MEDICAL EXPENSE COVERAGE - FORM 236 MN OUTLINE OF COVERAGE by weep00p

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									                                                                                                  Time Insurance Company
                                                                                        501 West Michigan Milwaukee, WI 53203




                          MEDICAL EXPENSE COVERAGE - FORM 236 MN
                                   OUTLINE OF COVERAGE

This outline of coverage provides a brief description of the important features of your policy. This is not the insurance
contract. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is
important that you READ YOUR POLICY CAREFULLY.
MAJOR MEDICAL EXPENSE COVERAGE: This policy is designed to provide coverage for major hospital, medical, and
surgical expenses incurred as a result of a covered illness (including complications of pregnancy) or injury. Coverage is
subject to any deductibles, coinsurance, copayments or other limitations of the policy.
AUTHORIZATION REQUIREMENT: To be eligible to receive the maximum benefits available read the Health Care Review
provision carefully. Failure to follow the Health Care Review provision could result in no payment or a reduction in
benefits.
This policy provides lifetime maximum benefit for each insured.
If there is other insurance which provides benefits for Covered Medical Services, benefits under this policy will be
reduced.
The Medical Deductible Amount is $_______. The Rate of Payment is _______% to a maximum of $_______.
A covered charge is an allowable charge that we determine is for services and supplies: 1) provided by a health care
practitioner; 2) that are medically necessary; 3) incurred by an insured for a covered illness or injury, or for a Covered
Wellness Service; 4) listed in the Covered Medical Services or Covered Prescription Drug Services sections; and 5) not
listed in the Exclusions section. In determining if or how much of a covered charge is allowable, we will consider
the actual charge, relative value scales, regional geographic factors, and the rate we negotiate with the provider of
service.
COVERED MEDICAL SERVICES:
Hospital Services: daily room and board up to the semi-private room rate, a critical care unit, all other inpatient or
outpatient treatment provided by a hospital, and an ambulatory surgical center.
Health Care Practitioner Services including surgery and anesthesia services.
X-ray and laboratory services.
Professional ground or air ambulance services to the nearest hospital that can provide emergency treatment.
Supplies and durable medical equipment.
Home health care services from a home health care agency to a maximum of 160 hours each calendar year.
Hospice care services provided in either an inpatient, outpatient or home setting.
Skilled nursing facility services up to 30 days each calendar year. Covered services include room and board, nursing and
ancillary services. Subacute care is covered under this provision.
Rehabilitation services include inpatient rehabilitation services up to 180 days per calendar year and outpatient
rehabilitation services up to $3,000 per calendar year. Rehabilitation services do not include treatment for
conditions related to vertebrae, disc, spine, back, neck and adjacent tissues or temporomandibular joint (TMJ) and
craniomandibular joint (CMJ) dysfunction.
Vertebrae, disc, spine, back and neck: Outpatient diagnosis and treatment for these conditions up to $750 each
calendar year. This includes massage, acupuncture, biofeedback, manipulation and electrical stimulation. The
maximum does not apply to inpatient stays, surgery, anesthesia, laboratory tests, x-rays, magnetic resonance images
(MRI) or electromyelograms.




