days after release
from hospital.
b. Proof of any other loss must be given to Lincoln National not later than 90 days after loss.
c. If proof of any claim is not given within 90 days, the claim will not be denied or reduced if that proof
was given as soon as was reasonably possible.
d. "Proof" as required in this subsection means proof satisfactory to Lincoln National.
3. EXAMINATION
a. Lincoln National, at its own expense, will have the right to have an insured individual examined, as
often as it may require, whenever his or her illness is the basis of a claim.
b. Lincoln National will have the right to require an autopsy, if not prohibited by law.
E. PAYMENT OF CLAIM
1. Benefits Paid for other than Loss of Life
All of these benefits will be paid to the employee, unless Lincoln National determines that he or she is
unable to receive such payment because he or she is not legally able to give a binding receipt for it.
If Lincoln National determines that the employee is not legally able to receive such payment, Lincoln
National may, at its option, pay the benefits to the employee's estate or to any or all of the following
relatives of the employee:
a. spouse;
b. child(ren);
c. parent(s);
d. brother(s); or
e. sister(s).
Any payment made under this option will completely discharge Lincoln National from further obligation
for such payment.
Lincoln National reserves the right to allocate the deductible amount to any eligible charges and to ap-
portion the benefits to the insured individual and to any assignees. Such actions will be binding on the
insured individual and on his or her assignees.
2. Benefits Paid for Loss of Life
Benefits for loss of life will be paid to the beneficiary named by the insured employee. The name of the
beneficiary must be filed with Lincoln National on a form and in a manner approved by Lincoln National.
The employee may change his or her beneficiary at any time if he or she files such change with Lincoln
FORM 19007-3-06 -41- 050158
National on a form and in a manner approved by Lincoln National. Any payment made by Lincoln Na-
tional before its receipt of notice of such change will fully discharge Lincoln National's obligation for such
payment.
a. If two or more beneficiaries are named, and if the employee did not state their respective interests,
they will share equally. If any of such beneficiaries die before the employee does, his or her interest
will pass to the surviving beneficiaries equally.
b. If the employee fails to name a beneficiary for all or a part of his or her insurance, or if no named
beneficiary survives the employee, payment will be made to the employee's estate or, at Lincoln
National's option, to:
1) the employee's spouse, if living; otherwise
2) the employee's then living children, if any; otherwise
3) the employee's surviving parent(s), equally; otherwise
4) any person appearing to be entitled by reason of having incurred verifiable funeral or other
expenses related to the last illness or the death of the employee. However, any payment made
under this option shall not exceed $5,000.
Any payment made under this paragraph b. will completely discharge Lincoln National from further
liability for the amount paid.
c. The most recently named beneficiary under the Conversion Section of this policy will be used for
any claims under the Extension of Life Insurance Benefits or Waiver of Premium Benefit provisions
of this policy.
F. CHOICE OF DOCTOR
The insured is free to be treated by any doctor he or she chooses.
G. WORKER'S COMPENSATION
This policy is not a worker's compensation policy. This policy does not satisfy any requirements for coverage
by worker's compensation insurance.
H. LAWSUITS
No lawsuit may be brought to recover on this policy within 60 days after written proof of loss has been given
as required by this policy. No such lawsuit may be brought after 3 years from the time written proof of loss
is required to be given.
FORM 19007-4-06-A -42- 050158
I. STATEMENTS
In the absence of fraud, all statements made by the insured individual and his or her dependents will be
deemed representations and not warranties. No such representations will void the insurance or be used to
deny a claim unless a copy of the instrument containing such representation is or has been furnished to the
insured individual or to his or her beneficiary, if any.
J. END OF INDIVIDUAL'S INSURANCE
An individual's insurance will end automatically on the earliest of the following dates:
1. The date this policy ends;
2. The end of the last period for which any required contribution agreed to in writing has been made;
3. The date after which he or she is no longer eligible for insurance;
4. The date the employee's employment with the Employer ends. For the purposes of this policy, an em-
ployee's employment will end on the last day of the month in which employment ends.
No benefits are payable for charges incurred after an individual's insurance ends.
