HomeMy WebLinkAbout000193.tiff • 1
• Certificate of Insurance
Allianz 15'!
Allianz Life Insurance Company of North America
1750 Hennepin Avenue South
Minneapolis, MN 55403-2195
A Stock Company
Certifies that under the Group Policy(ies) numbered below,the Insured Individual became insured for the benefits
stated in the Schedule of Insurance on the Effective Date shown below.
POLICYHOLDER: WELD COUNTY, COLORADO
GROUP POLICY(IES): 9172-059
TAKECARE'S ADMINISTRATION NUMBER: 50158
INSURED INDIVIDUAL: As on File with the Administrator
CERTIFICATE NUMBER: As on File with the Administrator
EFFECTIVE DATE: As on File with the Administrator
COVERAGES FOR INSURED EMPLOYEE
Medical Insurance Insured
COVERAGES FOR INSURED DEPENDENT(S):
Medical Insurance As on File with the Administrator
ADMINISTERED BY: TakeCare Administrative Services Corporation
5725 Mark Dabling Blvd.
Colorado Springs, CO 80919
This Certificate describes the principal provisions of the Group Policy(ies) and is subject to all provisions of the
Group Policy(ies) numbered above. No Insurance will become effective for any Individual on a date when he is
not in Active Service but will be deferred in accordance with the Group Policy(ies). This Certificate replaces any
and all Certificates previously issued for delivery to the Insured Individual.
ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA
Chairman of the Board, President & CEO
GI-7830-TASC-CO LOW DEDUCTIBLE
193
•
2
INDEX
Section 1
A. Schedule of Benefits
1. Major Medical Benefits
2. Allowable Benefit Maximums
3. Replacement of Organs or Tissue
4. Eligibility Requirements
B. Description of Benefits
1. Participating Provider
2. Utilization Review
3. Major Medical Benefits
Covered Charges
Home Health Care
Hospice
Prescription Drugs
Section 2
Benefit Exclusions and Limitations
Read carefully, it applies to All Benefits
Section 3
Other Coverage
A. Medicare
B. Coordination of Benefits
Section 4
Extension of Certain Benefits Upon End of Insurance while Totally Disabled
Section 5
Conversion & Continuation
A. Medical Insurance Conversion
B. Discontinuance and Replacement of Insurance
C. Continuation of Benefits Required Under Federal Law
D. Continuation of Benefits Required Under State Law
CI-TASC-01-CO
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Section 6
General Information
A. Individuals Eligible
B. Insurance Benefits
C. Notice and Proof of Claim
D. Payment of Claim
E. Time of Payment of Claim
F. Legal Actions
G. Choice of Hospital or Doctor
H. Independent Health Care Providers
Worker's Compensation
J. Statements
K. End of Individual's Insurance
Section 7
Definitions
CI-TASC-0I-CO
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4
SECTION 1 - LOW DEDUCTIBLE BENEFITS
A. SCHEDULE OF BENEFITS
EMPLOYEE AND DEPENDENT
•
The employee must be insured under this Policy in order for his or her dependents to be insured under this
Policy.
MAJOR MEDICAL BENEFITS
REFER TO UTILIZATION REVIEW
FOR AUTHORIZATION REQUIREMENTS TO AVOID PENALTY
•
NOTE: This Policy has certain benefit maximums,some are calendar year maximums and some are
benefit maximums while insured. Please refer to the Allowable Benefit Maximums Section.
Individual Deductible per Calendar Year $150.00
The Deductible is waived for Routine Mammograms.
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. The calendar year family unit
deductible may be satisfied by the combination of any eligible expenses that apply toward the individual
deductible. Except that, no more than $150.00 may be satisfied by any one Insured Individual.
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.
Deductible Carry Over
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.
Co-Payment
In those instances where a Co-Payment applies, the amount is indicated. A Co-Payment means the portion of
covered charges which are the responsibility of the insured and which are shown as copay on the Schedule of
Benefits.
Co-Payments do not apply towards the Deductible nor do co-payments accrue toward the full payment feature.
Co-payments will continue to be required after the full pay limit has been reached.
PCSCH P PO-TASC-01-CO
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Failure to Call Penalty
If the Insured Individual fails to call Utilization Review as required under Certification/Pre-Certification (Refer to
the page entitled Utilization Review) a penalty will result whereby the Insured Individual will be required to pay the
first $250.00 of all Covered Charges. This penalty of $250.00 will not apply toward satisfaction of a Deductible,
Copayment or Stop-Loss.
Stop Loss Provision
After $5,000.00 of covered charges are incurred by an Insured Individual during a calendar year, or after
$10,000.00 of covered charges are incurred by the insured members of a family unit during a calendar year, the
benefit percentage changes to 100% for Participating and Non-Participating Providers for the remainder of the
calendar year. Except that:
1. deductibles, all charges which are subject to a copayment, and those charges which are paid at
100%without a deductible or copayment will not apply towards reaching the$5,000.00 or the
$10,000.00 and
2. copayments remain the responsibility of an Insured Individual
3. charges for mental health, substance abuse, alcoholism, and charges not authorized through a
Utilization Review Program when applicable will never be paid at 100%. In addition,the Failure to
Call Penalty will be imposed for failure to comply with the Utilization Review procedures of this
Policy.
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.
NOTE:The maximum charge eligible for any services or materials will be the reasonable and customary
charge for those services or materials. .
NOTE: Other provisions and limitations apply.
PCSCHPPO-TASC-01-CO
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PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL
KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS
HEALTH CARE MAY BE OBTAINED TO RECEIVE THE GREATEST
LEVEL OF BENEFIT
Benefit Percentage:
Reasonable and Customary covered charges are covered at the benefit percentage shown below.
Note: Participating Provider Charges are covered based on the contracted rates.
Participating Non-Participating
Provider Provider
Inpatient
Room and Board (semiprivate and misc. charges) 80% 80%
Doctor Visits 80% 80%
Skilled Nursing Facility (Semi-private Room) - 80% 80%
Limited to 90 days per calendar year
Outpatient
Doctor Visits (home and office- not to include
the delivery of an Antigen to the Insured.)
Copay $15.00 per visit
Paid at 100% 80%
Emergency Room Charges'
Copay $50.00 per visit'
Paid at 100% 80%
' Treatment received from Non-Participating Providers for emergency care as defined below, including
ambulance, will be paid at 80%.
Emergency Care means 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 or limb of an Insured
Individual. If services received do not meet Emergency Care definition, regular benefits apply.
2 PPO Emergency Room Charges-copayment waived if admitted to the hospital and authorized by Utilization
Review.
PCSCH P PO-TASC-01-CO
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Participating Non-Participating
Provider Provider
Outpatient (Continued)
X-Ray Charges
Paid at 80% 80%
Laboratory Charges
Paid at 80% 80%
Surgery Performed at
Doctor's Office (including Doctor Charges)
Copay $15.00 per visit
Paid at 100% 80%
Doctor Charges(other than in doctor's office)
Paid at 80% 80%
Facility Charges(other than in doctor's office)
Paid at 80% 80%
Home Health Care- Limited to 60 visits per
calendar year
Paid at 80% 80%
Prescription Drug Benefits'
Copay $8.00 Brand-name
$5.00 Generic
Paid at 100% 80%
Outpatient Rehabilitation Therapy- Limited to
$2,000.00 per calendar year
Copay $15.00 per visit
Paid at 100% 80%
' Deductible is waived for Participating Provider Prescription Drugs.
PCSCHPPO-TASC-01-CO
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Participating Non-Participating
Provider Provider
Outpatient (continued)
Wellness Benefits'
Copay $15.00 per visit
Paid at 100% Not covered
Mental Health
Inpatient- Limited to 45 days per calendar year2.
Doctor charges are limited to$1,000.00 per
calendar year for Mental Health, Substance Abuse,
and Alcoholism combined.
Paid at 80% 80% Facility charges
50% Doctor's charges
Outpatient - Limited to$1,000.00 per calendar year.
Copay $15.00 per visit
Paid at 100% 50%
' Wellness benefits include physical exams for the first 2 years of life. Physical exams are: (a) doctor's
charges; (b) any tests performed, including x-ray and lab charges and, (c) charges for immunizations.
2 Each two days of partial hospitalization care shall reduce by one day the 45 days available for inpatient care.
Partial Hospitalization means continuous treatment for at least 3 hours but not more than 12 hours in any 24
hour period. Each day provided shall reduce by one day the available days provided under Alcoholism or
Substance Abuse.
PCSCHPPO-TASC-01-CO
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Participating Non-Participating
Provider Provider
Alcoholism
Inpatient-Limited to 45 days per calendar year Doctor's
charges limited to$1,000.00 per calendar year for Mental
Health, Alcoholism and Substance Abuse combined.'