Form 21627-MN                                              Page 1                             OUTLINE OF COVERAGE (Rev. 8/2005)
Temporomandibular joint (TMJ) and craniomandibular joint (CMJ) dysfunction: Benefits are payable for surgical and
nonsurgical treatment. Covered charges for nonsurgical treatment are limited to diagnostic examinations, diagnostic
x-rays, injection of muscle relaxants, therapeutic drug injections, physical therapy, diathermy and ultrasound therapy.
Cleft lip and cleft palate services including orthodontic and oral surgery for the management of cleft lip and cleft
palate for dependent children under age 18.
Organ transplants: The maximum lifetime transplant benefit is $100,000* for each transplant, combined transplants,
and sequential transplants. The maximum lifetime transplant benefit includes all related expenses from 14 days before
transplant until 365 days after transplant, including up to $10,000 for potential donor and donor expenses. This limit
does not apply to kidney and cornea transplants. Covered transplants include heart, lung, combined heart/lung,
combined kidney/pancreas and liver transplants. Covered charges for marrow reconstitution and support include all
chemotherapy, the harvesting, and the reinfusion of the marrow or blood precursor cells*. This maximum lifetime
transplant benefit is waived when certain transplant centers are used*.
Wellness services up to $500 each calendar year. This maximum will not apply to child health supervision services,
routine mammograms, pap smears and prostate specific antigen (PSA) tests.
Diabetic services include outpatient self management training and education, medical nutrition therapy, one routine
eye exam per calendar year and two routine foot care exams per calendar year.
Injectable drugs which require a written prescription.
Reconstructive surgery required due to illness, injury or congenital disease or anomaly due to a functional defect,
including initial reconstructive surgery after mastectomy for cancer and treatment of port wine stains.
Parenteral (intravenous infusion) therapy includes total parenteral nutrition and other fluids, blood and blood products,
and medications requiring a written prescription.
Dental treatment: Benefits are payable for: a) an injury resulting from an accidental blow to the mouth causing trauma
to sound teeth, the gums or supporting structures of the teeth. Treatment must begin within 90 days of the injury and
be completed within 365 days of the injury; and b) anesthesia and hospital expenses associated with a dental procedure
performed on an insured who is under 5 years of age; is severely disabled; or has a medical condition, for whom general
anesthesia or hospitalization is necessary.
Limited coverage for specific conditions of pregnancy include only spontaneous miscarriage, ectopic pregnancy,
medically necessary cesarean section, gestational diabetes mellitus and medical conditions whose diagnoses are distinct
from pregnancy but are adversely affected by pregnancy.
Sterilization: Benefits are payable to a maximum lifetime benefit of $500 after you have been continuously insured
under this policy for 365 days.
Removal of tonsils and adenoids are payable after you have been continuously insured under this policy for 90** days
except for emergency treatment.
Surgical treatment for hernia (except strangulated or incarcerated), bunions, varicose veins and hemorrhoids are
payable after you have been continuously insured under this policy for 180** days except for emergency treatment.
**The day limitation will be waived if other health insurance with reasonably similar benefits is shown on the application
and was in force until the effective date of this policy.
Prenatal care services.
Treatment for diagnosed Lyme disease.
Phenylketonuria dietary treatment.
Cancer screening, including routine screening procedures for cancer, including mammograms and pap smears, when
ordered by a Health Care Practitioner in accordance with the standard practice of medicine.
Port Wine Stain treatment for the elimination or maximal feasible treatment of port wine stains.
Ventilator-dependent patient care services rendered in a Hospital by a private duty nurse or personal care assistant up
to a lifetime maximum of 120 hours.
World wide coverage will be provided for services received outside the United States if services would be covered when
provided in the United States.


