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Home My WebLink About780846.tiff RESOLUTION RE: APPROVAL OF AMENDMENT NO. 9 TO THE PACIFIC MUTUAL GROUP INSURANCE POLICY. WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, after being briefed on the amendments to the Pacific Mutual Group Insurance Policy, the Board of County Commissioners deems it advisable and in the best interest of all Weld County employees to approve Amendment No. 9, a copy of which is attached hereto and incorporated herein by this reference. NOW, THEREFORE , BE IT RESOLVED by the Board of County Com- missioners of Weld County, Colorado that the aforementioned Amendment No. 9 be, and hereby is , approved. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 20th day of March, A.D. , 1978. BOARD OF COUNTY COMMISSIONERS WELD CO TY, COLORADO ,.-c-G a4_. in eco-sa�t •C fee ATTEST: ifl�j Ili/ Wel4 Coty Clerk and Recorder and Clerk• to the Bo - Deputy County rk al APPPR AS TO FORM: County Attorney Date Presented: March 29, 1978 i A\ - 780846 i—. AMENDMENT NO, 9 Attached to and part c' Group Policy No. GM-8864 by and between Pacific Mutual Life Insurance Company, and the Policyholder, WELD COUNTY, COLORADO. The Policyholder and Pacific Mutual hereby agree that the policy is amended, as of the effective date stated on each amended page by deleting from the policy the page or pages thereof listed under Column I and inserting into the policy the attached page or pages listed under Column II, each marked by "Amendment No. 9 effective January 1, 1978". COLUMN I- PAGES DELETED COLUMN II- PAGES INSERTED 9A-1-f 9A-1-f 11B-3- .c(2) 11B-3-c(2) 11C-1-c 11C-1-c 11D 11D 11E-1-c 11E-1-c NOTWITHSTANDING ANY CONTRARY PROVISION OF THE POLICY, THE INCREASE IN BENEFITS EFFECTED BY THIS AMENDMENT SHALL NOT APPLY TO ANY INSURED PERSON (EXCEPT A PERSON COVERED AS A DEPENDENT)IF HE IS ON LEAVE OF ABSENCE FOR ANY REASON OTHER THAN VACATION AND UNLESS HE ACTUALLY IS PERFORMING THE USUAL AND CUSTOMARY DUTIES OF HIS JOB ON A FULL TIME BASIS ON THE DATE THE INCREASE IN BENEFITS WOULD OTHERWISE TAKE EFFECT AS TO HIM. IF AN INSURED PERSON IS NOT ACTIVELY SO EMPLOYED ON A FULL TIME BASIS ON THE EFFECTIVE DATE OF THE BENEFIT INCREASE, SUCH INCREASE SHALL BE DEFERRED AS TO HIM UNTIL HE HAS SUBSEQUENTLY COMPLETED TWO CONSECUTIVE, CONTINUOUS WEEKS OF FULL TIME EMPLOYMENT IN AN ELIGIBLE CLASS. IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date set forth beneath their respective signatures. POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY beD4d-in ILO- 12. 414 s ature of Officer •y ~��rgn Wein � • TITLE/ �i man, Board of Commissioners /• Secretary DATE X March 20, 1978 ATTEST fiYM' ‘ -"- "_'r'"\ Registrar DATE /5-4 - f 1 / 72 c- GR-4829 COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS CASH DEDUCTIBLE, The cash deductible applicable to a covered person for each calendar year shall consist of eligible charges incurred in connection with an illness, in an amount determined as hereinafter provided, incurred during a period of twelve consecutive months, a less, in such calendar year in connection with the illnesses of such person; provided, however, that(1) the cash deductible shall apply only with respect to hospital charges incurred on an in-patient basis, and to charges for nursing, physiotherapy and appliances, and(2) no cash deductible shall apply with respect to any eligible charges incurred for treatment of bodily injuries sustained in an accident. Only eligible charges which are subject to the cash deductible may be applied toward satisfaction of the cash deductible. The cash deductible applicable to a covered person for a calendar year shall be $100. The cash deductible applicable to a covered person for a calendar year shall, subject to the provisions of the second paragraph of this section,be satisfied at the time as of which eligible charges, in an amount at least equal to the cash deductible applica- ble to such person for the calendar year, have been incurred during a period of twelve consecutive months, or less, in such cal- endar year in connection with the illnesses of such person. The cash deductible applies separately to the amount of eligible charges incurred during each calendar year by each covered person; provided, however, that if three "covered family members" incur eligible charges in excess of their cash deductible during a calendar year, then, during such calendar year, on or after the date the third covered family member" incurs eligible charges in excess of the applicable cash deductible, no additional cash deductible will be applied to eligible charges in- curred by any "covered family member". The term "covered family member" means an Individual and each of his qualified dependents insured under the policy. CARRY-OVER OF DEDUCTIBLE. If the cash deductible applicable to a covered person is satisfied by the application of eligible charges wholly incurred during the last three months of a calendar year, then(a) the cash deductible applicable