Standard Sercuity Life/HR STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK
(a New York Stock Life and Health Insurance Company)
Home Office:
485 Madison Avenue
New York, New York 10022
212- 355 -4141
POLICYHOLDER: City of Carmel
POLICY NUMBER: SSL- IHCRS- 00005 -12
EFFECTIVE DATE: 01/01/2012
/Obi;
EXPIRATION DATE: 12/31/2012 i► A
STATE OF DELIVERY: Indiana
This Policy is a legal contract. We issue it in consideration of: (1) Your Application, (2) Your Disclosure
Statement, and (3) Your payment of premiums when due. This Policy, Your Application, Your Disclosure
Statement, and a copy of the Plan form the entire agreement between You and Us.
In issuing this Policy, We have relied upon the information (including, without limitation, information in the
Disclosure Statement, Your Application, and the Plan) provided to Us by: (1) You, (2) Your Administrator,
and (3) Your agent or broker. We have also relied on this information being both complete and accurate.
If the information was incomplete or incorrect, We shall have the immediate right: (1) to modify the Policy
to reflect the complete or correct information, or (2) to terminate the Policy upon written notice.
We agree to make payments in accordance with the provisions of this Policy.
In this Policy, "You" and "Your" refer to the Policyholder, and 'We", "Us and "Our" refer to Standard
Security Life Insurance Company of New York.
This Policy is issued and governed by the laws of the state of delivery as indicated above.
Signed for Standard Security Life Insurance Company of New York as of the Effective Date.
Rachel Lipari David Kettig
President Secretary
EXCESS LOSS INSURANCE POLICY
Non Participating
SL2004 01/10/12
SCHEDULE OF EXCESS LOSS INSURANCE
(Hereinafter referred to as "the Schedule
POLICYHOLDER: City of Carmel
ADDRESS: One Civic Square, Carmel, Indiana 46032
ADMINISTRATOR: Benefit Administrative Systems, LLC
ADDRESS: 17475 Jovanna Drive, Suite 1B, Homewood, Illinois 60430
ALL AMOUNTS AND NUMBERS SHOWN IN THIS SCHEDULE APPLY ONLY TO THE POLICY YEAR IN
EFFECT. A NEW SCHEDULE WILL BE ISSUED FOR EACH NEW POLICY YEAR.
A. [X] AGGREGATE EXCESS LOSS INSURANCE:
1. BENEFITS COVERED:
X Medical Dental Weekly Income Vision X Prescription Drug Card
Other:
2. BENEFIT PERIOD:
Eligible Expenses Incurred from 01/01/2011 through 12/31/2012; and
Eligible Expenses Paid from 01/01/2012 through 12/31/2012.
If this Policy terminates prior to the Expiration Date, no Aggregate Excess Loss Benefits will be
payable and premium paid will not be refundable.
3. MINIMUM AGGREGATE ATTACHMENT POINT: $11,782,928
4. AGGREGATE LOSS LIMIT (per Covered Person): $150,000
5. AGGREGATE BENEFIT PERCENTAGE: 100%
6. MAXIMUM AGGREGATE BENEFIT (WHILE COVERED, AND WHILE THIS POLICY IS IN
FORCE): $1,000,000
7. RUN -IN /RUN -OUT LIMIT: $N /A
8. MONTHLY AGGREGATE FACTOR(S) /ENROLLMENT:
FACTORS: COVERED UNITS /ENROLLMENT:
Single: $746.97 Single: 150
Family: $1,999.69 Family: 435
Composite: $N /A Composite: 585
9. AGGREGATE PREMIUM ([N /A] Annual X Per Employee Per Month): $10.15
10. MINIMUM AGGREGATE PREMIUM ([N /A] Annual [N /A] Monthly): $N /A
11. PREMIUM PAYMENT MODE: Monthly
SL2004 i 01/10/12
SCHEDULE OF EXCESS LOSS INSURANCE (cont'd)
B. [X] SPECIFIC /INDIVIDUAL EXCESS LOSS INSURANCE:
1. BENEFITS COVERED: X Medical X Prescription Drug Card
2. BENEFIT PERIOD:
Eligible Expenses Incurred from 01/01/2011 through 12/31/2012; and
Eligible Expenses Paid from 01/01/2012 through 12/31/2012.
