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HomeMy WebLinkAboutHumana Specialty Benefits Policy- Employee HUMANA. Specialty Benefits HumanaLile.com HUMANA SPECIALTY BENEFITS Toll Free: 1 -800- 558 - 4:444 1100 Employers Blvd. Green Bay, WI 5434-4 662493 CITY OF JEFFERSONVILLE 500 QUARTERMASTER COURT JEFFERSONVILLE IN 47130 It, Dear CITY OF JEFFERSONVILLE: Thank you for choosing Humana Specialty Benefits. We appreciate the opportunity to work with you and to serve you and your employees — now and for years to come. The enclosed documents outline your plan benefits and explain how the plan works. If you have more than one type of coverage with us — such as medical, dental, and life — you may receive separate documents for each plan. These documents replace any other plan materials we may have sent you previously. If you find discrepancies in these documents or if you have questions about your plan benefits, please call us at 1 -800 -558 -4444. Current benefits information can always be found on our Website, HumanaLife.com. Employees enrolled in these benefits can view or print their documents through the Website or call us to request a copy by mail. Sincerely, Humana Specialty Benefits IM MO E MS MOW LL=-7 VIL M i MINN ; JUN 2 1 2012 L� JE - F — E - SOVILA DEPT. HUMAN -AN RESOURCES MIN MINN IMMO Immo GHC -24159 07/07 06n3 /2012 THIS IS A NON- PARTICIPATING GROUP INSURANCE POLICY. TERM LIFE INSURANCE, ACCIDENTAL DEATH OR BODILY INJURY, AND SHORT TERM DISABILITY BENEFITS INCLUDED, AS ELECTED BY THE POLICYHOLDER. Group Policy Number: 662493 Policyholder: CITY OF JEFFERSONVILLE Effective Date: 07/01/2012 This Policy is delivered in and governed by the laws of: Indiana O HUMANA INSURANCE COMPANY, GREEN BAY, WISCONSIN, (hereafter called the Insurer) agrees, subject to all terms and provisions of the Policy, to pay benefits as described in the Employee's certificate of insurance, incorporated by reference herein with respect to each Covered Person under the Policy. The Policy is issued in consideration of the application of the Policyholder, which is made part of the Policy, and such Policyholder's payment of premiums as provided and insured under the Policy. The Policy and the insurance it provides become effective at 12:01 A.M. (Standard Time) of the effective date stated above. The Policy and the insurance it provides terminates at 12:01 A.M. (Standard Time) of the date of termination. The provisions stated above and on the following pages are part of the Policy. IN WITNESS WHEREOF Humana Insurance Company has caused this Policy to be issued at the address of the Policyholder, as of the policy effective date. Issued by: 1111... 11 11... WWI 1111, 1e - , INNEIONO Michael B. McCallister President Niarair 11, 11.... .1111■. 1.1141. GN- 70050 -07 EM POLICY 5/06 GN- 70050 -07 EM POLICY 5/06 TABLE OF CONTENTS PAGE NUMBER BENEFITS 4 INCREASES OR DECREASES IN AMOUNTS OF INDIVIDUAL EMPLOYEE'S INSURANCE 4 SELECTION 5 DEFINITIONS 5 SUBSIDIARIES OR AFFILIATES 6 REQUIREMENTS FOR INSURANCE COVERAGE 7 UNDERWRITING AND PARTICIPATION REQUIREMENTS 8 TERMINATION 8 GENERAL PROVISIONS 10 PREMIUMS 11 0 O In Q1 O 0 0 0 MOIMN Mimin MINIM MINIM IMMO r-1 MONO IMMO �rM11 MOO rro GN- 70050 -07 EM POLICY 5/06 IMMO BENEFITS The benefits applicable to the Employee's Group Insurance Plan are the benefits specified in the Employer Group Application and approved by the Insurer, shown in the Certificate of Insurance, incorporated by reference herein. INCREASES OR DECREASES IN AMOUNTS OF INDIVIDUAL EMPLOYEE'S INSURANCE The Policyholder may elect that increases or decreases as specified below will be effective on the first day of the calendar month coinciding with or next following the increase or decrease, or on an immediate basis. Such election may be made on the Employer Group Application at the time the Employer becomes the Policyholder, or at such later date as may be agreed to in writing by the Insurer. INDIVIDUAL EMPLOYEE'S CHANGES RESULTING IN AN INCREASE IN INSURANCE UNDER THIS POLICY • Any Employee's change resulting in an increase in that Employee's amount of insurance under the Policy will, subject to the bullet directly below, become effective on the approved date of change. An increase will apply to covered conditions occurring on or after the effective date of the increase. The Insurer must be notified of the change no more than 31 days following the date of change. If the Insurer is not notified within 31 days of the date of change, any additional or increased insurance will become effective on the date the Insurer receives written notification and approves the change. • If an Employee is NOT in Active Status on the date an increase in the amount of insurance is to become effective, the effective date of the increase will be deferred until the date next following the date the Employee returns to Active Status. • COVERED DEPENDENT'S CHANGES RESULTING IN AN INCREASE IN INSURANCE UNDER THIS POLICY • Each covered Dependent's approved additional insurance coverage or increased benefit coverage will be delayed for such Covered Person