to such person for the next ensuing calendar year shall also be considered as having been satisfied as of January 1 of such ensuing calendar year, provided that the eligible charges so applied in the previous calendar year are equal to the cash deductible applicable to such person for such ensuing calendar year, otherwise(b) the cash deductible applicable to such person for such ensuing calendar year shall be reduced as of January 1 of such year by the amount of eligible charges so applied in the previous calendar year. Further- more, if the cash deductible is not satisfied for a calendar year but eligible charges are incurred during the last three months of such calendar year, or if the cash deductible is satisfied for a calendar year partially by the application of eligible charges incur- red during the last three months of such calendar year, then the cash deductible for the next ensuing calendar year may be satis- fied in part by eligible charges incurred during the last three months of the prior calendar year with respect to which no benefits were payable during such year. MAXIMUM AMOUNT. Not more than $1,000,000 of benefits in the aggregate(herein called the Maximum Amount) shall be payable by the Insurance Company under the provisions of this policy with respect to the entire duration of coverage of any one person, whether or not such coverage was interrupted by a previous termination of the person's insurance hereunder for any reason. In the event that benefits to the extent of the Maximum Amount become payable, the insurance under this policy as to the Individual or qualified dependent with respect to whom the maximum becomes operative shall automatically terminate as provided by the section entitled "Termination of Insurance". WHEN CHARGES DEEMED INCURRED. For the purposes of this policy, a charge shall be deemed to be incurred as of the date of the service, treatment or purchase of the supply giving rise to the charge. GR-231 (8864) PAGE 9A-1-f (CARRY-OVER DED.) AMBNDIkfNT NO. 9 EFFMTIVE JANUARY 1, 1978 • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued) SCHEDULE OF BENEFITS Classifications of Individuals One class applicable to all Hospital Expense Benefits Daily Service Charges -maximum eligible charges for each day in which the covered person occupies: (a) hospital accommodations other than an intensive care unit the hospital's charge for semi- private accommodation not to exceed$85 (b) an(i(including ncludiie co coron care ary, special, and respiratory care) 250%of charges specified in(a) above for the first ten days in such unit and 100%thereafter • (e) accommodations in a convalescent hospital 50% of charges specified in(a) above All Hospital Charges(including daily service charges) -maximum eligible charges during any period of confinement 100% of the first $5,000 of eligible charges incurred during a calendar year, 80% of the next $5,000 of eligible charges incurred during that year, and 100% of the balance of eligible charges incurred during the same calendar year. The eligible charges used in determining benefits under this section are subject to the cash deductible described in the section entitled "Cash Deductible", except eligible charges incurred for treatment of an illness on an out-patient basis or for treatment of bodily injuries sustained in an accident. GR-231(8864) AMENDMENT NO. 9 EFFECTIVE JANUARY 1, 1978 Page 11B-3-c(2) COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) SURGICAL EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". If an Individual or a qualified dependent, while a covered person, undergoes a surgical or radiotherapy procedure enumerated in the Relative Value Schedule of Surgical and Radiotherapy Procedures for the treatment of an illness, the insurance Company shall, . subject to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the eligible charges actually made to the Individual or qualified dependent for; (a) the surgical procedure, if such procedure is performed by a physician; and (b) services rendered by a physician assisting with such surgical procedure; and (c) anesthesia services rendered by a physician or professional anesthetist for the administration of an anesthetic in connection with such surgical procedure; and (d) the radiotherapy procedure, if such procedure is performed by a physician or professional radio-therapist; but not exceeding an amount equal to one hundred percent of the applicable Dollar Unit Value for Surgical Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure or services in the Relative Value Schedule of Surgical and Radiotherapy Procedures. - If two or more surgical or radiotherapy procedures are performed, payment shall be made for each procedure in accordance with the terms of the foregoing paragraph, provided that; (1) if multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total Relative Value for such procedures shall not; unless otherwise specified in the Relative Value Schedule of Surgical and Radiotherapy