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Home My WebLink About750704 RESOLUTION RE: AMENDMENT TO AGREEMENT BETWEEN WELD COUNTY AND PACIFIC MUTUAL LIFE INSURANCE COMPANY. WHEREAS, heretofore Weld County by Resolution did enter into a contract with Pacific Mutual Life Insurance Company for group insur- ance covering Weld County employees under various group insurance policies, including group policy No. GM-8864, and amendments thereto, and WHEREAS, now Pacific Mutual Life Insurance Company has sub- mitted an additional amendment to the aforementioned group policy No. GM-8864, and WHEREAS, the Board of County Commissioners, Weld County, Colorado, believes it to be in the best interest of the County to accept the aforementioned amendment No. 3 to group policy No. GM-8864 as proposed, covering its County employees, and to enter into such agreement to amend said group policy No. GM-8864 on the basis recited therein. NOW, THEREFORE, BE IT RESOLVED, by the Board of County Commissioners, Weld County, Colorado, that amendment No. 3 submitted by Pacific Mutual Life Insurance Company amending the aforementioned group policy No. GM-8864, copy of which is attached hereto and made a part hereof by reference, be, and it hereby is approved. BE IT FURTHER RESOLVED, that the Board be, and it hereby is authorized to execute amendment No. 3 to the aforementioned group policy No. GM-8864 as submitted and to make the same effective forthwith. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 11th day of February, 750704 A.D. , 1975. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO tt ATTEST: Weld County Clerk and Recorder and Clerk to the Board- � t , % cI B� ��Deputy,County lerk h APPROV D AS TO(FORM: �1) 1 � - C+ l , ' County Attorney -2- • POLICYHOLDER'S COPY AMENDMENT Attached to and part of Group Policy No. GM-8864 by and between Pacific Mutual Life Insurance Company and the Policyholder, WELD COUNTY, COLORADO. The Policyholder and Pacific Mutual Life hereby agree that, any provision of the policy to the contrary notwithstanding: The term "plan" as used in the "COORDINATION OF BENEFITS" or "ANTI-DUPLICATION" provisions of this policy shall include, in addition to the benefits already included thereunder, any medical benefits required by statute under automobile insurance policies. The term "plan" shall not otherwise include any plan of individual insurance. This amendment is attached to and made part of the policy effective the first day of January 19 75. GR-4877 POLICYHOLDER'S COPY AMENDMENT NO. 3 Attached to and part of 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. 3 effective January 1, 1975 . COLUMN I - PAGES DELETED COLUMN II- PAGES INSERI'FD 10A 10A 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 Signature of Officer ,��/ Prresiid�ennt TITLE '•�F! /• Secretary DATE ATTEST ' V"`,C t-f"-u.v•... Registrar DATE �..w�u / -7 Y f �/f GR-4829 _ p • • EXCEPTIONS. For the purposes of this policy, anything herein to the contrary notwithstanding, eligible charges shall in no event include: (i) charges incurred in connection with a bodily injury arising out of, or in the course of, any employment for wage or profit or disease covered by a workmen's compensation act or similar legislation or the maritime doctrine of main- tenance, wages and cure; (ii) charges for or in connection with any eye examinations, glasses, hearing aids, or the fitting of any thereof; (iii) charges incurred for cosmetic surgery unless necessary for repair or alleviation of damage resulting from an accident occurring while a covered person; (iv) charges incurred for any dental services and supplies for treatment of(a) teeth, (b) the gums other than for tumors, and(c) other associated structures primarily in connection with the treatment or replacement of teeth, unless the charges are necessary for repair or alleviation of damage to sound natural teeth resulting from an accident occurring while a covered person: (v) charges incurred for callus or corn paring, toenail trimming, or foot massage; (vi) charges for or in connection with travel or transportation, whether by ambulance or otherwise, except that charges for professional ambulance service used to transport the covered person directly to and from a hospital where treat- ment is given for an illness will not be excluded by this exception; (vii) charges with respect to confinement in an hospital owned or operated by the United States Government, or with respect to any surgical, medical, or other treatment received in such a hospital, or with respect to a hospital confinement or any surgical, or other treatment for which no charge is made that the Individual or qualified dependent is required to pay: (viii) charges incurred during confinement in a hospital owned or operated by a State, Province or political subdivision unless there is an unconditional requirement to pay such charges without regard to any rights against others, con- tractual or otherwise; (ix) charges for medical examinations of any covered person for "check-up" purposes when not incident and necessary to the treatment of an illness, except that this item(ix) shall not apply with respect to(a) the first $90 of such charges incurred, other than for routine immunizations, during each calendar year on behalf of a qualified dependent who is less than two years of age, and(b) an additional amount consisting of the first $45 of such charges incurred for routine immunizations of a qualified dependent who is less than two years of age; (x) charges for or in connection with any illness caused by any act of war, whether declared or undeclared, or by any atomic explosion or other release of nuclear energy(except only when being used soley for medical treatment of an illness of a covered person): (xi) charges incurred for