on the date the insurance or benefit would be effective if the Dependent: — Is confined in a Hospital or Qualified Treatment Facility; or — Is receiving Home Health Care or Hospice benefits. The Dependent's coverage will be effective on the day after: — Discharge from Confinement, if discharge from Confinement is certified by a Qualified Practitioner, or — A Qualified Practitioner certifies that Home Health Care is no longer required. GN- 70050 -07 EM POLICY 5/06 4 INCREASES OR DECREASES IN AMOUNTS OF INDIVIDUAL EMPLOYEE'S INSURANCE (continued) INDIVIDUAL COVERED PERSON'S CHANGES RESULTING IN A DECREASE IN INSURANCE UNDER THIS POLICY Any change resulting in a decrease in any Covered Person's amount of insurance under this Policy will become effective on the date the Insurer approves the change. However, no such decrease will act to prejudice any existing claim incurred prior to the effective date of the change. SELECTION Amounts of insurance provided by the Policy are available only on a basis which precludes individual selection. DEFINITIONS The Insurer shall apply the terms and meanings shown below wherever used in this Policy to determine the intent and administration of insurance benefits. 0 0 Covered Dependent means a Dependent whose coverage under this Policy is in effect in accordance with the "Requirements for Insurance Coverage" provision of this Policy. Covered Person means the Employee and/or the Employee's Covered Dependent(s). Insurer means the Insurance Company as stated on the Policy face page. The Insurer in its capacity as administrator has the authority to make claim determination as described in section 503 of ERISA. The Insurer shall make the final decisions under the Policy or Group Plan with respect to determining eligibility for coverage and paying claims for benefits, including appeals of denied claims. As claims administrator, the Insurer shall have full and exclusive discretionary authority to: • Interpret the Policy provisions; • Make decisions regarding eligibility for coverage and benefits; and • Resolve factual questions relating to coverage and benefits. Policyholder means the legal entity named as the Policyholder on the face page of this Policy. Probationary Period means•the waiting period as required by the Employer for an Employee before the -- Employee is eligible for coverage under this Policy. Immimarl •.rr. GN- 70050 -07 EM POLICY 5/06 5 SUBSIDIARIES OR AFFILIATES Any Employer which is a subsidiary or affiliate of a Policyholder is eligible under the Policyholder's Group Insurance Plan provided under this Policy if the following conditions are met: • The subsidiary or affiliate is listed in the Employer Group Application and Application for Insurance of the Policyholder, or in any amendment thereto; • The legal relationship between the Policyholder and the subsidiary or affiliate is in conformity with all applicable laws of the state in which the Policyholder is located; and • The subsidiary or affiliate has been approved for coverage under this Policy, in writing, by both the Policyholder and the Insurer. An Employee of such a subsidiary or affiliate of the Policyholder shall be considered to be an Employee of the Policyholder. A subsidiary or affiliate of a Policyholder shall cease to be eligible in the Policyholder's Group Insurance Plan provided under this Policy on the earliest of the following: • The date the legal relationship between the Policyholder and the subsidiary or affiliate is no longer in conformity with all applicable laws of the state in which the Policyholder is located; • The date the Policyholder's written notice of its intent to terminate the participation of the subsidiary or affiliate is received by the Insurer, or on any later date as may be stated in such notice; • The date the Policyholder terminates this Policy; or • The date this Policy terminates. The insurance of any Employee of a subsidiary or affiliate of a Policyholder, and the insurance of such Employee's Covered Dependents, shall immediately terminate on the date the subsidiary or affiliate ceases participation in the Policyholder's Group Insurance Plan. GN- 70050 -07 EM POLICY 5/06 6 REQUIREMENTS FOR INSURANCE COVERAGE THE FOLLOWING PROVISIONS APPLY TO THE PLAN OF BENEFITS AS REQUESTED ON THE EMPLOYER GROUP APPLICATION BY THE POLICYHOLDER AND ON THE EMPLOYEE ENROLLMENT FORM. ELIGIBILITY The Policyholder must indicate on the Employer Group Application the eligible classes of Employees under this Policy as defined below: • The Policyholder will indicate the Employee classes which are eligible for insurance under the Policyholder's Plan. Regular full time Employees in Active Status, if employed by the Policyholder and paid a salary or wage by the Employer that meets the minimum wage requirements of their state or federal minimum wage law and their Dependents, are in an eligible class. • Part -time Employees or their Dependents may be included in an eligible class, only if the Policyholder makes specific reference that part -time Employees be included and it is approved by the Insurer. • The