If this Policy terminates prior to the Expiration Date, the Benefit Period will not extend past the
date of termination. In addition, the deductible per Covered Person will apply as if the Policy
were in force for the entire Policy Year.
3. DEDUCTIBLE (PER COVERED PERSON): $150.000
Except for the following:
a. N/A N/A
4. SPECIFIC BENEFIT PERCENTAGE: 100%
5. SPECIFIC BENEFIT LIMIT (PER LIFETIME, PER COVERED PERSON) WHILE THIS
POLICY IS IN FORCE: No Lifetime Maximum.
6. RUN -IN /RUN -OUT LIMIT:
a. N/A N/A
7. MONTHLY SPECIFIC PREMIUM RATE /ENROLLMENT:
RATE: COVERED UNITS /ENROLLMENT:
Single: $38.86 Single: 150
Family: $110.90 Family: 435
Composite: $N /A Composite: 585
8. MINIMUM SPECIFIC PREMIUM ([N /A] Annual [N /A] Monthly): $N /A
SL2004 ii 01/10/12
SCHEDULE OF EXCESS LOSS INSURANCE (cont'd)
[X] WAIVER OF ACTIVELY AT WORK ELECTED
[X] ADVANCED FUNDING ELECTED
[X] RETIREE EXPENSES INCLUDED
OPTIONAL RIDERS ELECTED:
[n /a] Aggregating Specific Rider
[n /a] Monthly Cumulative Accommodation For Aggregate Excess Loss Rider
[n /a] Aggregate Excess Loss Terminal Liability Rider
[n /a] Specific Excess Loss Terminal Liability Rider
NOTES:
1. Sagamore and Beech Street will be the PPO's of choice. UR will be done by Medical Cost
Management.
AGREED: Citv of Carmel
Policyholder/You
Signature: Cam
v
Name (please print): S poi
Title:
Date:
SL2004 iii 01/10/12
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
7/
t� g
J es Brainard Presiding Officer Date A
di_LZ
Mary A Burke, Board Member Date
(3
Lori W. on, Board Member Date
ATTEST:
Dana Cordray, I 1 Clerk- Treasurer Date
TABLE OF CONTENTS
SCHEDULE OF EXCESS LOSS INSURANCE
SECTION 1 DEFINITIONS 2
SECTION 2 AGGREGATE EXCESS LOSS INSURANCE 4
SECTION 3 SPECIFIC EXCESS LOSS INSURANCE 4
SECTION 4 EXCLUSIONS AND LIMITATIONS 4
SECTION 5 TERMINATION 5
SECTION 6 PREMIUMS 5
SECTION 7 YOUR DUTIES 6
SECTION 8 GENERAL PROVISIONS 7
SL2004 1 01/10/12
SECTION 1 DEFINITIONS
Administrator means an organization which has been retained by You and approved by Us to provide
claim and administrative services for You.
Annual Aggregate Attachment Point means that portion of Eligible Expenses entirely retained by You.
This amount is not eligible for reimbursement under this Policy. The Annual Aggregate Attachment Point is
the greater of:
1. the sum of the Monthly Aggregate Attachment Points of each month of the Policy Year, or
2. the Minimum Aggregate Attachment Point shown in the Schedule.
The maximum amount of Losses per Covered Person that will be applied to the Annual Aggregate
Attachment Point is limited to the Aggregate Loss Limit shown in the Schedule.
Minimum Aggregate Attachment Point means an amount equal to 100% of the product of:
1. the total number of Covered Units of the first Policy Month, multiplied by
2. the corresponding Monthly Aggregate Factors shown in the Schedule, multiplied by
3. twelve.
Monthly Aggregate Attachment Point means the amount equal to the total number of Covered Units for a
Policy Month multiplied by the corresponding Monthly Aggregate Factors shown in the Schedule.
Application means the application for excess loss insurance submitted by You to Us in connection with the
issuance of this Policy.
Benefit Percentage means the factor that determines the amount of the Maximum Benefit payable to You
as shown in the Schedule. Separate benefit percentages may apply to either the Aggregate Excess Loss or
to the Specific Excess Loss.
Benefit Period means the period of time, as shown in the Schedule, during which a covered expense must
be Incurred and /or Paid to be eligible for reimbursement under this Policy.