K. MEDICAL INSURANCE CONTINUATION
1. An employee whose medical insurance would otherwise end for any reason except the ending of this
policy or the end of coverage for an insured class may continue his or her medical insurance and his
or her dependent's medical insurance, subject to the following terms:
a. the employee and dependents must have been insured under the policy for at least six months in
a row on the date insurance would otherwise end;
b. the employee and dependents are not covered by Medicare or Medicaid;
c. any premium required from or on behalf of the employee has been paid to the termination date.
2. The employer must provide the employee written notice of the right to continue coverage at the time of
termination of employment.
FORM 19007-5-06-A -43- 050158
Such notice will include the amount of premium due monthly, and the manner, place and time in which
payment must be received. The premium may not exceed the group rate.
3. The employee must notify the employer in writing of his election to continue coverage and pay the first
monthly contribution no later than the earliest of:
a. twenty days after the date coverage would otherwise terminate; or
b. thirty-one days after the date coverage would otherwise terminate if the employer fails to notify the
employee.
Subsequent monthly payments must be made to the employer in advance in order to continue coverage.
4. The medical insurance continued under the terms of this provision will automatically terminate on the
earliest of the following dates:
a. the date the employee becomes reemployed;
b. 90 days after the date on which the group insurance would otherwise have ended due to termination
of employment absent this provision;
c. the date the policy terminates;
d. the end of the monthly period for which any required premiums were paid if such premiums are not
paid as required;
e. the date the individual becomes covered under Medicare or Medicaid;
f. with respect to dependents, the date such dependent no longer qualifies as an eligible dependent
under the terms of the policy;
g. the date coverage under the policy ends for such employee's employer.
NOTE: AT THE END OF THE CONTINUATION OF COVERAGE, AN INDIVIDUAL MAY THEN ELECT THE CON-
^ VERSION COVERAGE THEN BEING ISSUED BY LINCOLN NATIONAL.
L. MISSTATEMENT OF AGE
For Life Insurance Benefits, if the age of any insured individual has been misstated, the premium may be
adjusted. If the amount of insurance would be affected by such misstatement, it will be changed to the
amount the insured individual would have had at his or her correct age, and the premium will be based on
the corrected age and amount.
M. LIFE INSURANCE INCONTESTABILITY
1. Policyholder
The validity of the Life Insurance Benefits provision of this policy will not be contested, except for non-
payment of premium by the Policyholder, after this policy has been in force for at least two consecutive
years from its Date of Issue.
FORM 19007-6-06 -44- 050158
2. Insured Individual
No statement made by an insured individual relating to his or her insurability for life insurance under this
policy will be used in contesting the validity of the insurance with respect to which the statement was
made, after such insurance has been in force, prior to the contest, for a period of two consecutive years
during such insured individual's lifetime, nor unless it is contained in a written instrument signed by that
individual.
FORM 19007-7-06 -45- 050158
SECTION 7 - DEFINITIONS
"Actively at work," "active work" and "actively working" mean the active expenditure of time and energy in the
service of the Employer. Except that, an insured individual will be considered actively at work on each day of a
regular paid vacation or on a regular non-working day on which he or she is not disabled provided he or she was
actively at work on the last preceding regular working day.
Beneficiary - a person or entity named, on a form and in a manner approved by Lincoln National, to receive
benefits for loss of life.
Benefit Period -the period of time (shown on the Schedule of Benefits) during which covered charges are incurred
for which benefits may be paid.
Calendar Month - any one of the twelve months of the calendar.
Cognitive Therapy - treatment given to improve an insured individual's thinking processes and intellectual capa-
bilities.
Contributory - the employee pays a part of the cost of the insurance.
Cosmetic - surgery or other treatment to make a person better looking.
Covered Charges - charges covered under this policy.
Custodial Care - health services or other related services (such as assistance in activities of daily living) which:
1. do not seek to cure;
2. are provided during periods when acute care is not required or when the medical condition of an insured
individual is not changing; or
3. do not require continued administration by licensed medical personnel.
Deductible - a set amount of covered charges which must be paid by the insured individual.
Dependent - see the last definition in this section.
Doctor - a person licensed to treat illness by the state in which the treatment is rendered.
Durable Medical Equipment - medical equipment which:
1. can withstand repeated use;
2. is not disposable;
3. is prescribed by a doctor only when medically necessary;
4. is appropriate for use in the home; and
5. is not useful in the absence of an illness or injury.