Paid at 80% 80%Facility charges
50% Doctor's charges
Outpatient-Limited to$500.00 per calendar year
Copay $15.00 per visit
Paid at 100% 50%
Substance Abuse
Inpatient-Limited to 45 days per calendar year'. Doctor's
charges limited to$1,000.00 per calendar year for mental
health, alcoholism and substance abuse combined.
Paid at 80% 80% Facility charges
50% Doctor's charges
Outpatient- Limited to$500.00 per calendar year
Copay $15.00 per visit
Paid at 100% 50%
Hospice - Limited to 365 days3 while insured
Paid at 80% 80%
Routine Mammogram- Limited to$65.00 per
mammography screening. Coverage amount to be
adjusted each July 1st in accordance with the average
percentage increase/decrease in the"Consumer Price
Index" (CPI)
Paid at 100% 100%
Other Covered Charges
Paid at 80% 80%
Note: Other provisions and limitations apply.
' Each day provided shall reduce by one day the available days provided under Mental Health or Substance
Abuse.
2 Each day provided shall reduce by one day the available days provided under Mental Health or Alcoholism.
3 Insured's doctor must certify that the Insured Individual is terminally ill, and the Insured Individual is
expected to live less than six months.
PCSCH PPO-TASC-01-CO
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ALLOWABLE BENEFIT MAXIMUM
•
per calendar year or per treatment
Benefit Maximums (Participating and Non-Participating combined):
Skilled Nursing Facility Limited to 90 days per calendar year
Outpatient Rehabilitation Therapy Limited to$2,000.00 benefit maximum per calendar
year.
Wellness Benefits Physical exams for the first two years of life.
Home Health Care Limited to 60 visits per calendar year.
Mental Health
Inpatient Limited to 45 days' per calendar year. Doctor's charges
limited to $1,000.00 per calendar year for mental health,
alcoholism and substance abuse combined'
Outpatient Limited to$1,000.00 benefit maximum per calendar
year.
Alcoholism
Inpatient Limited to 45 days'per calendar year. Doctor's charges
limited to$1,000.00 per calendar year for mental health,
alcoholism and substance abuse combined.
Outpatient Limited to $500.00 benefit maximum per calendar year.
Substance Abuse
Inpatient Limited to 45 days`per calendar year. Doctor's charges
limited to $1,000.00 per calendar year for mental health,
alcoholism and substance abuse combined.
Outpatient Limited to $500.00 benefit maximum per calendar year.
Routine Mammogram Limited to $65.00 per mammography screening.
Coverage amount to be adjusted each July 1st in
accordance with the average percentage
increase/decrease in the"Consumer Price Index" (CPI).
Manual Manipulation of the Spine $10.00 per visit; one visit per day; 50 visits per calendar
year.
' Each day provided shall reduce by one day the available days provided under Alcoholism or Substance
Abuse.
2 Each dollar paid for inpatient Mental Health Doctor charges shall reduce by one dollar the benefit provided
for Alcoholism or Substance Abuse inpatient Doctor charges.
' Each day provided shall reduce by one day the available days provided under Mental Health or Substance
Abuse.
' Each day provided shall reduce by one day the available days provided under Mental Health or Alcoholism.
PCABM-TASC-01-CO
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ALLOWABLE BENEFIT MAXIMUM
while insured
Benefit Maximum While Insured (Participating and Non-Participating combined):
Temporomandibular Joint Dysfunction (TMJ) Diagnosis and Treatment of TMJ. Limited to
$1,000.00 benefit maximum while insured for
each Insured.
Hospice Care 365 days while insured for each Insured.
Maximum Benefit While Insured $2,000,000.00
Note: Other provisions and limitations apply.
PCABM-TASC-01-CO
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REPLACEMENT OF ORGANS OR TISSUE
A. The following procedures are covered on the same basis as any other illness:
1. cornea transplants
2. artery or vein transplants
3. kidney transplants
4. joint replacements
5. heart valve replacements
6. implantable prosthetic lenses in connection with cataracts
7. prosthetic by-pass or replacement vessels
8. heart transplants
9. combined heart and lung transplants
10. liver transplants
11. bone marrow transplants, as described below:
a. Allogenic bone marrow transplants for the following diseases:
•Aplastic anemia
*Leukemia
*Severe combined immunodeficiency disease
•Wiskott-Aldrich syndrome
b. Autologous bone marrow transplants for the following diseases:
*Acute leukemia in remission
•Resistant non-Hodgkin's lymphomas or those who have a poor prognosis following an initial
response
•Recurrent or refractory neuroblastoma
•Advanced Hodgkin's disease in those who have failed conventional therapy and have no
HLA-matched donor.
B. No other replacement of tissue or organs are covered by the Policy.
C. Donor costs are excluded when recipient is not an insured on the policy or if the expenses are covered
by another insurance.
D. Transportation and lodging expenses are excluded except as covered by the ambulance benefit.
E. All procedures must be performed in a designated facility; otherwise all charges will be denied.
13
ELIGIBILITY REQUIREMENTS
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 20 hours per
week in the employ of the Employer(herein called employees within the eligible classes), and
2. dependents of those employees who are meeting the requirements of 1. above.
Retired employees and their dependents are not eligible.
If an individual elects to be covered under a Health Maintenance Organization Plan (HMO) offered by this
employer that individual will not be eligible or insured under this Policy.
EFFECTIVE DATES OF INSURANCE
Subject to section 3 "Employee and Dependents Hospitalized or Absent from Work" below, 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 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 the date he or she becomes eligible.
b. If the employee applies after:
31 days from the date he or she first becomes eligible; or
ii. 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 Allianz Life
before he or she may be considered for insurance. If Allianz Life approves insurance for that
employee, he or she will become insured on the date of approval.
PCER-TASC-01-CO
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2. DEPENDENTS
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 applies for dependent
insurance on a form approved by Allianz Life 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 becomes eligible for dependents'
insurance, his or her dependents will be insured on the date the employee becomes insured.
b. If the employee applies after:
31 days from the date he or she became eligible for dependents'insurance;or
ii. 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
Allianz Life evidence of insurability, at his or her own expense, for each dependent he or she
wants to enroll. Insurance for those dependents must be approved by Allianz Life, and will only
become effective on the date of approval.
A newly acquired dependent will be automatically insured if the employee is already insured and there is
no change in the premium rate.
If an insured employee acquires his or her first newborn child while not insured for dependents'
insurance,the following rules apply:
a. coverage for the newborn child of an insured employee will be effective on the date the child is born if
the employee applies for dependents' insurance, and agrees in writing to pay any premium due,
before or during the 31-day period; and
b. if the employee does not apply for dependents'insurance, or pay any premium due, before or during
this 31 day period, coverage will terminate the date after the first 31 days of insurance. Evidence of
insurability will be required in order for that child to become insured after such 31-day period. The
effective date of the insurance will be the date of approval.
3. EMPLOYEE AND DEPENDENTS HOSPITALIZED OR ABSENT FROM WORK
If on the date coverage would otherwise begin, the employee is not actively at work or is absent from
work because of illness or injury when coverage would normally become effective, coverage for the
employee and his/her eligible dependents will become effective on the date the employee returns to
active work. If the dependent is confined in a hospital or health care facility at a time when coverage
would normally become effective, coverage for the dependent will become effective on the date the
dependent is discharged from the hospital or health care facility.
EXCEPT THAT, employees and their dependents who were insured under the policy this Policy replaced
on the day prior to the Date of Issue of this Policy will become insured on the Date of Issue of this Policy
even though (i)the employee may not be actively at work;or(ii)the dependent may be confined in a
hospital or skilled nursing facility.
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.
PCER-TASC-01-CO
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ELIGIBILITY REQUIREMENTS
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 20 hours per
week in the employ of the Employer(herein called employees within the eligible classes), and
2. dependents of those employees who are meeting the requirements of 1. above.
Retired employees and their dependents are not eligible.
If an individual elects to be covered under a Health Maintenance Organization Plan (HMO) offered by this
employer that individual will not be eligible or insured under this Policy.
EFFECTIVE DATES OF INSURANCE
Subject to section 3 "Employee and Dependents Hospitalized or Absent from Work" below, 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 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 the date he or she becomes eligible.
b. If the employee applies after:
31 days from the date he or she first becomes eligible;or
ii. 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 Allianz Life
before he or she may be considered for insurance. If Allianz Life approves insurance for that
employee, he or she will become insured on the date of approval.