Covered Person means an individual eligible for coverage, and covered, under the Plan.
Covered Unit means an employee, an employee and their dependents, or such other defined unit as
specifically agreed upon between You and Us.
Disclosure Statement means the disclosure statement submitted by You to Us in connection with the
issuance of this Policy.
Deductible (Per Covered Person) means that portion of Eligible Expenses for a Covered Person entirely
retained by You. This amount is not eligible for reimbursement under this Policy.
Eligible Expenses means the Reasonable and Customary Charges covered by the Plan and
Incurred during the Benefit Period by a Covered Person.
Experimental or Investigative means care, procedures, treatments, or technology that are not widely
recognized and accepted as effective, safe and appropriate for the injury or illness by the medical profession
in the U.S., that are in research or Investigative stage, or conducted for research or similar purposes; or for
which the patient has been asked to give, or has signed, a release or other document, indicating that the
treatment is Experimental or Investigative or other similar term.
In determining any of the criteria stated above We will rely on recognized medical sources such as, but not
limited to the American Medical Association, the Council of Technology Assistance Program and the
SL2004 2 01/10/12
Council on Medical Special Services, the National Institute of Health, Medicare, the Food and Drug
Administration; and other accepted medical authorities and sources.
Incurred means the date on which the Covered Person receives a medical treatment, service or supply for
which a charge is made.
Loss or Losses mean Eligible Expenses Paid during the Benefit Period for health benefits under the Plan,
in settlement of claims for health benefits under the Plan; or in satisfaction of judgments for health benefits
under the Plan. "Health benefits" are benefits listed in the BENEFITS COVERED section of the Schedule.
Loss or Losses does not include:
1. any payment which does not strictly comply with the provisions of the Plan; or
2. any payment for which there is any other insurance, reinsurance or plan established pursuant to
federal, state or local law or any other indemnity against Loss which would, except for the existence
of this Policy, indemnify the Insured; or
3. extra contractual damages of any nature, compensatory damages, exemplary and punitive
damages or liabilities of any kind whatsoever, including but not limited to those resulting from
negligence, intentional wrongs, fraud, bad faith or strict liability on the part of You, Your
Administrator or Your agent or broker; or
4. salaries paid to Your employees as well as Your claim and administrative expenses.
Minimum (Aggregate /Specific) Premium means the minimum premium that must be paid for the Policy's
Aggregate and/or Specific coverage to remain in force.
Paid (Pay, Payment) means that a claim has been adjudicated by the Administrator and funds are actually
disbursed by the Plan prior to the end of the Benefit Period. Payment of a claim must be unconditional and
directly made to a Covered Person or their health care provider(s). Payment will be deemed made on the
date that You or Your Administrator directly tenders payment by mailing (or by other form of delivery) a draft
or check, provided the account upon which the payment is drawn contains, and continues to contain,
sufficient funds to permit the check or draft to be honored by the institution upon which it is drawn.
Plan means the employee benefit plan You provide Your eligible employees and their eligible dependents,
which has been received and accepted by Us. Plan does not include life insurance, accidental death and
dismemberment insurance, long and short-term disability insurance coverages, or fully insured major
medical insurance coverages.
Policy Month is determined from the Effective Date. Each Policy Month will begin on the date of each
calendar month which corresponds with the Effective Date. If there is no such date in any applicable month,
then the last date of that month will be used.
Policy Year means the time period beginning on the Effective Date and ending on the Expiration Date.
Reasonable And Customary Charge means the prevailing charge for a medical treatment, service or
supply in the geographical area such treatment, service or supply is provided, as determined by the Health
Insurance Association of America (or similar organization) using nationally and regionally adjusted data.
Run -In Expenses means Eligible Expenses Incurred during the Benefit Period, but prior to the Policy Year.
Run -In Limit means the maximum amount of Run -In Expenses that will be applied to this Policy.
Run -Out Expenses means Eligible Expenses Paid during the Benefit Period, but following the Policy Year.
Run -Out Limit means the maximum amount of Run -Out Expenses that will be applied to this Policy.
SL2004 3 01/10/12
SECTION 2 AGGREGATE EXCESS LOSS INSURANCE
If at the end of a Policy Year, Losses exceed the Annual Aggregate Attachment Point, We will reimburse
such Losses in an amount equal to:
1. the amount by which Losses Paid during the Policy Year exceed the Annual Aggregate Attachment
Point, multiplied by,
2. the Aggregate Benefit Percentage.