FORM 19001-A -46- 050158
Earnings - money paid to the employee by his or her Employer as base pay. This does not include:
1. Overtime, bonus, incentive, commission, and other non-base pay; or
2. Professional fees, retainers, and directors' fees.
Emergency Care - care for a serious medical condition resulting from injury or illness which arises suddenly and
requires immediate care and treatment to avoid jeopardy to the life of an insured individual.
Employed on a part-time basis - working less than 32 hours per week.
Employee - a person who is:
1. Actively working for the Employer; and
2. Receiving earnings.
Employer - the Employer(s) shown on the Face Page of this policy.
Evidence of Insurability - satisfactory proof, as determined by Lincoln National, that a person is acceptable for
insurance.
Grace Period - a 31-day period which begins on the day following the due date of any premium due other than the
first premium. During this period the premium due must be paid in order to prevent this policy from ending.
Hospital - a facility which:
1. Is licensed (if required) as a hospital; and
2. Is open at all times; and
3. Is operated mainly to diagnose and treat illnesses on an inpatient basis; and
4. Has a staff of one or more doctors on call at all times; and
5. Has 24-hour nursing services by Registered Nurses; and
6. Is not mainly a skilled nursing facility, clinic, nursing home, rest home, convalescence home or like
place; and
7. Has organized facilities for major surgery or has a bona fide arrangement, by contract or otherwise, with
an accredited hospital to perform such surgical procedures.
For the purposes of treatment of mental illness, substance abuse or alcoholism, the term "hospital" also
means any other public or private facility or portion thereof licensed, certified or approved by the State in
which it is located to provide treatment or rehabilitation services for mental illness, substance abuse or
alcoholism.
Illness - means:
1. A disorder or disease of the body or mind; or
2. An accidental bodily injury;or
3. Pregnancy.
All illnesses due to the same cause, or to a related cause, will be deemed to be one illness. The donation
of an organ or of tissue by an insured individual for transplanting into another person is considered to be an
illness of the insured individual making the donation.
Individual - an employee or one of his or her dependents.
Insured Individual - an individual insured under this policy.
FORM 19001-1-06-A -47- 050158
Lifetime Maximum - the maximum amount of benefits which may be payable while insured under this policy.
Lincoln National - The Lincoln National Life Insurance Company.
Medical Insurance - benefits in this policy other than Life Insurance, Accidental Death and Weekly Income.
Medicare - medical benefits provided by Title XVIII of the Federal Social Security Act.
Month - a period starting at 12:01 a.m. on any day in a given Calendar Month, and ending at 12:01 a.m. on that
same-numbered day in the next Calendar Month. If that next Calendar Month does not have a same-numbered
day, the month will end at 11:59 p.m. of the last day of that Calendar Month. (Examples: 12:01 a.m. of May 14 up
to 12:01 a.m. of June 14; 12:01 a.m. of May 31 through 11:59 p.m. of June 30.)
Necessary to the Care or Treatment of Illness--recommended by a doctor which is required to treat the symptoms
of a certain diagnosis. The care or treatment:
1. must be consistent with the diagnosis and prescribed course of treatment for the insured individual's
condition;
2. must be required for reasons other than the convenience of the insured individual, or his or her doctor;
3. is generally accepted as an appropriate form of care for the condition being treated; and
4. is likely to result in physical improvement of the patient's condition which is unlikely to ever occur if the
treatment is not administered.
Noncontributory - the employee pays no part of the cost of the insurance.
Occupational Therapy - treatment which consists primarily of instructing an insured individual to perform the
normal activities of daily living.
Officer - The President, a Vice President, the Secretary or an Assistant Secretary of The Lincoln National Life In-
surance Company.
Physical Therapy - treatment given to improve the physical capabilities of an insured individual in an attempt to
restore such individual to a previous level of good health.
Policy - means this policy.
Policy Anniversary - the date shown as such on the Face Page of this Policy.
Policyholder - the legal entity named as the Policyholder on the Face Page of this policy.
Premium - money paid to Lincoln National by the Policyholder to pay for this insurance.
FORM 19001-2-A -48- 050158
Pre-existing Illness - an illness for which medical advice or treatment was received prior to the individual's ef-
fective date of insurance.
Reasonable and Customary Charges - charges which Lincoln National determines do not exceed the amount
usually charged by most providers in the same geographic area for services, treatment or materials, taking into
account the nature of the illness involved.