Form 21627-MN                                              Page 2                            OUTLINE OF COVERAGE (Rev. 8/2005)
PRESCRIPTION DRUG BENEFITS: Benefits are payable for: a) legend drugs and medicines, that by Federal law can
only be obtained with a prescription; b) injectable insulin, with a prescription; and c) disposable insulin syringes,
and disposable blood/urine, glucose/acetone testing agents or lancets. After you have paid the prescription drug
deductible, copayment, coinsurance and/or ancillary charge, we will pay benefits for up to a 30 consecutive day supply
for each prescription or up to a 90 consecutive day supply for mail order prescriptions.
If you do not use a network pharmacy or do not present your ID card at a network pharmacy, you will have to pay the
pharmacy in full and file a claim for reimbursement. Reimbursement will be at the negotiated network rate minus any
applicable prescription drug deductible, copayment, coinsurance and/or ancillary charge.
Prescription Drug Deductible $ _________ Generic Copayment $_________ Brand Name Copayment $_______
Prescription Drug Exclusions
In addition to the Exclusions section listed below, we will not pay benefits for any of the following:
  1) Replacement of lost, stolen, destroyed or damaged prescriptions;
  2) Drugs or devices used directly or indirectly to promote or prevent conception;
  3) Immunization agents, biological sera, blood, blood plasma or its derivatives;
  4) Drugs containing nicotine or its derivatives;
  5) Injectable drugs which we do not authorize to be paid under this benefit;
  6) More than we determine is an average quantity of medication required to treat an immediate condition or
     symptom on an “as needed” basis; or
  7) Over-the-counter medications that can be obtained without a prescription; drugs which we determine have
     an over-the-counter equivalent or contain the same active ingredient(s) as over-the-counter medication; or
     compounded medications not containing at least one legend ingredient.
PRE-EXISTING CONDITIONS LIMITATION: We will not pay benefits for covered charges incurred due to a pre-existing
condition until you have been continuously insured under this policy for 12 months. This 12 month period will be
reduced by the length of time the insured was covered under a prior health plan if this policy becomes effective
within 30 days of the prior plan’s termination date. After this 12 month period, benefits will be paid for a pre-existing
condition on the same basis as any other condition.
EXCLUSIONS: We will not pay benefits for any of the following:
  1) Illness or Injury eligible for benefits under Worker’s Compensation, Employers’ Liability or similar laws even when
     you do not file a claim for benefits.
  2) Illness or Injury contributed to or caused by: (a) war or act of war (declared or undeclared); (b) active duty in the
     military service of any country; (c) commission of a felony, crime or illegal act; (d) participation in a riot; (e) an
     Insured over age 19 being under the influence of illegal narcotics or non-prescribed controlled substances; or (f)
     attempted suicide or self-inflicted injury.
  3) Charges that are payable or reimbursable by: (a) a plan or program of any governmental agency (except
     Medicaid), or (b) Medicare Part A or Part B (where permitted by law). If you do not enroll in Medicare we will
     estimate benefits.
  4) Routine hearing, vision or foot care, surgery to correct vision, or foot orthotics.
  5) Cosmetic services.
  6) Not covered services, complications of an excluded or not covered service, or charges for which you are not liable.
  7) Charges by a Health Care Practitioner or medical provider who is an immediate family member.
  8) Custodial Care.
  9) Growth hormone stimulation treatment including drugs or hormones.
 10) Dental care except as provided under the Covered Medical Services.
 11) Any treatment for correction of malocclusion, protrusion, hypoplasia or hyperplasia of the jaws.
 12) Charges for which there is automobile or liability insurance providing medical payments.

Form 21627-MN                                              Page 3                             OUTLINE OF COVERAGE (Rev. 8/2005)
 13) Charges for educational testing or training, vocational or work hardening programs, transitional living, or services
     provided through a school system.
 14) Infertility.
 15) Maternity and routine nursery charges unless you have a Maternity Rider.
 16) Genetic testing, counseling and services.
 17) Charges for sex transformation, and treatment of sexual dysfunction or inadequacy or to enhance sexual
     performance or desire.
 18) Over-the-counter products including vitamins and food supplements, herbal and homeopathic medications.
 19) Treatment of “quality of life” or “lifestyle” concerns including but not limited to: smoking cessation; obesity; hair
     loss; sexual function, dysfunction, inadequacy or desire; or cognitive enhancement.
 20) Treatment used to improve memory or to slow the normal process of aging.
 21) Telemedicine or treatment rendered without the Health Care Provider being physically present with a patient.
 22) Mental Illness or Substance Abuse.
RENEWABILITY PROVISION: The policy will remain in force at the option of the insured, except for the following
reasons:
  1) Nonpayment of premiums;
  2) Fraud or material misrepresentation made by or with the knowledge of an insured;
  3) All policies with the same form number are non-renewed in the state in which your policy was issued or the state
     in which you presently reside;
  4) You have a PPO plan and move outside of the service area;
  5) You enroll in Medicare; or
  6) You are no longer a covered dependent.


The initial premium for this plan is: $ __________.
$ __________ Semi-Annually; $ __________ Quarterly; $ __________ C.O.M.
(Insert the mode wanted.) After the first premium, you have 31 extra days to pay each premium after it is due.


_____________________________________________________________                 ____________________________
Licensed Agent’s Signature                                                       Date




Form 21627-MN                                             Page 4                             OUTLINE OF COVERAGE (Rev. 8/2005)

								
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