spouse or a child of an Employee may be included in an eligible class as a Dependent of the 0 Employee, only if the Employee is covered under this Policy. DATE ELIGIBLE Each Policyholder's Group Insurance Plan may provide one of the following as the Date Eligible for Employees and Dependents as provided by this Policy. The Date Eligible must be elected by the Policyholder on the Employer Group Application. IMMEDIATE DATE ELIGIBLE • Each Employee included in an Eligible Class on the date the Employer becomes the Policyholder will be eligible under this Policy on that date, provided the Employee has completed any required Probationary Period (waiting period) indicated on the Employer Group Application. • Each Employee included in an Eligible Class on the date the Employer becomes the Policyholder under this Policy, and who had partially satisfied the required Probationary Period prior to the Policyholder's effective date under this Policy, will be eligible for coverage under this Policy on the first day after completion of the Probationary Period. M INIM IMMO • Each Employee who enters an Eligible Class AFTER the date the Employer becomes the Policyholder under this Policy, will be eligible for coverage under this Policy on the first day after: — •• – Completion of any required Probationary Period (waiting period); or MINIM - The Employee's date of employment, if a Probationary Period (waiting period) is not required. IMMO i MIr MEM MEM ANON MUM MOWN GN- 70050 -07 EM POLICY 5/06 7 REQUIREMENTS FOR INSURANCE COVERAGE (continued) DEFERRED DATE ELIGIBLE • Each Employee included in an Eligible Class on the date the Employer becomes the Policyholder will be eligible under this Policy on that date, provided the Employee has completed any required Probationary Period (waiting period) indicated on the Employer Group Application. • Each Employee included in an Eligible Class on the date the Employer becomes the Policyholder under this Policy, and who had partially satisfied the required Probationary Period (waiting period) prior to the Policyholder's effective date under this Policy, will be eligible under this Policy on the first day of the calendar month coinciding with or next following the date of completion of the Probationary Period (waiting period). • Each Employee who enters an Eligible Class AFTER the date the Employer becomes the Policyholder under this Policy will be eligible under this Policy on the first day of the calendar month coinciding with or next following: — Completion of any required Probationary Period (waiting period); or — The Employee's date of employment, if a Probationary Period (waiting period) is not required. EMPLOYEE ENROLLMENT • Each Employee must complete the Employee Enrollment Form to apply for coverage for him /her self and any eligible Dependent. • The Insurer reserves the right, based upon the Insurer's underwriting procedures, to require that the eligible Employee and/or eligible Dependent submit evidence of insurability and any applicable evidence of health status before coverage will be approved or effective for the Employee and/or Dependent. The Insurer will administer this provision in a non - discriminatory manner. UNDERWRITING AND PARTICIPATION REQUIREMENTS The Policyholder is required to maintain the minimum Underwriting and Participation requirements of the Insurer, as specified on the Employer Group Application. The Insurer reserves the right to waive or modify the Underwriting and Participation requirements. TERMINATION RIGHT TO TERMINATE THIS POLICY The Insurer may terminate the Policy by giving written notice to the Policyholder no later than 31 days prior to the desired termination date. GN- 70050 -07 EM POLICY 5/06 8 TERMINATION (continued) The Insurer may terminate the insurance provided under any provision of this Policy by giving written notice to the Policyholder no later than 31 days prior to the desired termination date. However, no advance notice is required from the Insurer to terminate coverage for a group or individual when the group or individual is not or has not been eligible for coverage. The Policyholder may terminate this Policy by giving written notice to the Insurer no later than 31 days prior to the desired termination date. The Policyholder may terminate the insurance provided under any provision of this Policy, including any Voluntary benefits, with the consent of the Insurer, as of a date mutually agreeable to the Policyholder and the Insurer. The Policyholder may terminate an eligible class of Covered Persons from the Policyholder's Group Insurance Plan, with the consent of the Insurer, as of a date mutually agreeable to the Policyholder and the Insurer. Termination will occur only with respect to Covered Persons included in the terminated class. Upon termination of this Policy, it is the Policyholder's obligation to notify all Employees of such termination. If the Policyholder requires a contribution from the Employees to offset a portion of that Employer's premiums, the Policyholder will refund to those Employees the portion of the contribution, if