Room and Board Charges - charges made by a hospital or skilled nursing facility for the room, meals, and routine
nursing services for insured individuals confined as bed patients.
Schedule of Benefits - that part of Section 1 of this policy outlining the benefits.
Skilled Nursing Facility - a facility considered as such under Medicare.
Special Charges - charges made by a hospital for other than for room and board.
Speech Therapist - someone who:
1. Has a master's degree in speech pathology; and
2. Has completed an internship; and
3. Is licensed by the state in which he or she performs his or her services, if that state requires licensing.
Speech Therapy - treatment administered to improve an insured individual's speech capabilities after a decrease
in those capabilities following an illness.
Total Disability - for purposes of this policy, an insured individual shall be deemed to have a total disability under
the following circumstances:
1. If an EMPLOYEE is claiming waiver of premium for Life Insurance benefits, then total disability is defined
as the EMPLOYEE's inability to work, because of an illness, in his or her normal job, or in any job for
which he or she is or could be trained;
2. If an EMPLOYEE is claiming benefits other than for item 1. above, then total disability is defined as the
EMPLOYEE'S inability to work, because of an illness, in his or her normal job;
3. If a DEPENDENT is claiming benefits under any coverage provided in this policy, then total disability is
defined as the inability of the dependent to do the substantial and material duties of a person in similar
circumstances who is in good health;
"One continuous period of total disability" means a period of time during which an individual is totally disabled.
Under the following circumstances, successive periods of total disability due to the same or related causes will
be considered one continuous period of total disability:
1. When an EMPLOYEE has successive periods of total disability which are due to the same or related
causes, and which are not separated by two or more continuous weeks of active work with the Employer
on a full-time basis; or
FORM 19001-3-A -49- 050158
2. When a DEPENDENT has successive periods of total disability which are due to the same or related
causes, and which are not separated by a period of three or more months during which the DEPENDENT
is free from total disability which stems from those same or similar causes.
Totally disabled - having a total disability as defined above.
Vocational Rehabilitation - teaching and training which allows an insured individual to resume his or her previous
job or to train for a new job.
Waiting Period - the length of time an employee must continuously work for the Employer before he or she is el-
igible for insurance.
Dependent - means:
1. An employee's spouse (if not legally separated from the Employee), or
2. An employee's unmarried child (including a stepchild or legally adopted child) from live birth through the
end of the calendar month in which the child attains age 19. Except that, the term dependent includes
an employee's unmarried child who has attained age 19 while:
a. the child is:
1) mentally or physically unable to earn his or her own living and proof of incapacity is furnished
to Lincoln National within 31 days of the date his or her insurance would have ended due to
age; and
2) actually dependent on the employee for a majority of his or her support; and
3) insured under this policy on the date just prior to the day his or her insurance would have ended
due to age.
r
FORM 19001-4-A -50- 050158
b. the child is enrolled in an accredited school as a full-time student, as defined in the rules of such
school, through the end of the calendar month in which the child attains age 23.
To remain insured under a. or b. above, due proof that the employee's child continues to qualify as a
dependent must be furnished to Lincoln National as it reasonably asks. Except that, in the case of a.
above, Lincoln National will not ask for such proof more than once each twelve months in a row after two
years from the date the child attains age 19.
3. A spouse or child who:
a. is insured under the policy as an employee; or
b. has benefits due under any extension of such insurance
is not a dependent.
If a husband and wife are both insured under the policy as employees, their dependent children may be in-
sured dependents of either the husband or the wife.
FORM 19001-5 -51- 050158
SECTION 8 - POLICYHOLDER
A. EFFECT OF ACTIONS OF POLICYHOLDER
In all matters regarding this policy, the Policyholder acts for the Employer and for all Subsidiaries and Affil-
iates shown on the Face Page of this Policy. Each agreement made with the Policyholder will be binding on
all such parties. Each notice given to the Policyholder will be deemed to have been given to all such parties.
B. RECORD OF EMPLOYEES INSURED
As required to administer this insurance, the Policyholder will furnish to Lincoln National information about
individuals:
1. Who qualify to become insured;
2. Whose amounts of insurance change; and/or
3. Whose insurance ends.
If the Policyholder makes an error in furnishing such information, this policy will be administered as if the
correct information had been furnished.