Procedures, exceed the Relative Value of the major procedure plus 500/0 of the Relative Value of each of the lesser procedures as specified in said Relative Value Schedule; and (2) if an incidental surgical procedure(such as incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst, etc.) is performed through the same incision, payment shall be made only for that one pro- cedure for which the largest Relative Value is specified in said Relative Value Schedule. SCHEDULE OF BENEFITS Classifications of Individuals One class applicable to all Surgical Expense Benefits Dollar Unit Value for Surgical Expense Benefits; Surgery $34.60 Anesthesia $10.40 . Radiotherapy $ 8.10 The eligible charges used in determining benefits under this section are rot subject to the cash deductible described in the section entitled "Cash Deductible". • GR-231 (8864) Page 11C-1-c AMENDMENT NO. 9 EFFECTIVE JANUARY 1, 1978 • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) MEDICAL CARE EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". If an Individual or qualified dependent, while a covered person, receives any necessary medical service enumerated in the Schedule of Medical Services in connection with the therapeutic treatment of an illness, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the eligible charges actually made to the Individual or qualified dependent for such service, but not exceeding an amount equal to one hundred percent of the applicable Dollar Unit Value for Medical Care Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified in the Schedule of Medical Services for such service; provided, however, that (1) no benefits shall be payable with respect to charges which are related to the performance of any surgical operation or to any post-operative care, except charges incurred after the applicable number of days of follow-up care indicated in the Schedule of Surgical and Radiotherapy Procedures for services which are reasonably necessary for the therapeutic treatment of an illness; and (2) no benefits shall be payable with respect to any charges for x-ray examinations, drugs, medicines or supplies, except as may be provided under other sections of this policy; and (3) the requirement that medical services must be received in connection with the therapeutic treatment of an illness in order for the charges for those services to qualify as eligible charges shall not apply to the charges of a physician for care of a dependent child during the first two years of the child's life, except that unless the charges are for routine immunizations or for therapeutic treatment of an illness, the amount of those charges that qualify as eligible charges shall not exceed $90 per year; and (4) benefits for treatment of mental infirmity rendered outside of a hospital shall not be payable for more than 26 treatments during a calendar year and shall not exceed (a) 80%of the Daily Psychiatric Maximum shown in the Schedule of Benefits for all treatment rendered during each of the first 10 days of treatment during a calendar year, or(b) 50%of the Daily Psychiatric Maximum for all treatment rendered during each of the next 16 days of treatment during that year. Medical Care Expense Benefits Dollar Unit Value for Medical Care Expense Benefits: $4.00 Daily Psychiatric Maximum The Relative Value specified in the Schedule of Medical Services for the treatment rendered multiplied by the Dollar Unit Value shown above The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section entitled "Cash Deductible", GR-231(8864) PAGE 11D AMENDMENT NO, 9 EFFECTIVE JANUARY 1, 1978 • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) DIAGNOSTIC LABORATORY AND X-RAY EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". If an Individual or qualified dependent, while a covered person, incurs eligible charges for a nerneary laboratory or x-ray procedure enumerated in the Schedule of Diagnostic Laboratory and X-Ray Procedures for diagnostic purposes in connection with the therapeutic treatment of an illness, and if such person is not entitled to other benefits of any kind under this policy by reason of such procedure, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the eligible charges actually made to the Individual or qualified dependent for such procedure consistent with the usual charges made for such procedure, but not exceeding an amount equal to one hundred percent of the Dollar Unit Value for Diagnostic Laboratory and X-Ray Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure in the Schedule of Diagnostic Laboratory and X-Ray Procedures. SCHEDULE OF BENEFITS Classifications of Individuals One class applicable to all Diagnostic Laboratory and X-Ray Expense Benefits Dollar Unit Value for Diagnostic Laboratory and X-Ray Expense Benefits: X-ray Procedures $8.10 Laboratory Procedures $7.50 The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section entitled "Cash Deductible". GR-231(8864) PAGE 11E-1-c AMENDMENT NO.9 EFFECTIVE JANUARY 1, 1978 Hello