Reimbursement under this Section is limited to the Maximum Aggregate Benefit shown in the Schedule,
and:
1. is determined according to the Benefit Period.
2. is subject to all terms, conditions, limitations and exclusions in this Policy.
3. is contingent upon Our receipt of proof of Loss satisfactory to Us (including, without limitation, an
on -site audit), and Your request for reimbursement.
4. will not include any amount paid or payable by Us to You for Specific Excess Loss Insurance
according to the terms in Section 3 of this Policy.
If this Policy terminates prior to the Expiration Date, no Aggregate Excess Loss Benefits will be payable.
SECTION 3 SPECIFIC EXCESS LOSS INSURANCE
If during the Policy Year, or any fraction of a Policy Year, Losses for any Covered Person exceed the
Deductible, We will reimburse such Losses in an amount equal to:
1. the amount by which Losses Paid during the Policy Year exceed the Deductible, multiplied by
2. the Specific Benefit Percentage.
Reimbursement under this Section is limited to the Specific Benefit Limit shown in the Schedule minus the
Deductible, and:
1. is determined, for any Covered Person, according to the Benefit Period.
2. is subject to all terms, conditions, limitations and exclusions in the Policy and the Plan.
3. is contingent upon our receipt of proof of Loss satisfactory to Us (including, without limitation, an on-
site audit), and Your request for reimbursement.
4. will not include any amounts paid or payable by Us to You for Aggregate Excess Loss Insurance
according to the terms in Section 2 of this Policy.
If this Policy terminates prior to the Expiration Date, the Benefit Period will not extend past the date of
termination. In addition, the deductible per Covered Person will apply as if the Policy were in force for the
entire Policy Year.
SECTION 4 EXCLUSIONS AND LIMITATIONS
Our liability under this Policy will not be increased if the Plan provides more liberal exclusions and limitations
provisions.
In addition to the exclusions and limitations provided under the Plan, this Policy will not cover any of the
following, unless specifically waived by rider or endorsement:
1. Deductibles, co- payment amounts, or any other charges which are not payable under the terms of
the Plan or charges which are payable to You from any other source.
2. Charges for Experimental or Investigative services, treatments or supplies; or drugs which have not
been approved by the Food and Drug Administration.
3. Any conditions for which benefits of any kind are paid or payable, by judgment or settlement, under
any Worker's Compensation or occupational law, even if the Covered Person opts out of such law,
or fails to claim his or her rights to such benefits.
SL2004 4 01/10/12
4. Claims for a Covered Person who, on the date that coverage under this Policy would otherwise
begin: a) is an employee who is not actively at work performing the ordinary duties of his or her job
on a scheduled work day; or b) is a retired employee or dependent of an employee who is unable
to perform the normal activities of a person of like age or sex. No reimbursement will be provided
for any charges Incurred until the day after the date that such Covered Person: a) if an employee,
returns to active work on a full -time basis; or b) if a retired employee or eligible dependent of an
employee, is able to perform the normal activities of a person of like age and sex. This provision
does not apply if Waiver of Actively at Work is approved by Us as indicated in the Schedule.
5. Charges resulting from any extra or non contractual damages or actions, or legal fees and
expenses for the defense or litigation thereof, or any fines or statutory penalties.
6. Any services furnished by an institution which is primarily a rest home, a place for the aged, a
nursing home, a convalescent home, a place for custodial care, or any other place of like character.
7. Legal expenses of any kind or description, including legal expenses related to or Incurred for the
confinement of a Covered Person or any compulsory process to adopt, abstain from, or cease to
continue a particular mode of treatment, care or therapy.
8. Expenses arising out of, caused by, contributed to or in consequence of war, declared or
undeclared, civil war, hostilities, or invasion.
9. Expenses for any COBRA continuee or retiree whose continuation of coverage was not offered in a
timely manner or according to COBRA regulations.
10. Expenses incurred as a result of any lost savings or discounts offered by a facility or provider due to
untimely Payment of the bill by You or Your Administrator.