treatment of mental infirmity(a) while confined to an institution which is primarily for treat- ment of the mentally ill, or(b) all other such charges incurred while not confined to a hospital, which(1) exceed 80% of the amount determined by multiplying the applicable number of Relative Value Units specified in the "Psychiatric Services" section of the Relative Value Schedule of Medical Services by the Dollar Unit Value specified in the Schedule of Benefits on page 11D for all treatment of mental infirmity during each of the first 10 calendar days of such treatment in a calendar year, or(2) exceed 50% of such amount for all such treatments during each of the next 16 calendar days of such treatment in such calendar year, or(3) are incurred during the portion of a calendar year which follows the 26th(reduced in the first year a person is insured hereunder by multiplying 26 by the ratio of 12 to the number of months between the date he became insured hereunder and the end of such calendar year) calendar day in which such charges are incurred during such calendar year; (xii) charges incurred for or in connection with the treatment of alcoholism or narcotism; (xiii) charges for any services or supplies other than those which are certified by a physician who is attending the Individual or qualified dependent as being required for the treatment of the illness, except that this item(xiii) shall not apply with respect to charges for circumcision or dilation and curettage, or any of the charges specified in parts(a) and(b) of item(ix) above; (xiv) charges incurred for any services rendered for pregnancy or for resulting childbirth or for prenatal or postnatal care, except that in the case of Caesarean section, abortion, miscarriage, dilation and curettage, or medical or surgical complications of a pregnancy, no charges shall be excluded if they otherwise qualify as eligible charges; GR-231 (8864) AMENDMENT NO. 3 EFFECTIVE JANUARY 1, 1975 Page 10A COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued) SCHEDULE OF BENEFITS Classification of Individuab One class applicable to all Hospital Expense Benefits Daily Service Charges -maximum eligible charges for each day in which the covered pawn occupies: (a) hospital accommodation other than an Intensive care unit the hospital's charge for semi- private accommodation not to exceed$59 (b) an intenive care unit (including coronary, special, and respiratory care) 250%of charges specified in(a) above for the first ten days in such unit and 100%thereafter • (e) accommodatiotr 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 such charges plus 80%of the balance of such charges 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 far treatment of an illness on an out-patient basis or for treatment of bodily injuries sustained in an accident. GR-231(8864) AMENDMENT NO, 3 EFFECTIVE JANUARY 1, 1975 Page 11B-3-c(2) • • COMPREIIENS(VE MAJOR MEUICAI. EXPENSE BENEFITS (Continued) Sill(•ICAI F\DENSE BENEFITS. For the pmupoaes of this secuun, eligible charges shall be the charges which are used in determining benefits tinder 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 rite 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 comectlon 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 Bene- fits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure or services, as the case may be. in the Relative Value Schedule of Surgical and Radiotherapy Procedures, less, in the event the cash deductible applicable to such covered person for the then current calendar year has not been satisfied, an amount equal to the part(or all) of such cash deductible that has not been satisfied. 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 50^x,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: The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section entitled "Cash Deductible", If the procedure is performed in a hospital $7 30 except$7.80 for anesthesia service If the procedure is performed in a physician's office or in a clinic. . $8.30, except $8.80 for anesthesia service GR=231(8864) Page 11C-1- AMENDMENT NO. 3 EFFECTIVE JANUARY 1, 1975 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, less, in the event the cash deductible applicable to such covered person for the then current calendar year has not been satisfied, an amount equal to the part (or all)of such cash deductible that has not been satisfied; 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 such services to qualify as eligible charges shall not apply with respect to (a) the first$90 of such charges incurred, other than for routine immunizations, during each calendar year on behalf of a qualified depen- dent who is less than two years of age, and (b) an additional amount consisting of the first$35 of such charges incurred for routine immunizations of a qualified dependent who is less than two years of age, SCHEDULE OF BENEFITS Classifications of Individuals One class applicable to all Medical Care Expense Benefits Dollar Unit Value for Medical Care Expense Benefits: $3.10 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. 8 EFFECTIVE JANUARY 1, 1975 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 coveted person, incurs eligible charges for a necessary 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 mason of such procedure, the Insurance Company shall, subject to the tenns 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, less, in the event the cash deductible applicable to such covemd person for the then current calendar year has not been satisfied, an amount equal to the part (or all)of such cash deductible that has not been satisfied. 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: $7.30 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. 3 EFFECTIVE JANUARY 1, 1975 Hello