PCER-TASC-01-CO
• 15
Dependent- means:
1. An employee's spouse(if not legally separated from the Employee)
2. An employee's unmarried child from live birth, unmarried stepchild or legally adopted child from moment
of placement in the home until the end of the 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 retarded or physically disabled and unable to earn his or her own living and
proof of incapacity is furnished to Allianz Life 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 on the date just prior to the day his or her insurance would have ended due to
age.
b. the child:
1) is enrolled in an accredited school as a full-time student as defined in the rules of such
school; and
2) has not attained age 23.
To remain insured under 2. above, due proof that the employee's child continues to qualify as a
dependent must be furnished to Allianz Life as it reasonably asks. Except that, Allianz Life 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 for 2a. above.
3. A 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.
DUAL CHOICE PERIOD
Each year;an employer will allow their employees to choose coverage under this Policy and/or an optional HMO
plan. The employee may apply to transfer from either the PPO Policy or the HMO to the other during an open
enrollment period established by the employer.
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 without evidence of insurability during the employer group's open enrollment period or in
the event of changes in the availability of the employer's plan offerings, provided the individual was insured by the
HMO in the month immediately preceding enrollment in this Policy.
If the employee is not currently enrolled in a health plan sponsored by the employer, evidence of insurability must
be provided to be considered for eligibility at the time of application. Evidence of insurability is waived for a newly
hired employee if he/she and his/her dependents enroll within thirty-one (31) days following the initial eligibility
date of the employee.
REINSTATEMENT OF COVERAGE FOR A MILITARY RESERVIST
Military Reservists returning to work from active duty in the Armed Forces may have coverage reinstated, for
themselves and any eligible dependent provided:
1. such individual was eligible under the group plan on the day employment with his or her employer ended
due to being called to active duty in the Armed Forces; and
2. such individual becomes re-employed with his or her employer within 90 days of an honorable discharge;
and
PCER-TASC-01-CO
16 •
3. the individual applies for coverage according to the enrollment requirements outlined in this Policy.
The coverage provided under this provision will be the benefits currently provided under this Policy. If an
individual returns to active employment within the same calendar year, eligible charges accumulated toward the
satisfaction of provisions such as deductibles or calendar year maximums will be taken into consideration when
determining benefits available for the remainder of the calendar year. Provisions such as waiting periods and
pre-existing condition limitations will be treated as if the Insured Individual's coverage had not ended.
REINSTATEMENT OF COVERAGE UPON RETURN FROM AN APPROVED LEAVE UNDER THE FAMILY
AND MEDICAL LEAVE ACT(FMLA)
Insurance will be reinstated for formerly Insured Individuals retuming from an approved leave under the FMLA,
provided the employer requests reinstatement from Allianz Life within 31 days of the date of such return.
The coverage provided under this provision will be the benefits currently provided under this Policy. If an
individual returns from an approved leave within the same calendar year, eligible charges accumulated toward
satisfaction of provisions such as deductibles or calendar year maximums will be taken into consideration when
determining benefits available for the remainder of the calendar year. Provisions such as waiting periods and
preexisting condition limitations will be treated as if the Insured Individual's coverage had not ended except that
time spent on the leave will not accrue toward satisfaction of any preexisting condition period or similar waiting
period.
WAITING PERIOD
The waiting period is the period of time between the date of full-time employment and the first day of the Calendar
Month coincident with or next following one full pay-period of employment.
PRE-EXISTING ILLNESS OR CONDITION LIMITATION
Payment for charges incurred in connection with an illness or condition starting prior to the Insured Individual 's
effective date of coverage is limited to a maximum of$1,000.00 unless the charges are incurred:
1. after a period of three months in a row ending on or after the effective date of coverage during which the
person has received no medical advice or treatment with respect to the illness or condition; or
2. after a period of twelve months in a row during which the person is continuously insured under this Policy
and the policy replaced by this Policy.
PC E R-TASC-01-CO
•
17
CLASSIFICATION CHANGE DATE
A change in an employee's benefits caused by a change in his or her classification will be effective immediately
on the date such change in classification becomes effective.
CONTRIBUTIONS TOWARD PREMIUM BY EMPLOYEE
Insurance for employees is contributory.
Insurance for dependents of an employee is contributory.
Insurance becomes effective as provided in Section 6.
PCER-TASC-01-CO
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B. DESCRIPTION OF BENEFITS
PARTICIPATING PROVIDER BENEFITS
This Policy includes Participating Provider (PPO) Benefits. A TakeCare Participating Provider has agreed to
provide medical services to a specified group of Insured Individuals at a contracted rate. The Schedule of
Benefits shows the Co-Payment,the Deductible,the Benefit Percentage and other details.
The insured employee will be provided with a list of TakeCare Participating Providers. Insured Individuals will
always have the freedom to choose either a TakeCare Participating Provider or Non-TakeCare Participating
Provider each time medical care is needed.
FREE CHOICE OF HOSPITAL AND PHYSICIAN
If the Insured Individual disagrees with the payment level, he/she may appeal the claim. The claim will be referred
to the Appeals Consultant. If it is determined that the services were not reasonably available within the network,
but were in fact medically necessary to the care and treatment of the illness, payment of the charges at the
participating level may be authorized.
The Policy in no way interferes with the right of any Insured entitled to hospital benefits to select a hospital.
Except for required second opinions through Utilization Review, the Insured may choose any physician who holds
a valid physician and surgeon's certificate and who is a member of, or acceptable to, the attending staff and
board of directors of the hospital where services are received. However, the Insured's choice may affect the
benefits payable according to the terms of the Policy except as noted under the Utilization Review portion of this
Policy.
PC DB-TASC-01-CO
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UTILIZATION REVIEW
Utilization Review is a program which reviews the setting, necessity, and appropriateness of health care.
TAKECARE Review furnishes each Insured Individual with Utilization Review. Utilization Review's telephone
number is 1-800-255-1189. Many services require Utilization Review to avoid penalty. In all instances, benefits
are not payable when services are not authorized and determined not to be medically necessary or appropriate.
Please review the Utilization Review procedure below.
The insured is responsible for making sure Utilization Review is contacted for pre-certification of services
requiring certification at least five (5) days prior to receiving services. Certification from Utilization Review is
required for:
Hospital Admissions(includes Skilled Nursing Facility stays and inpatient Rehabilitation);
Outpatient Surgeries performed in other than the doctor's office;
Home Health Care;
Inpatient and outpatient Hospice care;
Certification by Utilization Review does not guarantee benefits or that all charges are covered under the Policy.
Charges submitted for payment are subject to all other terms and conditions of the Policy.
As part of the Utilization Review process, Utilization 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: As set forth below, certification must be obtained before services are received. If
the Insured Individual fails to call Utilization Review as required under Certification/Pre-Certification below, a
penalty of an additional individual deductible will apply. Refer to the Schedule of Benefits, Section 1 - Benefits,
for an explanation of such penalty. This penalty is in addition to any other deductible under the Policy.
CERTIFICATION/PRE-CERTIFICATION
1. Hospital admissions
The Insured Individual is responsible for making sure Utilization Review is contacted about any hospital
stay at least 5 days before admission to a hospital as a bed patient. Utilization Review will review the
doctor's recommendation to determine whether the proposed services are medically necessary and
appropriate, whether a hospital stay is necessary, or if the services can be safely performed on an
outpatient basis. Benefits will be covered only for authorized services.
PCUR-TASC-01-CO
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2. Outpatient Surgery:
The Insured Individual is responsible for making sure Utilization Review is notified at least five (5)days
before outpatient surgery is performed in other than a doctor's office. Utilization Review will review the
doctor's recommended course of treatment. Benefits will be covered only for authorized services. No
benefits will be covered for outpatient surgery not authorized.
3. Emergency/Urgent/Pregnancy Related/Hospital Admission:
For an emergency or urgent hospital admission (including all pregnancy related events),the Insured
Individual is responsible for making sure Utilization Review is contacted within 48 hours after admission
so that care can be reviewed and authorized as appropriate. For admission on a holiday,or after 5:00
p.m. on a Friday, or during a weekend, Utilization Review must be informed of the admission on the next
business day. Benefits will be covered only for authorized days.
"Emergency hospital admission" means an admission for hospital confinement, which, if delayed, would
result in a significant 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 three (3) days in order to avoid
significant disability.This includes pregnancy related events.
In the event that the services are not found to be emergent or urgent,the Failure to Call Penalty will
apply.
4. A second opinion may be required for inpatient admissions or outpatient services. Utilization Review will
inform the doctor and Insured if a second opinion is necessary. Utilization Review will direct the Insured
in the second opinion process (including the choice of providers).
A"second opinion" means an evaluation of the need for inpatient admission and treatment 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 Utilization Review will be covered at 100%with no deductible.
If the second opinion is not obtained as required by Utilization Review,the benefit percentage will
be 50%for any charges associated with the inpatient admission or outpatient treatment, as
considered medically necessary.