Lincoln National may check Employer's and/or Policyholder's records which, in the opinion of Lincoln Na-
tional, relate to this insurance.
C. PAYMENT OF PREMIUMS
All premiums due for this policy, including any adjustments, are to be paid by the Policyholder on or before
their due dates. The due date is stated on the Face Page of this policy. Premiums will only be considered
paid when they are received at the Home Office of Lincoln National in Fort Wayne, Indiana (or, at Lincoln
National's option, at a specified Lincoln National Depository Facility). The payment of any Renewal Premium
will not keep this insurance in force beyond the day just before the next Renewal Premium due date, except
as provided in D. below.
D. GRACE PERIOD
If the Policyholder does not pay in full any Renewal Premium on or before its due date, the Policyholder will
have a grace period in which to pay that Renewal Premium. This policy will remain in force during the grace
period. If the premium is not paid in full before the grace period ends, this policy will end on the last day of
the grace period.
The grace period will end 31 days after the premium due date. If the Policyholder gives written notice to
Lincoln National at its Home Office, before or during the grace period, that it desires to end this policy before
the end of the grace period, this policy will end either on the date the notice is received by Lincoln National
at its Home Office, or on the date stated in the notice, whichever is later.
ON THE DATE THIS POLICY ENDS, THE POLICYHOLDER MUST PAY LINCOLN NATIONAL ALL PREMIUMS
THEN DUE, INCLUDING ANY PREMIUM DUE FOR THE GRACE PERIOD OR FOR ANY PART OF THE GRACE
PERIOD.
FORM 19008 -52- 050158
E. PREMIUM ADJUSTMENT
No unearned premium will be returned to the Policyholder for any period prior to the most recent policy an-
niversary.
F. PREMIUM REFUNDS - EMPLOYEE PORTION
If any insurance under this policy is contributory, any premium refund in excess of an amount which equals
the Policyholder's contribution to premium must be used for the sole benefit of the employees. The
Policyholder, not Lincoln National, will be responsible for seeing that premium refunds are so used.
G. REPRESENTATIONS
In the absence of fraud, the Policyholder's statements are deemed representations, not warranties.
H. EMPLOYEE CERTIFICATE
The Policyholder will deliver to each insured employee a certificate issued by Lincoln National.
I. EMPLOYEE IDENTIFICATION CARDS
If Lincoln National furnishes identification cards for verification of coverage, the Policyholder will deliver them
to each insured employee. When an employee's insurance ends, the Policyholder will collect all such cards
from the employee. The Policyholder will be responsible for any benefits paid in error, if such payment is
made because the Policyholder failed to collect a card from an employee whose insurance has ended or if
the Policyholder failed to promptly notify Lincoln National that an employee's coverage has ended.
FORM 19008-1-ID -53- 050158
SECTION 9 - LINCOLN NATIONAL
A. COMPUTATION OF PREMIUMS
1. Premiums for this policy will be based on Lincoln National's rates, adjusted to reflect Lincoln National's
underwriting risk. Lincoln National may change these premiums:
a. on any Policy Anniversary; or
b. on any premium due date (if Lincoln National notifies the Policyholder of the change at least 31 days
before such premium due date); or
c. whenever the terms of this policy are changed.
The premiums may not be changed as stated in b. above during the first 12 months after the Date of Is-
sue.
Any changed premiums will apply to all future premiums as well as to the one then due.
2. If premiums are payable on a basis other than monthly, and if a change occurs during a premium pay
period which affects premiums, a pro rata charge or credit will be made for such change on the next
closest premium due date.
3. Premiums may also be figured by any other method upon which Lincoln National and the Policyholder
have agreed.
B. NON-PARTICIPATING POLICY
This policy does not share in the profits of Lincoln National.
C. EXPERIENCE PREMIUM REFUNDS
1. At Lincoln National's sole discretion, an experience premium refund may be made. Both the amount of
such refund, if any, and the method of calculating it, will also be at Lincoln National's sole discretion.
In the process of calculating whether a refund is due, Lincoln National will combine the experience of this
policy with the experience of any other group policies issued to this Policyholder by Lincoln National or
its Affiliates. A refund calculation will be made at the end of each refunding period. A refunding period
may only end on a policy anniversary. A refund may only be made if, at the end of a refunding period:
a. the required number of employees is insured; and
b. the required amount of premium has been accumulated; and
c. this policy is in force; and
d. all premiums have been paid.
