Outpatient Plan: The monthly Insurance Premium related to coverage underwritten by First Continental Life and Accident Insurance Company and MMMG Rx as a part of this plan is as follows; Member= $96.74, Member Plus Spouse = $166.40, Member Plus Children = $155.06, Family = $258.16. Fundamental Care also includes the following services to enhance your plan value and provide increased savings: physician network, online wellness, EAP, financial wellness, Rx discounts, and association membership benefits.
Standard Plan: The monthly Insurance Premium related to coverage underwritten by First Continental Life and Accident Insurance Company and MMMG Rx as a part of this plan is as follows; Member= $161.55, Member Plus Spouse = $276.58, Member Plus Children = $258.76, Family = $433.15. Fundamental Care also includes the following services to enhance your plan value and provide increased savings: physician network, online wellness, EAP, financial wellness, Rx discounts, and association membership benefits.
Critical Med Plan (30-49 Age bracket): The monthly Insurance Premium related to coverage underwritten by First Continental Life and Accident Insurance Company as a part of this plan is as follows; Member= $71.56, Member Plus Spouse = $121.65, Member Plus Children = $114.50, Family = $193.21. Fundamental Care also includes the following services to enhance your plan value and provide increased savings: physician network, online wellness, EAP, financial wellness, and association membership benefits.
Gap Coverage Plan: The monthly Insurance Premium related to coverage underwritten by First Continental Life and Accident Insurance Company and MMMG Rx as a part of this plan is as follows; Member= $26, Member Plus Spouse = $45, Member Plus Children = $50, Family = $70. Fundamental Care also includes the following services to enhance your plan value and provide increased savings: physician network, online wellness, EAP, financial wellness, Rx discounts, and association membership benefits.
LIMITED INDEMNITY LIMITATIONS
PRE-EXISTING CONDITION LIMITATION: We will not pay benefits for charges, services, or supplies incurred as a result of a Pre-Existing Condition within the Pre-Existing Condition Period stated on the Schedule of Benefits. Benefits under this Certificate are not payable in connection with a Pre-Existing Condition for the following Benefits; 1. Daily Hospital Confinement Benefit; 2. Daily Intensive Care Benefit; and 3. Inpatient Surgery and Anesthesia Benefit If the Insured was covered under a prior carrier’s group limited medical indemnity policy at the date of change in coverage to a group limited medical indemnity policy provided by Us and was not subject to a Pre-Existing Condition limitation under the prior carrier’s policy, there shall be no Pre-Existing Condition limitation under Our Policy. However, if the Insured was subject to a Pre-Existing Condition limitation under the prior carrier’s policy, credit will be given toward satisfaction of the Pre-Existing Condition limitation of Our Policy for that period of time that the Insured was continuously covered under the prior carrier’s policy.No consideration will be given to prior group limited medical indemnity coverage in determining the effect of Pre-Existing Conditions on benefits payable. A claim for benefits diagnosed after the Pre-Existing Condition Period will not be reduced or denied on the grounds that it is caused by a Pre-Existing Condition.
PREGNANCY LIMITATION: We will not pay benefits for Hospital Confinement or Hospital Admission Benefit for any Confinement caused by or occurring as a result of the Insured’s normal pregnancy or childbirth within the first 9 months after the Coverage Effective Date. Confinement as a result of Complications of Pregnancy will be covered to the same extent as any other Sickness. After coverage has been in force for 9 months following the Coverage Effective Date, benefits for a Confinement caused by or occurring as a result of the Insured’s normal pregnancy or childbirth will be payable in accordance with the terms and conditions of the Policy.