any, which the Policyholder may have collected for any period of time following the termination of this Policy. TERMINATION OF INSURANCE Termination of Insurance will occur on the date as specified below, with respect to all Covered Persons under this Policy, when the first of any of the following events occurs: • The date this Policy terminates in accordance with its terms; • The termination date according to the Right To Terminate This Policy section of this Policy; • The Policyholder terminates this Policy by giving written notice to the Insurer no later than 31 days prior to the desired termination date; • The date this Policy is amended to terminate any specific insurance coverage; termination will occur only with respect to such coverage; • The date this Policy is amended to terminate the eligibility of a class of Employees; termination will occur only with respect to Covered Persons in the terminated class; °' • The date the Policyholder fails to meet the Underwriting and Participation requirements as shown on the Employer Group Application; • The date the Policyholder, acting with the knowledge and written consent of the Insurer, deletes an Optional Benefit under this Policy; termination will occur only with respect to such deleted Optional ""' Benefit coverage; GN- 70050 -07 EM POLICY 5/06 9 TERMINATION (continued) • The date the Policyholder, acting with the knowledge and written consent of the Insurer, deletes an eligible class of Covered Persons from the Policyholder's Group Insurance Plan; termination will occur only with respect to Covered Persons included in the terminated class; • The Policyholder, acting with the knowledge and written consent of the Insurer, terminates any provision of this Policy; termination will occur on a date mutually agreeable to the Policyholder and the Insurer; or • The Policyholder fails to remit premium when due, except that coverage is continued during the Grace Period applicable to the due but unpaid premium. GENERAL PROVISIONS ENTIRE CONTRACT This Policy, and the Employer Group Application of the Policyholder and the Employee Enrollment Form, constitute the entire contract between parties. All statements made by the Policyholder or by any Employee will be deemed representations and not warranties. CERTIFICATES The Insurer will issue to the Policyholder, for delivery to each Employee, or in some cases to the Employee directly, an individual certificate setting forth a statement of the insurance protection to which the Employee and the Employee's Covered Dependents are entitled. INFORMATION TO BE FURNISHED Each Policyholder will furnish the Insurer information required to enable the Insurer to administer the provisions of this Policy and to determine the premiums to be charged. All of the Policyholder's records, which have a bearing on the insurance provided under this Policy, will be available for inspection by the Insurer when and as often as required. MODIFICATION OF POLICY This Policy may be modified at any time by agreement between the Insurer and the Policyholder without consent of any Employee or any beneficiary. No modification will be valid unless approved by the President or Secretary of the Insurer. The approval must be endorsed on or attached to this Policy. No agent has authority to modify this Policy, waive any of this Policy's provisions, extend the time for premium payment, or bind the Insurer by making any promise or representation. GN- 70050 -07 EM POLICY 5/06 10 GENERAL PROVISIONS (continued) This Policy may be amended by the Insurer at any time without the consent of the Policyholder. The Policyholder will be notified of such amendment, in writing, at least 31 days prior to its effective date. Payment of premium beyond the effective date of the endorsement constitutes the Policyholder's consent to the amendment. PREMIUMS PREMIUM RATE CHANGE The Policy premiums will be calculated as specified in the "Premium Computation" section below. The Insurer reserves the right to change any premium rate when the: • Terms of the Policy are changed; • Policyholder changes the terms of this Policy with the written consent of the Insurer; or • Insurer changes the rates, provided the Policyholder is given written notice prior to the change. 0 0 rn 0 PREMIUM COMPUTATION 0 • The first premium is due on this Policy's effective date. Subsequent premiums are due on the first day of each calendar month thereafter. The required premium due on each premium due date is the sum of the premiums for all covered Employees under this Policy. All premiums are payable to the Insurer at the Insurer's address. • If an individual's insurance coverage or policy benefits are modified other than on a premium due date, the change in premium resulting from the modification will become effective as follows: — Group with 2 — 99 eligible employees the change in premium will be effective on the date the change in coverage becomes effective. — Group with over 99 eligible employees: — If the change is effective on or before the 15 of the month, the change in premium will be effective on the first of the month during which the change in coverage is effective; — If the change is effective after the 15` of the month, the change in premium will be effective •= on the first of the month following the effective date of change in coverage. 