No benefits will be covered for medically unnecessary services as determined by Utilization
Review.
PCUR-TASC-01-CO
21
5. Health Care Services and Supplies Review:
The Insured Individual is responsible for making sure Utilization Review is notified to obtain a plan of care
approval for the following health care services and supplies prior to obtaining these services or supplies:
Home Health Care
Hospice Care
Benefits will be covered only for authorized health care services and supplies. No benefits will be covered
for health care services and supplies not authorized.
CONCURRENT REVIEW
After admission to the hospital, Utilization Review will continue to evaluate the patient's progress. If after
consulting with the doctor and performing a medical review, Utilization Review determines that continued
confinement is no longer medically necessary, the Insured and the doctor will be advised. Benefits will be covered
only for authorized days. No benefits will be covered for hospital days not authorized.
Utilization Review will also evaluate the Insured's progress under authorized Health Care Services and Supplies
Review. If after consulting with the doctor and performing a medical review, Utilization Review determines that
continued treatment is no longer medically necessary, the Insured Individual and the doctor will be advised.
Benefits will be covered only for authorized treatment and services. No benefits will be covered for treatment and
services not authorized.
SPECIAL CARE MANAGEMENT
Special Care Management is performed by Utilization Review to arrange for alternate methods of medical care or
treatment not otherwise covered under the Policy in lieu of hospital confinement at the discretion of Utilization
Review.
Benefits may be covered for these charges when an Insured Individual in the determination of the Utilization
Review:
1. is discharged from the hospital sooner than would have been possible without Special Care Management;
or
2. would otherwise have been required to be confined as a bed patient in a hospital.
RETROSPECTIVE REVIEW
Utilization Review will evaluate the medical records of those individuals whose medical treatment or hospital stay
was not reviewed under Certification/Pre-Certification or Concurrent Review as described above.
If Utilization Review is unable to authorize any portion of the stay or treatment, the doctor will be contacted to
provide additional information for review.
Benefits will be covered only for those days or treatment which would have been prior authorized. No benefits will
be paid for any days or treatment considered not medically necessary. Penalty will be applied for non-compliance
with any utilization review procedures.
PCUR-TASC-01-CO R-TASC-01-CO
22
MAJOR MEDICAL BENEFITS
Benefits will be covered if an Insured Individual has covered charges due to an illness or condition during his or
her Benefit Period.
Benefit Period
A Benefit Period begins and ends as shown in the Schedule of Benefits section.
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 or Co-Payment.
Maximum Benefit While Insured
Payment will never be more than the Maximum Benefit While Insured for all of an Insured Individual's illness' or
conditions, even though the person may not have been continuously insured.
The Maximum Benefit While Insured will be renewed when an Insured Individual submits evidence of insurability
to Allianz Life at his or her own expense. This renewed Maximum Benefit While Insured will apply to all charges
made after the date such increase is effective.
CHANGE IN INSURANCE CLASSIFICATION
NOT AS A RESULT OF AMENDMENT OF POLICY
It the Insured Individual's insurance classification changes and results in an increase in the Maximum Benefit
While Insured, such increase will not apply to any illness which exists on the date of such change. The increase
will not apply to those illness' until a three-month period has elapsed during which the Insured Individual has not
received any treatment for the existing illness.
COVERED CHARGES
Covered charges are subject to medical necessity determination by Allianz Life, the provisions listed in
the Exclusions and Limitations Section, and such other limitations and maximums as set forth in this
Policy.
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. Drugs which are approved by the Food and
Drug Administration (FDA), not experimental or investigational, and are supplied by and used in the
hospital. (Refer to the Exclusions and Limitations Section.)
5. Anesthetics and their administration.
PCMMB-TASC-01-CO
23
6. Medical treatment including FDA approved drugs 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.
8. X-ray exams(other than dental), lab tests and other diagnostic services.
9. X-ray and radiation therapy.
10. Ambulance service for emergency transportation and care from the area where the Insured is first
disabled to the nearest hospital qualified to provide necessary care and treatment. Ambulance service is
not for the convenience of the Insured and is covered only when medically necessary.
11. Drugs which require a prescription and obtained from a licensed pharmacy and are not excluded
elsewhere in this Policy (refer to the Prescription Drugs Benefit section.)
12. Medical supplies as follows:
a. artificial limbs and eyes for loss of natural limbs and eyes which occurred while insured;
b. lens, each eye (contact or frames) immediately following and because of cataract surgery only;
c. casts, splints,trusses, braces, crutches and surgical dressings requiring a written prescription or
administered by a physician;
d. purchase or rental of durable medical equipment. Covered charges 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. The total purchase price to be eligible will be on a monthly
pro-rata basis. In determining Allianz Life'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.
e. blood and other fluids to be injected into the circulatory system.
13. Charges for any treatment for cosmetic purposes or for cosmetic surgery, including aging of the skin are
not covered. Except that Allianz Life will cover cosmetic treatment or surgery:
a. due solely to an accidental bodily injury which occurred while the individual was insured under
this Policy; or
b. for the reconstructive surgery and prosthetic devices following mastectomy for breast cancer;
c. due solely to a birth defect of an individual who was insured under this Policy on the date of his or
her birth.
14. Charges for inpatient rehabilitation services which are pre-authorized by TakeCare 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; and
b. is furnished to restore a physically disabled Insured Individual to useful activity.
Continuing measurable progress must be demonstrated at regular intervals.
15. Charges for outpatient rehabilitation therapy are limited to a maximum payment of$2,000.00 per calendar
year. Outpatient rehabilitation therapy includes physical therapy, speech therapy, occupational therapy
and biofeedback therapy provided in an outpatient setting and is furnished to restore a physical disabled
Insured Individual to useful activity.
PCMMB-TASC-01-CO
24
16. The charge made for a baseline routine mammogram for female Insured Individuals age 35 to 39
inclusive; a routine mammogram every 2 years or more frequently at the Doctors recommendation for
female Insured Individual's age 40 to 49 inclusive; and a routine mammogram every year for female
Insured Individual's age 50 and over. Benefit not to exceed $65.00 per mammography screening.
Coverage amount to be adjusted each July 1st in accordance with the average percentage
increase/decrease in the"Consumer Price Index" (CPI). The charge made for a diagnostic mammogram
is subject to the applicable Individual Deductible and Benefit Percentage for All Other Covered Charges
as shown in the Schedule of Benefits.
17. Wellness Benefits as shown in the Schedule of Benefits.
18. Charges for services and supplies for infertility evaluation and surgical procedures to correct documented
physiological abnormalities of the reproductive system.
19. Hospice Care as shown in Hospice Benefits Section.
20. Home Health Care as shown in Home Health Care Benefits Section.
21. Charges for the repair of natural teeth (including their replacement) which are the result of and within 24
months of an accidental bodily injury which occurs while the person is insured.
22. Elective sterilization.
23. Professional services for the treatment of acupuncture/acupressure performed by a doctor or certified
acupuncturist/acupressurist, for the relief of pain. Eligible diagnoses include but not limited to: a) pain
from surgical procedures; or b) pain from injuries that involve strains or sprains of muscles, ligaments or
tendons of any body part. Ineligible diagnoses include but not limited to: a) hepatitis, b) flu, c) allergies,
d)weight loss, e) smoking cessation, f) internal pain;or g) other general illness'.
24. Charges otherwise covered under the policy for the treatment of mental health provided in a:
a. A Hospital
b. A comprehensive health service corporation;
c. A community mental health center or mental health clinic approved by the Department of
Institutions to provide mental health services.
Services will include those by or under the supervision of a doctor or psychologist if the doctor or
psychologist either saw the patient or had a written summary of consultations or a personal consultation
with the therapist at least once every 90 days. Services will also include those furnished by a Registered
Nurse, Licensed Clinical Social Worker whether or not under supervision of a doctor or psychologist.
Benefits are limited as shown in the Schedule of Benefits.
25. Orthotic and prosthetic devices, to include original and replacement devices when prescribed by a doctor.
26. Elective abortions.
27. Charges for Alcoholism as shown in the Schedule of Benefits.
28. Charges for Substance Abuse as shown in the Schedule of Benefits.
PC MMB-TASC-01-CO
•
25
HOME HEALTH CARE BENEFITS
Benefits will be covered as authorized by Utilization Review. Covered Charges shall not exceed the benefit
maximum amount shown in the Schedule of Benefits.
Each visit by a representative of a home health care agency shall be considered as one Home Health Care visit;
each visit up to a maximum of 4 hours of Home Health Care service by a representative shall be considered as
one Home Health Care visit.
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 home bound and:
a. the Insured Individual is under the direct care of a doctor and requires skilled services in the
home;
b. the plan of treatment including FDA approved drugs 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 at least 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.