EXCLUSIONS: The Policy does not provide any benefits for the following: (1) services or supplies that are not Medically Necessary, even if prescribed, recommended, or approved by a Physician; (2) intentionally self-inflicted Injury or suicide attempt while sane or insane;(3) voluntary abortion except, with respect to You or Your Dependent Spouse or Domestic Partner: (a) where You or Your Dependent Spouse’s or Domestic Partner’s life would be endangered if the fetus were carried to term, or (b) where medical complications have arisen from abortion; (4) procedures, services, or drugs related to artificial insemination, in vitro or test tube fertilization, including any related testing; (5) procedures, services, or drugs for exogenous obesity or weight control; (6) services for purchase and fitting of hearing aids; (7) services and supplies related to smoking cessation; (8) charges for food, food supplements, or vitamins; (9) charges related to marriage, family, child, career, social adjustment, pastoral, or financial counseling; (10) services related to therapy, supplies, treatment or counseling for sexual dysfunction or inadequacies that do not have a physiological or organic basis; The policy does provide benefits for Medically Necessary treatment, drugs, services or supplies related to gender transition (including gender dysphoria), medically appropriate gender-specific services, and other related dysfunctions; (11) procedures, services, or drugs for the reversal of a tubal ligation or a vasectomy; (12) charges for rental or purchase of durable medical equipment that is not prescribed or ordered by a Physician or is available without a prescription (over the counter); (13) Injury or Sickness resulting from (a) an act of war, declared or undeclared, while serving in any Armed Forces or an auxiliary unit thereto; (b) active participation in a riot, civil commotion, civil disobedience or unlawful assembly; (c) committing a felony; (d) participation in a contest of speed in a power-driven vehicle, parachuting, parasailing, bungee jumping, scuba diving, stunt driving, rock climbing, flying ultra-light aircraft, skydiving, hang gliding or any hazardous sports activity for exhibition purposes; (e) air travel, except as a fare-paying passenger on a commercial airline; or (f) the Insured being intoxicated or under the influence of any narcotic unless the narcotic is administered on the advice of a Physician; (14) cosmetic surgery or elective surgery except organ donation or Medically Necessary gender reassignment, including any expenses related to Hospital Confinement, unless due to a covered Injury or Sickness; (15) any Treatment, drugs, or surgery considered Investigational or Experimental by the American Medical Association, the Health Care Finance Administration, or the Federal Drug Administration; (16) any Injury or Sickness occurring while the Insured is in the service of the Armed Forces of any country. Orders to active military service for training purposes of two months or less will not constitute service in the Armed Forces. When the Insured provides Us notice of entering the Armed Forces, We will return to the Insured pro rata any premium paid, less any benefits paid, for any period during which the Insured is in such service; (17) an Injury or Sickness for which the Insured receives benefits under Workers’ Compensation or similar coverage or for which the Insured would receive benefits under Workers’ Compensation if the employer had enrolled the Insured for such coverage and the Insured and employer had cooperated in filing a claim under that coverage; (18) dental or vision services, including but not limited to treatment, surgery, extractions or x-rays, unless: (a) resulting from an Injury occurring while the Insured’s coverage is in force and if performed within 12 months of the date of such Injury; (b) due to congenital disease or anomaly of a newborn Dependent Child; (c) dental services or oral surgery due to excision of impacted third molars, closed or open reduction of fractures, or dislocation of the jaw; or (d) services are provided by the Dental Benefit Rider or Vision Benefit Rider and all required additional premium has been paid. (19) any charges incurred prior to the Coverage Effective Date or in excess of the Benefit Year Maximums shown on the Schedule of Benefits; or (20) pregnancy of a Dependent Child, except Complications of Pregnancy; (21) routine examinations, such as health exams, periodic check-ups or routine physicals; or (22) routine newborn care and nursery charges, including charges incurred for routine Hospital Confinement; (23) treatment for Mental or Nervous Disorders, unless specifically stated in the Schedule of Benefits; or (24) treatment for Substance Abuse, unless specifically stated in the Schedule of Benefits.
ACCIDENT MEDICAL EXPENSE BENEFITS: The Company will pay Accident Medical Expense Benefits for the Covered Medical Expenses listed below that result directly, and from no other cause, from a Covered Injury. Accident Medical Expense Benefits are only payable: 1. when Covered Medical Expenses incurred exceed any applicable Deductible specified in the Schedule of Benefits; 2. as long as the first Covered Medical Expense has been incurred within the time period specified in the Schedule of Benefits; 3. until the Maximum Benefit Period shown in the Schedule of Benefits has expired; 4. until Benefits paid equal the Benefit Maximum shown in the Schedule of Benefits. No benefits will be paid for any Covered Medical Expenses incurred that are in excess of Usual and Customary Charges.