2. Any premium refunded will, at the Policyholder's option:
a. be paid in cash to the Policyholder; or
b. either be held by Lincoln National in a Premium Stabilization Fund, or be used for future premium
payments.
FORM 19009-MC -54- 050158
D. AMENDMENT AND ALTERATION OF CONTRACT
1. This policy may be amended or changed at any time by written agreement between the Policyholder and
Lincoln National.
2. This policy may also be amended by Lincoln National when it determines that such amendment is re-
quired for consistent application of policy provisions due to new or amended legislation or due to new
medical discoveries or procedures. The Policyholder will be notified of such amendment, in writing, at
least 60 days prior to its effective date. Payment of premium beyond the effective date of the amendment
constitutes the Policyholder's consent to the amendment.
3. Only an Officer of Lincoln National may change, amend. alter, or waive in any manner the provisions of
this policy, and then only when in writing and signed by the Officer.
4. Lincoln National will not be bound by any promise made by any agent or person other than an Officer
of Lincoln National.
E. END OF POLICY DUE TO LOW ENROLLMENT
Lincoln National may end this policy on any premium due date by giving written notice to the Policyholder
at least 31 days in advance of that date, if:
1. On any two premium due dates in a row, the number of employees insured is less than 10 (if there were
fewer than 25 employees insured on the Date of Issue or on the date this policy was last amended); or
2. On any two premium due dates in a row, the number of employees insured is less than 25 (if there were
25 or more employees insured on the Date of Issue or on the date this policy was last amended); or
3. The percentage of eligible employees insured is less than 100%.
F. EMPLOYEE'S CERTIFICATE
Lincoln National will issue to the Policyholder, for delivery to each insured employee, an individual certificate.
It will describe:
1. The coverage provided; and
2. To whom benefits are to be paid; and
3. The limitations or requirements of this policy that may apply to insured individuals.
The certificate is not a part of this policy.
G. NON-WAIVER OF POLICY PROVISIONS
Failure of Lincoln National to insist on compliance with any of the provisions of this policy at any given time
under any given set of circumstances will not operate; with respect to any other time or as to any other oc-
currence, whether the circumstances are, or are not, the same, to:
1. waive or modify such provisions; or
2. in any way render it unenforceable.
FORM 19009-1-83 -55- 050158
SECTION 10 - RECORDS
1. Lincoln National will maintain a record which will show at all times:
a. the names of all employees insured; and
b. the beneficiary(ies), if any, named by each employee; and
c. the date on which each employee became insured; and
d. the effective date of any increase or decrease in the amount of each employee's insurance; and
e. such other information as may be required to administer this insurance.
2. Lincoln National will furnish the policyholder with a copy Of such record, as of the Date of Issue of this policy,
and will report to the policyholder all changes in such record.
FORM 19010 -56- 050158
)
Application for Group Insurance to THE LINCOLN NATIONAL LIFE INSURANCE COMPANY, Fort Wayne, Indiana
Application is hereby made for the following Group Insurance Benefits on the renewable term plan on the lives of the eligible employees of the employer and. If this
application is accepted by the Insurance Company, the policy (policies) is to be issued to:
LA COu- (1C C� V O ervt rAe Vit
p p (Correct Legal Nm•)
Address l (SS Lti St P (�O . f 0)6 nS O GI-ee (e_i CO Q C>O637-
Sv«t City Steno Zia Coo•
o
EFFECTIVE DATE of this Insurance will be / — I I except that, if employees contribute to the cost, the Insurance shall not become effective
until at least 75%of those eligible have enrolled.
s
EMPLOYER CONTRIBUTION-Employer will pay 0 100%E Less than 100% of cost for employees and O 100% X Less than 100% of cost for dependents. (The
employer must pay at least 25%of the total cost).