3. They are for one or more of the following:
a. part-time, intermittent nursing care by a Registered Nurse (R.N.) or a Licensed Practical Nurse
(L.P.N.);
b. part-time or intermittent Home Health Aide services for direct personal care in connection with
skilled services;
c. social work performed by a licensed social worker;
d. physical rehabilitation services provided by physical, speech or other therapist.
Exclusions
No Home Health Care Benefits will be paid for:
1. non-skilled services;or
2. general housekeeping services; or
3. services for custodial care; or
4. services not authorized by Utilization Review.
THE DEDUCTIBLE AND BENEFIT PERCENTAGE ARE ALL SHOWN ON THE SCHEDULE OF BENEFITS.
PC H HC-TASC-01-CO
26
HOSPICE BENEFITS
Covered charges include services and supplies furnished directly by a hospice agency if authorized by Utilization
Review. Certification is required once every 30 days to verify that an Insured Individual's condition continues to
require hospice services.
COVERED CHARGES
1. Room and board for confinement in a Hospice.
2. Services and supplies furnished by the Hospice while the Insured is confined.
3. Home Hospice care.
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 an 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. respite care (services provided in the home or Hospice facility to temporarily relieve the family or
other care providers from daily care demands.
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 by a licensed social worker or a licensed pastoral counselor.
6. Bereavement support services for the individual's family unit (including immediate family, the primary care
giver and individuals with significant personal ties) as follows:
a. The Benefit Percentage will be 50%for such services; and
b. No more than a maximum of$500.00 will be covered for the Insured Individual's immediate
family; and
c. Such services will only be covered during the 3-month period following the patient's death.
LIMITATIONS
Hospice Benefits will only be paid if the Insured Individual's attending doctor certifies that:
1. the Insured Individual is terminally ill and is expected to die within six months or less; and
2. the Insured Individual can safely and appropriately be managed through hospice services.
Hospice Benefits will be paid up to a maximum of 365 days while insured.
EXCLUSIONS
Services excluded under the Hospice benefit are:
1. services or supplies for personal comfort or convenience, including homemaker 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.
ANY COVERED CHARGE PAID UNDER HOSPICE BENEFITS WILL NOT BE CONSIDERED A COVERED
CHARGE UNDER ANY OTHER BENEFIT IN THIS POLICY.
PCHOS-TASC-01-CO
27
DEFINITIONS
"Hospice" means an agency that provides counseling and medical services and may provide room and board to a
terminally ill Insured Individual and which meets all of the following tests:
1. it has the required state or governmental Certificate of Need approval;
2. it provides services 24 hours a day, 7 days a week;
3. it is under the direct supervision of a doctor;
4. it has a nurse coordinator who is a Registered Nurse (R.N.);
5. ft has a social service coordinator who is licensed;
6. it is an agency that has as its primary purpose the provision of hospice services;
7. it has a full-time administrator;
8. it maintains written records of services provided to the patient;
9. it is licensed, if licensing is required.
"Patient's immediate family" means the patient's spouse and children or parents and siblings who are insured
under this Policy.
THE DEDUCTIBLE AND BENEFIT PERCENTAGE ARE ALL SHOWN ON THE SCHEDULE OF BENEFITS.
PCHOS-TASC-01-CO
• 28
PRESCRIPTION DRUG BENEFITS
Benefits will be covered based on the deductible, copayment, and benefit percentage shown on the Schedule of
Benefits for drugs prescribed by a licensed prescriber.
Covered Charges:
1. Medically necessary non-injectable drugs which under federal or state law may only be dispensed upon
the prescription of a physician or other lawful prescriber.
2. Injectable drugs: Insulin, glucagon, and bee sting kits.
3. Disposable insulin needles/syringes.
4. Compounded medications of which at least one ingredient is a plan covered prescription drug.
5. A quantity not in excess of a 34 day supply.
Exclusions: (in addition to all other Exclusions and Limitations listed elsewhere in this Policy.)
1. Oral contraceptives.
2. Any drug which is taken by or provided to an Insured Individual while a patient in a doctor's office,
hospital, skilled nursing facility, convalescent home or similar facility;
3. Smoking cessation drugs and/or aids;
4. Drugs for cosmetic use and dietary aids, including products used to retard or reverse the effect of aging
of the skin;
5. Drugs used to treat hair loss;
6. Appetite suppressants or any drug used for the purpose of weight loss;
7. Any drug labeled, "Caution: Limited by the Food and Drug Administration (F.D.A.) to Investigational Use"
or experimental drugs, even though a charge is made to the Insured Individual;
8. Immunization agents, biological sera, blood or blood plasma;
9. Medications which can be obtained without a prescription or have a non-prescription equivalent, except
insulin;
10. Therapeutic/diagnostic devices or appliances including non-insulin needles/syringes, support garments,
diabetic supplies, diabetic testing and other non-medical substances;
11. Charges for injection or administration of a drug;
12. Injectable drugs except Insulin, Glucagon, and bee sting kits;
13. Any prescription drug prescribed in connection with a non-covered service;
PCPX-TASC-01-CO
29
14. Refills for prescriptions due to loss or theft;
15. Athletic performance enhancing drugs;
16. Progesterone in any compounded dosage form.
Dispensing Limitation:
For Prescriptions Filled at Participating Provider Pharmacies: The amount normally prescribed by a
physician, but not to exceed a 34 day supply.
Using a Non-Participating Provider Pharmacy:
In the event an insured obtains drugs from a non-participating provider pharmacy, the submission of the
Prescription Drug Claim Form is required for reimbursement at the deductible and benefit percentage shown on
the Schedule of Benefits.
THE DEDUCTIBLE, COPAYMENT, AND THE BENEFIT PERCENTAGES ARE SHOWN ON THE SCHEDULE
OF BENEFITS.
PC PX-TASC-01-CO
30
SECTION 2- BENEFIT EXCLUSIONS AND LIMITATIONS
A. THE FOLLOWING EXCLUSIONS AND LIMITATIONS APPLY TO ALL BENEFITS:
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.
2. Any illness for which the individual is entitled to benefits under any worker's compensation or
occupational disease law, or receives any settlement from a worker's compensation carrier.
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.
5. Charges which are not medically necessary to the care or treatment of an illness or injury except as
described elsewhere in this Policy.
6. Charges incurred for the reversal of sterilization.
7. Charges which would not have been made if no insurance existed.
8. Charges which the Insured Individual is not legally obliged to pay.
9. Charges which are in excess of the reasonable and customary charges for services and materials.
10. Charges for treatment by a doctor which is not within the scope of his or her license.
11. Charges for which benefits are not provided in this Policy.
12. Charges for medical and related services including but not limited to drugs, biological products, devices
and medical, surgical and diagnostic services which are determined by Allianz Life to be experimental or
investigational. Drugs, biological products and devices are considered experimental or investigational if:
a. they have not received final approval from the appropriate government regulatory bodies,
including the FDA, and
b. their use for the particular illness or injury being treated is not accepted as the standard of
medical practice in the community, and
c. drugs and biological products, when prescribed for experimental or non-FDA approved
indications, unless listed as a specific indication in the Drug Information for the Health Care
Professional, published by the United States Pharmacopeial Convention or in the American
Hospital Formulary Services edition of Drug Information.
Allianz Life considers any health care service, including organ and tissue transplants,to be experimental
or investigational, unless all of the following criteria are met:
a. the health care services are accepted in the appropriate medical community in which the
treatment is rendered as standard, safe, effective, and non-experimental or non-investigational
for the illness or injury being treated;
b. the health care services are attainable outside of a research institution or research program for
the illness or injury being treated;
PCEXC-TASC-02-CO
•
31
c. based on credible and accepted medical evidence,the health care services clearly improve the
net health outcomes as evaluated against alternative non-experimental or non-investigational
health care services for the illness or injury being treated.
13. Charges for dental services or supplies for treatment of the teeth, gums or alveolar processes. Except
for hospital charges if the Insured Individual is a bed patient and the admission is necessary for a medical
reason as authorized and pre-certified and except for any dental charges covered under the Major
Medical.
14. Charges for the purchase or repair of hearing aids, if hearing aid benefits are not included in this policy.
15. Charges for the treatment of refractive errors, including but not limited to, eye exams, and radial
keratotomy procedures.
16. Charges for eye glasses or contact lenses or the fitting of them, if Vision Benefits are not included in this
Policy.
Except as specified under Major Medical Benefits for cataract surgery.
17. Charges for any treatment for cosmetic purposes or for cosmetic surgery, including aging of the skin, hair
loss, or excess hair. Except 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. for the reconstructive surgery and prosthetic devices following surgery for mastectomy;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.