1111... To determine the applicable employer group size for premium changes please reference the Small Employer definition on the Employer Group Application. • If premiums are due for the Insurer or premium refunds are due for the Policyholder or Employee as a result of clerical error in the reporting of data to the Insurer, all premiums or refunds will be calculated at the current rate of premium payment, limited to a maximum period of six months. .■11.11 MEMO The effective date of a change in premium will only vary from the above upon mutual written agreement between the policyholder and us. IMMO 1111.. GN- 70050-07 EM POLICY 5/06 11 PREMIUMS (continued) GRACE PERIOD While this Policy continues in force after the first premium, a grace period of 31 days will be allowed to the Policyholder, following the premium due date, for the payment of required premium due. The Policy will remain in force during the grace period. If the required premium is not paid by the end of the 31 day grace period, the Policy will terminate. The Policyholder will be required to pay premium for the grace period. UNPAID PREMIUM Any premium due and unpaid or covered by any note or written order may be deducted from the claim payment of an eligible claim under the Policy. RETURN OF PREMIUM • The Insurer reserves the right to rescind coverage on one or all Employees due to misrepresentation or fraud on the Employer Group Application, the Employee Enrollment Form, or any other enrollment form, if such misrepresentation materially affected the acceptance of the risk. • If on the date coverage is rescinded no claims have been paid under this Policy, the Insurer will return to the Policyholder or Employee all premiums paid for such coverage. • If on the date coverage is rescinded claims have been paid under this Policy, the Insurer reserves the right to deduct an amount equal to the amount of such claims paid from the premiums returned to the Policyholder and Employee. GN- 70050 -07 EM POLICY 5/06 12 HUMANADENTAL INSURANCE COMPANY P. O. Box 14313 Lexington, KY 40512 -4313 (866) 537 -0229 Group Vision Insurance Policy POLICYHOLDER: CITY OF JEFFERSONVILLE POLICY NUMBER: 662493107- 662493 131 POLICY EFFECTIVE DATE: JULY 1, 2012 STATE OF DELIVERY: INDIANA Read Your Policy Carefully This Policy is a legal contract between the Policyholder and HumanaDental Insurance Company (hereinafter referred to as "HumanaDental "). The consideration for this contract is the group application and the payment of premiums as provided hereinafter. Agreement This Policy is the entire contract with the Policyholder and HumanaDental. This Policy shall be effective for an initial term of [twelve months] from the Policy Effective Date and continuing thereafter for periods of [twelve months] each until terminated by either party upon [30 days] written notice prior to the anniversary date or as otherwise specified in the Policy. Only authorized officers may make changes for HumanaDental. Such changes must be in writing and attached to this Policy. HumanaDental reserves the right to amend the Policy from time to time. HumanaDental will pay, with respect to each Insured, the insurance benefit provided in this Policy. Payment is subject to the conditions, limitations and exceptions of this Policy. Eligibility requirements to be insured under this Policy are stated in the section entitled Becoming Insured. This Policy is governed by the laws of the state shown above. Certificates HumanaDental will furnish a Certificate for each Insured person which will contain the benefits provided by this Policy. Incorporation Provision The provisions of the attached Certificate and all rider(s) issued to amend this Policy after the effective dates are made a part of this Policy. This Policy was signed by the Policyholder on the Group Application form. We sign here on behalf of HumanaDental. r c Ur L '�� Gerald L. Ganoni D President ;1 SEP 11 2012 .� '� VGRP- POLICY.002 12/09 1 HUM608- 1 JEFFERSONVILLE DEPT. HUMAN RESOURCES HUMANADENTAL INSURANCE COMPANY P. O. Box 14313 Lexington, KY 40512 -4313 (866) 537 -0229 CERTIFICATE OF GROUP VISION INSURANCE This Certificate outlines the features of the Group Vision Insurance Policy issued to the Policyholder by HumanaDental Insurance Company (hereinafter referred to as "HumanaDental "). Read it carefully to become familiar with Your coverage. In this Certificate, the masculine pronouns include both masculine and feminine gender unless the context indicates otherwise. Your coverage may be terminated or amended in whole or in part under the terms and provisions of the Policy. If you should have any questions, or to obtain coverage information or assistance in resolving complaints. please call (866) 537 -0229. Signed for HumanaDental Insurance Company r Gerald L. Ganoni President VGRP- CERT.002 IN 12/09 1