GROUP INSURANCE BENEFITS applied for Ernp
Dep as follows:
(mpX Life Insurance [m"V Accidental Death, Dismemberment and Loss of Sight imp Travel Accident imp Accident and Sickness (Weekly Income)
Dep Dept Dep Dep
pro ilia Major Medical Expense imp Hospital Expense 1mr Surgical Expense Er" Medical Care Expense
t mp■ Diagnostic X-Ray Erg Additional Accident imp Radiation Therapy tmp Other
Dep. Dep■ Dep Dep
CLASSES OF FULL TIME EMPLOYE_: TO BE INSURED: fAIl 0 All except
ELIGIBILITY— Each employee must be working full-time (employees working less than an average of ❑30 31 hours per week (not less than 25) are not
eligible.) Each employee must be actively at work when the Insurance provided under the policy becomes effective;otherwise, it will not become effective with respect to him
until the next following day on which he is actively at work 18i (except that the employer requests the Insurance.Company to consider waiving this requirement on the
effective date of the policy for the following employees who are not presently at work, and who are now insured under a similar group plan)—
1WA
Name Reason for Absence Name Raison tot Absence
IT IS UNDEr^,CTJOD AND b..GR E: that the policy(policies) if issued or if amended from time to time, shall include the premium rates, benefit provisions and
administrative provisions applicable to the In, u'ance: that such premium rates, benefit provisions and administrative provisions shall be binding upon the applicant as
applicable, by the Insurance Company. Prem.,jms are to be payable)54 Monthly O Attached is a check for $150,000 to be applied toward
the first premium. //
Dated at _ Greef-` 1 c n this �S day Ali,, II 19 7 r)
Weld CO V.v.
pony oiaer(Corr el Name) iii /
/11
Witness L_I.
/� By i / v�[.�i/�!T hue 2 h 11,101 _
I3806-App 4.75) ly Liteesta Resident Agenl.&oser Onto NstneiAnd T,le
LINCOLN
NATIONAL
June 5, 1991
Don Warden
Weld County
915 10th Street
Greeley, Colorado 80632
Re: 50,158
Enclosed is the legal instrument which amends your master policy to include the change in your Group Insurance
Program. This material is a part of your master policy and should be attached to it.
Please review the attached promptly to be sure both your Company and Lincoln National are in agreement re-
garding the change in your policy.
Yo rs truly,
Na cy Daugh
Doc ra,ent P Aeration peci ' t
Group Divi on
Master Contract Section
Enc.
cc: Northern Colorado EBO - #9443
Colorado Springs GCO - 9544
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
GROUP INSURANCE AMENDMENT
Attached to and made a part of:
Group Insurance Policy No. 50,158 dated January 1, 1991
Policyholder WELD COUNTY
Greeley, Colorado
Effective date of this Amendment January 1, 1991
FOR VALUE RECEIVED, IT IS HEREBY AGREED BETWEEN THE POLICYHOLDER AND LINCOLN NATIONAL THAT:
On the Schedule of Benefits, the Wellness Benefit is changed to read:
Non-
Preferred Preferred
Provider Provider
Wellness-Children (2A)
Benefit Not
Paid At 100% * Available
Wellness Benefits (28)
Paid At 100% " 100% "
2. Wellness benefits are payable
A. for physical exams and immunizations for the first two years of life and
B. for physical exams including pap smears and prostate exams up to $150 for any 12-month period for in-
dividuals two years of age and older.
The following paragraph is added and becomes a part of"WAITING PERIOD" as it appears in Section One:
For employees previously insured under this policy whose insurance ended because of termination of em-
ployment and who return to work, the waiting period is determined according to the guidelines established
by the employer.
Item 4. of the provision of the Policy entitled "END OF INDIVIDUAL'S INSURANCE" as it appears in Section 6, is
changed to read:
"The date the employee's employment with the Employer ends. For the purposes of this policy, an employee's
employment will end on the last day of the month if the termination date is the first through the fifteenth of the
month, or on the last day of the following month if the termination date is the sixteenth through the last day
of the month."
The payment of premiums due for insurance extended under this policy on and after the effective date of this
Amendment will be deemed to constitute written acceptance of this Group Insurance Amendment by the
Policyholder. Such payment of premiums is the only method by which this Group Insurance Amendment may be
accepted by the Policyholder. If this Amendment is unacceptable to the Policyholder and the Policyholder desired
to continue insurance under the Policy without this Amendment being placed in effect, written notice thereof must .
FORM 13000-GIA -2- 050158
be given to Lincoln National at its home office in Fort Wayne, Indiana, within 31 days from the date the
Policyholder receives this form.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Examined by:
Edward R. Ricker,Assistant Secretary
FORM 13000-GIA -3- 050158
Hello