18. 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.
19. Charges for services or supplies furnished by an agency of the United States Government or a foreign
government or agency, unless excluding them is prohibited by law.
20. Charges due to a pre-existing illness or condition, except as shown in the Schedule of Benefits.
21. Charges related to changing the sex of an individual.
22. Charges for cognitive therapy, by any name called.
23. Charges for vocational rehabilitation, by any name called.
24. 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.
Except that,this limitation does not apply if such services are rendered:
a. during general anesthesia;
PCEXC-TASC-02-CO
• 32
b. during a cutting operation;or
c. while the patient is confined in a hospital.
25. Charges for diagnosis or treatment of temporomandibular joint dysfunction, by any name called.
EXCEPT, this limitation does not apply to such charges which result in payments not exceeding a total of
$1,000.00 while insured, subject to the deductible and benefit percentage shown on the Schedule of
Benefits.
26. 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.
27. Smoking cessation programs for treatment of nicotine or tobacco use, including nicotine gum and
patches.
28. Educational services, nutritional counseling or food supplements.
29. Charges for private duty nursing.
30. Contraceptive devices and implants. This includes oral contraceptives unless listed as a Covered
Charge under the Prescription Drug Benefit.
31. Charges for custodial, domiciliary, convalescent, and/or intermediate care, including rest cures
(collectively "custodial care"), whether furnished in the home or in an institution, including a nursing home
or similar facility. See the definition of"custodial care" in the Definition Section, Section 7.
32. Surgery for morbid obesity, unless medically necessary and appropriate treatment measures have failed
for reasons other than compliance of the Insured.
33. Penile prostheses are not covered unless in treatment of a documented non-psychiatric organic
condition.
34. The rental or purchase of aids, including but not limited to, ramps, elevators, stair lifts, swimming pools,
air filtering systems, environmental control equipment, spas, hot tubs, or automobile hand controls, or any
modification made to dwellings, property or motor vehicles.
35. Support garments; disposable medical supplies used at home; devices used at home to perform tests on
body substances. Except that coverage is provided for test strips and glucometers used by diabetics and
subject to copayment, deductible and benefit percentage shown in the Schedule of Benefits.
36. All services for a surrogate mother who is not an Insured are not covered.
37. To the extent that a natural disaster, war, riot, civil insurrection, epidemic, labor dispute not involving the
Policy, or that other similar circumstances not within the control of the Policy results in the facilities,
personnel or financial resources of the Policy being unavailable to arrange for the provisions of benefits
under the Policy, the Policy's obligation to provide such services or benefits will be limited to the
requirement that Allianz Life make good faith effort to provide or arrange for the provision of such
services or benefits within the resulting limitations on the availability of its facilities, personnel or
resources, and the Policy will have no liability or obligation on account of any delay or failure to provide
services or benefits under the Policy.
38. Charges for medical supplies unless provided elsewhere in this Policy.
PCEXC-TASC-02-CO
33
39. Charges for vision therapy by any name called.
40. Charges for donor semen for artificial insemination, artificial insemination, in vitro fertilization, in vivo
fertilization, embryo transport procedures, surrogate parenting, injectable substances, medications used
to correct physiological abnormalities or to stimulate the individuals natural reproductive system, supplies,
procedures and all other associated expenses related to infertility.
B. CHARGE FOR SERVICE OR PURCHASE
The charge for service or purchase will be deemed to have been incurred on the date the service is performed or
the date the purchase occurs.
C. RETURN OF OVER PAYMENT
Payment made for charges must be returned to Allianz Life if it is found that such charges were paid in error.
PCEXC-TASC-02-CO
• 34
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
Section 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 Benefits.
B. COORDINATION OF BENEFITS
BENEFITS SUBJECT TO THIS PROVISION
All medical expense benefits provided under this Policy are subject to this provision.
EFFECT ON BENEFITS
Coordination of Benefits (COB) means that the benefits provided by this Policy will be coordinated with the
benefits 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
Determination 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.
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.
PCOC-TASC-03-CO
35
The difference between the cost of a private hospital room and the cost of a semi-private hospital room is nal
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
benefits 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 the 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.
If a "No Fault" policy provides coverage 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
PCOC-TASC-03-CO
36
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. 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, or as the dependent of a laid-off or retired employee/member. NOTE: If a Plan which
is being considered for COB does not have a provision regarding laid-of or retired employees/members,
then this rule will not apply.
3. 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
considered 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 to rule 3.
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 before the benefits of a
Plan which covers the child as a dependent of his or her stepparent; and the benefits of a Plan
which covers the child as a dependent of the parent without custody of the child will be
considered last.
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.
d. If there is a court decree which states that the parents shall share joint custody and the decree
does not stipulate which parent has financial responsibility, then the rules for dependent children
of parents not separated or divorced should be followed. The Policy and state requirements
should be reviewed to determine if the Birthday Rule or the Gender Rule applies.
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 continuous
period of time will be considered first.
PCOC-TASC-03-CO
37
OPERATION OF COB
In order to make this COB provision work properly:
1. Upon request, the Insured Individual is required to furnish complete information conceming all Plans
which cover the individual for whom claim is made.
2. As permitted by law, Allianz Life 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 Allianz Life have been made under any other Plans,Allianz
Life may reimburse such other Plans to the extent necessary to make this provision work. My such
payment will be a benefit paid under this Policy.
4. If Allianz Life has paid benefits which result in payment in excess of the amount necessary under this
Policy to make this provision work, Allianz Life 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.
THIRD PARTY REIMBURSEMENT AND SUBROGATION
This provision apples 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 are payable under this policy. If a third party or its insurer is liable
for past, present, or future medical charges,the following rules will apply:
1. If the third party makes payment before Allianz Life 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 Allianz Life pays:
a. Allianz Life will pay any benefits due under this policy.
b. When payment is later made by the third party, Allianz Life is entitled to be repaid first;the
Insured Individual or legal representative is obligated to return the payment to Allianz Life 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 Allianz Life will be binding upon the Insured Individual
or legal representative regardless of whether:
1) the payment received from the third party, or its insurer, is the result of a court judgment,
arbitration award, compromise settlement,or any other arrangement;or
2) the third party or its insurer admits liability; or
3) the medical expenses 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.
PCOC-TASC-03-CO 54
38
Subrogation
Before payment is made by the third party, Allianz Life has the right of subrogation to attempt to recover the
amount of Allianz Life's payment. This includes the right to file or intervene in a lawsuit. Allianz Life will give the
Insured Individual or representative prior written notice of Allianz Life's intent to file suit. The Insured Individual
must cooperate in full with Allianz Life's effort to seek recovery from the third party. The Insured Individual must
do nothing to hinder Allianz Life's attempt to recover from the third party or to resolve the claim with the third party
unless Allianz Life gives prior written consent. Allianz Life's recovery will be limited to the lesser of:
1. the amount Allianz Life paid in benefits under this policy as a result of the medical charges;or
2. the amount recovered from the third party.
Allianz Life's recovery will apply whether or not payment has been made by the third party for all of the Insured
Individual 's losses.
PCOC-TASC-03-CO 55
39
SECTION 4
EXTENSION OF CERTAIN BENEFITS UPON END OF
INSURANCE WHILE TOTALLY DISABLED
If the Policy between Allianz Life and the entire employer group should terminate, and an Insured Individual is
totally disabled (as defined in this Policy) at the time coverage would so terminate, the coverage period under this
Policy for treatment of the condition causing the total disability may, for such totally disabled individual, be
temporarily extended until one of the following dates, whichever comes first:
1. the end of that total disability;
2. 12 months from the date his or her insurance ends;
3. the date the individual becomes eligible for coverage for the disabling illness or condition under any other
group Policy or plan; or
4. the date the maximum benefit is reached.
PCEXT-TASC-04-CO
40
SECTION 5-CONVERSION& CONTINUATION
A. MEDICAL INSURANCE CONVERSION
1. An individual whose medical insurance ends for reasons other than failure to pay contributions agreed
upon may convert to conversion coverage then being issued by Celtic Life provided the individual:
a. has been continuously insured under this Policy for three months immediately prior to the end of
insurance;
b. is not eligible for benefits under any other group Policy;
c. is not eligible for Medicare.
An individual may not convert coverage if this Policy terminates and is replaced within 60 days of the date
of termination.
The provisions of the conversion coverage will not be the same as the provisions of this Policy. It will
usually not include all the benefits of this Policy, nor the same level of benefits as this Policy. Upon
request, Celtic Life will furnish complete details of the benefits available.
2. The conversion coverage 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 conversion coverage to Celtic Life within 31
days from the time his or her insurance ends under this Policy.
