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
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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
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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
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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:
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Michael B. McCallister
President
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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
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GN- 70050 -07 EM POLICY 5/06
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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.
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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.
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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
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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.
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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.
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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.
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0 PREMIUM COMPUTATION
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• 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.
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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.
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The effective date of a change in premium will only vary from the above upon mutual written agreement
between the policyholder and us.
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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.
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c Ur L '�� Gerald L. Ganoni
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President
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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
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Gerald L. Ganoni
President
VGRP- CERT.002 IN 12/09 1