COMMON EXCLUSIONS: In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section: 1. Intentionally self-inflicted injury, suicide or any attempt while sane or insane; 2. Commission or attempt to commit a felony or an assault; 3. Commission of or active participation in a riot or insurrection; 4. War or acts of war, declared or undeclared, while serving in the military or any auxiliary unit thereto.; 5. An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days; 6. Flight in, boarding or alighting from an Aircraft except as a fare-paying passenger on a regularly scheduled commercial or charter airline; 7. Travel in any aircraft owned, leased or controlled by the Policyholder Subscriber, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder; Subscriber if the Aircraft may be used as the Policyholder Subscriber wishes for more than 10 straight days, or more than 15 days in any year; 8. Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage; 9. Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice unless it occurs during treatment of injuries sustained in a Covered Injury; 10. The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officers report, or similar items will be considered proof of the Insured Person’s intoxication; 11. Aggravation or re-injury of a prior injury the Insured Person suffered prior to His Coverage Effective Date, unless the Company receives a written medical release from the Insured Person's Physician; 12. Sickness, disease or any bacterial infection, except one that results from an Accidental cut or wound, or pyogenic infections that result from Accidental ingestion of contaminated substances. In addition, benefits will not be paid for services or treatment rendered by any person who is: 1. employed or retained by the Policyholder Subscriber; 2. living in the Insured Person’s household; 3. an Immediate Family Member of either the Insured Person or the Insured Person’s spouse; 4. the Insured Person.
EXCLUDED EXPENSES: In addition to the Common Exclusions, The Company will not pay Outpatient Accident Medical Expense Benefits for any Covered Medical Expense, treatment or services resulting from or contributed to by: 1. treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances; 2. treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appendicitis; 3. osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness; 4. detached retina unless caused by a Covered Accident; 5. mental disorder or psychological or psychiatric care or treatment whether or not caused by a Covered Accident; 6. pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions; 7. mental and nervous disorders; 8. damage to or loss of dentures or bridges, or damage to existing orthodontic equipment; 9. expenses incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial disorders; 10. injury covered by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder. 11. any elective treatment, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States; 12. eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; 13. expenses payable by any automobile insurance policy without regard to fault; 14. conditions that are not caused by a Covered Accident; or 15. any treatment, service or supply not specifically covered by the Policy Certificate. 16. injuries paid under medical payment coverage or no-fault coverage contained in an automobile insurance policy or liability insurance policy.
CRITICAL ILLNESS LIMITATIONS
Pre-Existing Condition Limitation Benefits under this Certificate are not payable in connection with a Pre-Existing Condition. This Pre-Existing Condition Limitation shall not apply to a Diagnosis commencing after the earlier of: 1. the end of a continuous period of 24 months commencing on or after the Insured Person's Coverage Effective Date, during all of which the Insured Person has received no medical advice or treatment in connection with such disease or physical condition; and 2. the end of the two year period commencing on the Insured Person's Coverage Effective Date.
COMMON EXCLUSIONS: In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section: 1. the Insured Person’s suicide or intentional self inflicted injury or Sickness, while sane or insane; 2. the Insured Person’s being under the influence of an excitant, depressant, hallucinogen, narcotic, and other drug, or intoxicant including those taken as prescribed by a Physician; 3. the Insured Person’s commission of or attempt to commit an assault or felony; 4. the Insured Person’s engaging in an illegal activity or occupation; 5. the Insured Person’s voluntary participation in a riot; 6. any illness, loss or condition specifically excluded from the definition of any Critical Illness; 7. a Critical Illness that was initially Diagnosed before the Coverage Effective Date; 8. war, whether declared or not; 9. balloon angioplasty, laser relief of an obstruction, and/or other intra-arterial procedure unless covered under this Certificate; or 10. any injury or Sickness covered under any state or federal Worker’s Compensation, Employer’s Liability law or similar law.