4. The conversion coverage will.take effect on the day after the individual's group insurance ends.
5. The premium for the conversion coverage will be Celtic Life's scheduled premium based on the age and
sex of the applicant.
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 a
conversion Policy.
PCCC-TASC-05-CO
41
TAKEOVER PROVISIONS
When this Policy replaces another Policy,the following provisions apply:
The following provisions apply only to a Insured Individual who,on the day before this Policy's effective date, was
covered under the Prior Coverage. Prior Coverage means the Policyholders group medical plan that this Plan
replaced.
The Company will automatically insure any such person under this Policy on its effective date, subject to the
following provisions.
A. Those persons eligible according to the terms of this Policy will be insured at the level of benefits of this
Policy. This includes persons who were covered under a continuation provision of the Prior Coverage to
the extent it was required by state or federal law. This continued coverage under this Policy will
terminate on the date that coverage would have terminated according to the law under the Prior
Coverage had the Prior Coverage remained in force.
The Limitation for Pre-existing Conditions will be waived to the extent the Pre-existing Condition
requirements as defined in the Eligibility Requirements of this Group Policy have been satisfied under the
Prior Coverage. For a Pre-existing Condition that is not waived, benefits under this Policy with respect to
that Condition will be at the lesser of:
1) at the benefits of the Prior Coverage; or
2) the benefits of this Policy without application of its Pre-existing Conditions limitation.
B. Those employees not in Active Work as defined in this Policy (or those dependents confined in an
Institution) who are covered under an extension of benefits under the Prior Coverage will be insured
under this Policy
1) at the Prior Coverage level of benefits; reduced by
2) any benefits payable under the Prior Coverage
This insurance under this Policy will terminate on the date that extension would have terminated under
the Prior Coverage had the Prior Coverage remained in force.
C. Those employees not in Active Work as defined in this Policy (or those dependents confined in an
Institution) who are not covered under an extension of benefits under the Prior Coverage but would have
been had the Prior Coverage provided an extension like that provided in this Policy will be insured under
this Policy at the Prior Coverage level of benefits. This insurance under this Policy will terminate on the
date that extension like that provided in this Policy would have terminated if it had been provided under
the Prior Coverage and the Prior Coverage had remained in force.
Those employees not in Active Work as defined in this Policy (or those dependents confined in an
Institution) who are not covered under an extension of benefits under the Prior Coverage and would not
have been had the Prior Coverage provided an extension like that provided in this Policy will be insured
under this Policy at the Prior Coverage level of benefits until:
1) they become eligible under this Policy;or
2) their insurance terminates according to the termination provisions of this Policy.
PCDR-TASC-05-CO
42
D. Deductible Carryover: Any expenses incurred by the Insured Individual while covered under the Prior
Coverage will be credited toward satisfaction of the Deductible of this Policy if:
1) the expenses were incurred during the current calendar year or the 90 days preceding
the effective date of this Policy whichever period of time is greater; and
2) the expenses were applied toward satisfaction of the deductible under the Prior
Coverage;and
3) the expenses would be considered Covered Charges under this Policy.
E. Waiting Period Carryover: Any number of days credited toward satisfaction of the waiting period under
the Prior Coverage will be credited toward satisfaction of the waiting period under this Policy.
PCDR-TASC-05-CO
43
CONTINUATION OF BENEFITS REQUIRED
UNDER FEDERAL LAW
NOTE: This Policy includes Medical Continuation Provisions required under Federal Law. Once an Insured
Individual obtains continuation of insurance under the following provision, no further right of continuation under
any State Law continuation provision is available.
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 is determined the Insured Individual was totally disabled for Social Security purposes at the
time of the qualifying event; and
b. the Insured 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 Insured 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 Insured Individual with a pre-existing condition which is limited to 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.
PCCOBRA-TASC-05-CO
44
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
employee 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
continuation.
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 employee's reduction in hours or end of employment;
b. 29 months from the date continuation began for individuals whose coverage was extended due to
a qualifying event and the Insured Individual was totally disabled for Social Security purposes at
the time of the qualifying event;
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
unless that plan includes a pre-existing condition exclusion which excludes the individual until
such exclusion is no longer in effect;
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
administrator will notify the individual of any right to conversion coverage within 180 days prior to the end
of continuation.
PCCOBRA-TASC-05-CO
45
CONTINUATION OF BENEFITS
REQUIRED UNDER STATE LAW
Continuation of benefits may be available to an Insured Individual as follows provided they are not eligible for
continuation under the Federal law continuation provisions under the Policy:
Insured Individuals whose insurance under the Policy would otherwise cease will have the option to continue
insurance for up to 180 days provided the Insured Individual has been covered under.the Policy, or any policy
which the Policy replaces, for at least 6 months immediately prior to termination.
TERMINATION: An Insured Individual's continued insurance under the Policy will terminate on the earliest of the
following dates:
1. the date the Policy terminates.
2. the date ending the period for which premium is paid, if a required premium is not paid when due.
3. the date the Insured Individual becomes entitled to either or both Parts of Medicare, whether or
not enrolled.
4. the date the Insured Individual becomes re-employed.
5. the end of the 180 day period.
PCCOBRASTATE-TASC-05-CO RASTATE-TAS C-05-CO
46
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 Allianz Life.
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. EXCEPT THAT:
1. If the insured employee is not actively at work on the date of 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 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.
A Classification Change Date: a change in an employee's benefits caused by a change in his or her classification
will be effective immediately on the date such change in classification becomes effective.
C. NOTICE AND PROOF OF CLAIM
1. NOTICE OF CLAIM - 20 DAYS
a. Written notice of claim must be given to Allianz Life within 20 days of the date of any 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.
2. CLAIM FORMS
a. When Allianz Life receives notice of claim, forms for filing proof of claim will be furnished to the
Insured Individual.
b. If these forms are not furnished to the Insured Individual within 15 days from the time notice is
received by Allianz Life,the Insured Individual will have met the proof of loss requirements if
written proof of loss is submitted within the time required.
3. PROOF OF LOSS -90 DAYS
a. Proof of claim for hospital confinement must be given to Allianz Life within 90 days after release
from hospital.
b. Proof of any other loss must be given to Allianz Life 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, and in no event, except in the absence of
legal capacity, later than one year from the time proof is otherwise required.
d. "Proof" as required in this subsection means proof satisfactory to Allianz Life.
PCGI-TASC-06-CO •
47
4. PHYSICAL EXAMINATION AND AUTOPSY
a. Allianz Life, at its own expense,will have the right to have an Insured Individual examined, as
often as ft may require,whenever his or her illness is the basis of a claim.
b. Allianz Life will have the right to require an autopsy, if not prohibited by law.
D. PAYMENT OF CLAIM
All of these benefits will be paid to the employee, unless Allianz Life 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 Allianz Life determines that the employee is not legally able to receive such payment, Allianz Life 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. parents;
d. brother(s);or
e. sister(s).
Any payment made under this option will completely discharge Allianz Life from further obligation for such
payment.
Allianz Life reserves the right to allocate the deductible amount to any eligible charges and to apportion 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.
E. TIME OF PAYMENT OF CLAIMS
All benefits payable will be paid to the employee or assignee immediately upon receipt of due written proof of
loss.
F. LEGAL ACTIONS
No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after
written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall
be brought atter the expiration of three years atter the time written proof of loss is required to be furnished.
G. CHOICE OF HOSPITAL OR DOCTOR
This Policy in no way interferes with the right of any insured entitled to hospital benefits to select a hospital.
Except for required second opinions through Utilization Review, the Insured may choose any doctor who holds a
valid physician and surgeon's certificate and who is a member of, or acceptable to, the attending staff and board
of directors of the hospital where services are received. However, the Insured's choice may affect the benefits
payable according to the terms of the Policy and as noted under the Utilization Review portion of this Policy.
H. INDEPENDENT HEALTH CARE PROVIDERS
Health care providers selected by the Insured (see Section 6 (G) above) are neither employees nor agents of
Allianz Life or TASC. Participating Providers are independent contractors. Allianz Life and/or TASC are not liable
for any claim or demand for damages connected with or arising out of any injury resulting from the actions or
failure to act of any health care provider.
PCGI-TASC-06-CO
48
WORKER'S COMPENSATION
This Policy is not a worker's compensation Policy and does not cover work related expenses. This Policy does
not satisfy any requirements for coverage by worker's compensation insurance.
J. STATEMENTS
In the absence of fraud, all statements made by the Insured Individual 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.
K. 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 contributions 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
employee's employment will end on the last day of the month in which employment ends. EXCEPT
THAT: The Policyholder may, at its option, continue insurance as shown below for individuals whose
employment has ended, if it does so without individual selection between employees and if it continues
making premium payments for those individuals.
Insurance may be continued for all benefits for:
a. up to two months if such employee is employed on a part-time basis; or
b. for an employee on an approved leave of absence under the Family and Medical Leave Act or
c. up to two months if such employee is temporarily laid off;or
d. longer than shown above if such employee is unable to work because of disability up to a
maximum of twelve (12) months.
No benefits are covered for charges incurred after an individual's insurance ends, except as provided in
Section 4 of this Policy.
NOTE: See Section 5- Conversions.
PCGI-TASC-06-CO
49
SECTION 7 -DEFINITIONS
"Actively at work," "active work"and "actively working" mean the active and compensated expenditure of at
least 20 hours per week 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.
Allianz Life -Allianz Life Insurance Company of North America.
Benefit Period - the period of time (shown on the Schedule of Benefits) during which covered charges are
incurred and for which benefits may be paid.
Biofeedback Therapy - A treatment program designed to develop techniques by which an Insured Individual
can control unconscious or involuntary bodily processes by conscious mental control.
Calendar Month -any one of the twelve months of the calendar.
Calendar Year- January 1 through December 31 of any given year.
Cognitive Therapy - treatment given to improve an Insured Individual's thinking processes and intellectual
capabilities.
Contributory-the employee pays a part of the cost of the insurance.
Cosmetic - cosmetic products, health or beauty aids, cosmetic appearance and which are not primarily for the
purpose of improving bodily function essential for necessary life activities.
Covered Charges -eligible charges under this Policy.
Custodial Care - means any skilled or non-skilled 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 - means:
1. An employee's spouse (if not legally separated from the Employee)
2. An employee's unmarried child from live birth, your unmarried stepchild or legally adopted child from
moment of placement in the home until the end of the 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 retarded or physically disabled and unable to earn his or her own living and
proof of incapacity is furnished to Allianz Life 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 on the date just prior to the day his or her insurance would have ended due to
age.
PCDEF-TASC-07-CO
50 •
b. the child:
1) is enrolled in an accredited school as a full-time student as defined in the rules of such
school; and
2) has not attained age 23.
To remain insured under 2. above, due proof that the employee's child continues to qualify as a
dependent must be furnished to Allianz Life as it reasonably asks. Except that, Allianz Life 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 for 2a. above.
3. A 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.
Designated Transplant Facility-A hospital named as such by TakeCare Administrative Services Corp.
Doctor - a doctor of medicine, doctor of podiatry, or a doctor of osteopathy licensed by the state where he/she
practices medicine, podiatry, or osteopathy.
Durable Medical Equipment (DME) - medically necessary physical medical equipment which:
1. can withstand repeated medical use by multiple individuals;
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.
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 20 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 Allianz Life, 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 illness' on an inpatient basis; and
PCDEF-TASC-07-CO
51
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.
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 of rehabilitation services for mental illness, substance abuse or alcoholism.
Except that, the term hospital also means
1. With respect to the care of mental illness, a general acute care hospital, an acute psychiatric hospital and
a licensed psychiatric health facility, or such a facility that is operating under a waiver of licensor by the
State.
2. With respect to the care of alcoholism and substance abuse, hospital also includes a facility licensed to
provide alcoholism and substance abuse services.
Illness or Condition - means:
1. a disorder or disease of the body or mind;or
2. an accidental bodily injury;
3. pregnancy.
An illness due to the same cause or to a related cause will be deemed to be one illness.
Insured or Insured Individual - an employee or one of his or her dependents who is enrolled as an insured
under this Policy.
Maximum While Insured - the maximum amount of benefits which may be payable while insured under this
Policy with or without a break in coverage.
Medicare- medical benefits provided by Title XVIII of the Federal Social Security Act.
Medical Necessity - The benefits of the Policy are provided only for the services and supplies that are Medically
Necessary as determined by Allianz Life and/or pursuant to the Utilization Review provisions of this Policy. The
service and/or supplies provided by a hospital, physician, surgeon or other provider which are: appropriate for the
diagnosis, or the direct care and treatment of a condition, illness or injury; and provided for the diagnosis, or the
direct care and treatment of the condition, illness or injury; and in accordance with the standards of good medical
practice in this community; and not primarily for the convenience of the Insured or personal preference as the
Insured or the convenience of the Insured's physician and surgeon or other provider or caretaker; and the most
appropriate supply or level of service which can safely be provided.
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 a.m. of June 30.)
Noncontributory - 1) (for employees) insurance for employees will be considered contributory unless all
employees are covered under a Policyholder sponsored health plan and no employee is allowed to decline
coverage for any reason.
2) (for dependents) insurance for dependents will be considered contributory unless all dependents are covered
under a Policyholder sponsored health plan and no dependent is allowed to decline coverage for any reason.
PCDEF-TASC-07-CO
52
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 Allianz Life.
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. Such treatment program:
1. uses procedures which are not experimental or investigational and are generally accepted by the
physician therapy profession to assist in diagnosis, prognosis and treatment of acute or prolonged
movement dysfunction of anatomic or physiologic origin; and
2. is performed by a qualified licensed provider,typically a physical therapist.
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.
PPO Network/ParticipatingProvider Service Area means the geographic areas in which Participating
Providers have agreed to provide services to Insured Individuals under this Policy. These geographic areas may
be changed during the term of the Policy. Allianz Life may, from time to time, modify the PPO Network Service
Area by written notice to the Insured and/or Employer.
Premium -money paid to Allianz Life by the Policyholder to pay for this insurance.
Provider- a doctor, hospital or other licensed health care entity.
Pre-existing Illness or Condition - an illness or condition for which medical advice or treatment was received
prior to the individual's effective date of insurance.
Participating Provider-a hospital, doctor or other health care provider as to whom there is in effect, at the time
the services are rendered, an agreement with TakeCare (the Participation Agreement") pursuant to which the
health care provider agrees to be part of the Participating Provider Network and to accept a specified rate as
payment in full for covered charges provided to an Insured. A Non-Participating Physician or other
non-participating provider is a physician or other health care provider who/which is not a Participating Provider.
Reasonable and Customary Charges - charges which Allianz Life 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 or condition 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 Medical Services - medical care and services which are medically necessary and which may legally be
provided to the Insured Individual only by a licensed medical professional. In no event does skilled medical
services include assistance to an Insured Individual in meeting the activities of daily living such as help in walking,
getting in and out of bed, bathing, dressing, feeding, preparation of special diets, and supervision of medications
which are ordinarily self-administered;these are considered custodial services.
PCDEF-TASC-07-CO
53
Skilled Nursing Facility - a facility which provides continuous skilled nursing services and is licensed in
accordance with state and local laws pertaining to such institutions and which is recognized as a skilled nursing
facility by the Secretary of Health and Human Services of the United States for participation under the Medicare
Act.
Speech Therapy-treatment administered to improve an Insured Individual's speech capabilities after a decrease
in those capabilities following an illness or injury.
Such treatment program:
1. uses procedures which are not experimental or investigational and are generally accepted by the speech
therapy professional to assist in diagnosis, prognosis and treatment of acute or prolonged speech
dysfunction of anatomic or physiologic origin; and
2. is performed by a qualified licensed provider, typically a speech therapist.
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 benefits under extension of benefit, then total disability when the Employee,
as a result of illness or injury, is either confined in a hospital as determined medically necessary or is
unable to engage in any employment or occupation for which the Employee is (or becomes) qualified by
reason of education, training or experience and is not, in fact, engaged in any employment or occupation
or wage or profit;
2. If a DEPENDENT is claiming benefits under any coverage provided in this Policy, then total disability is
when the Dependent, as a result of illness or injury, is either confined in a hospital as determined
medically necessary and/or is prevented from performing substantially all regular and customary activities
usual for a person of that age and family status.
"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;
or
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
eligible for insurance.
PCDEF-TASC-07-CO
COLORADO OPTIONAL BENEFIT RIDER FOR
PROSTATE CANCER SCREENING
Prostate Cancer screening benefits for an Insured Person or Insured Dependent will be payable subject
to the applicable Percentage Payable shown in the Schedule of Insurance and limited as follows:
Prostate cancer screening lesser of:
1. $65.00 per prostate
cancer screening;or
2. the actual charge for
such screening
The Deductible as shown in the Schedule of Insurance will be waived.
The screening shall be performed by a qualified medical professional,including but not limited to.
a urologist, internist, general practitioner, doctor of osteopathy. nurse practitioner.or Physician assistant.
The screening shall consist, at a minimum, of the following tests:
1. prostate-specific antigen (PSA) blood test;
2. digital rectal examination
Coverage shall consist of the following:
1. one screening every year for males age 50 and over;
2. one screening every year for males age 40 to 49 inclusive who are at increased risk of developing
prostate cancer as determined by the male's Physician.
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