SECTION 5 TERMINATION
This Policy and all Policy benefits will terminate upon the earliest of:
1. on any premium due date, if the premium due on that date is not paid in full by the end of the Grace
Period;
2. the premium due date following Our receipt of Your written notice to cancel or terminate this Policy;
3. on any premium due date We specify if We give You at least thirty -one (31) days advance written
notice to cancel or terminate this Policy;
4. the end of the Policy Year;
5. the date of termination of the Plan or the Policy;
6. the date You suspend active business operations or become insolvent or a bankruptcy action is
commenced (whether voluntary or involuntary) or You are in liquidation or receivership;
7. the date You do not Pay claims or make funds available to Pay claims as required by the Plan; or
8. the date on which Your employees are covered under another employee benefit plan or fully
insured medical program.
In addition, this Policy shall automatically terminate upon the cancellation of the agreement between You
and the Administrator, unless We have, prior to such cancellation, agreed in writing to Your designation of a
successor Administrator.
SECTION 6 PREMIUMS
Payment Of Premiums
No coverage under this Policy shall be in effect until the first premium for the Policy is paid. For coverage to
remain in effect, each subsequent premium must be paid on or before its due date. You are responsible for
paying premiums when they become due. Premium due dates are determined from the Effective Date.
Each premium due date is the same day of each month corresponding with the Effective Date. If there is no
such date in any applicable month, the last day of that month shall be used.
Grace Period
We will allow a thirty-one day Grace Period for the payment of each premium due after the payment of the
first premium. During this Grace Period, this coverage shall remain in effect. If any premium is not paid
within this thirty -one day period, coverage under this Policy will automatically terminate without further
notice, and We may offset reimbursement due You against such premium. Termination will be effective as
of the premium due date immediately following the end of the last period for which the minimum monthly
premium has been paid.
SL2004 5 01/10/12
Premium Rate Change
We have the right to modify Monthly Aggregate Factor(s) or Monthly Specific Premium Rates on any of the
following dates:
1. the effective date of any change in benefits or other amendment to the Plan; or
2. the date that You acquire or dispose of any subsidiary, affiliated company, corporate division or
assets relating thereto; or
3. any renewal Effective Date; or
4. any premium due date, when there is a ten percent or more change in the number of Covered
Persons during a Policy Year; or
5. for Aggregate Excess Loss Insurance, at such time as We determine that the last two months of
claims in the preceding Policy Year vary by more than ten percent from the average monthly paid
claims for the prior ten months.
SECTION 7 YOUR DUTIES
You shall be solely responsible for the investigating, auditing, calculating, adjudication and paying of all
claims under the Plan, and the defense of any legal action instituted against You.
You shall maintain and make available to Us, at all times, such information and records as We may
reasonably require evidencing Your proof of Payment of amounts which qualify for coverage under this
Policy.
You shall maintain a record of any and all amounts paid in excess of Payments required by the Plan.
You shall prepare and submit to Us the following:
1. a monthly report of the total claims paid during the month,
2. a monthly report of the total number of Covered Units under the Plan during the month,
3. any other report as required by Us, and
4. any notice of claim as required under this Policy.
You shall maintain records reasonably required by Us and shall furnish to Us upon Our request, all pertinent
data with respect to Covered Persons.
You shall immediately notify us if You acquire or dispose of any subsidiary, affiliated company, corporate
division or assets relating thereto.
You shall immediately notify Us of the date that You suspend active business operations or become
insolvent or a bankruptcy action is commenced (whether voluntary or involuntary) or You are in liquidation or
receivership.
You shall immediately notify Us if the Plan is amended or terminated. If You do not give Us notice of
amendment of the Plan Our liability is limited to the lesser of the benefits payable: a) under the Plan as
revised; or b) as if the Plan had not been amended.
You may retain an Administrator as Your agent to perform any or all of the duties listed in this Section. We
are not liable under this Policy for any charges or expenses that may be incurred by You and/or Your
Administrator for the performance of these duties. You and the Plan acknowledge that:
1. The Administrator is not Our agent.
2. Payments by or notices from Us to the Administrator are deemed received by You upon receipt
by the Administrator. Payments from You to the Administrator are not deemed received by Us.
We act only as a provider of excess loss insurance coverage to the Plan. We do not act as a
fiduciary. We do not assume any duty to perform any of the functions or provide any of the
reports required by the Employee Retirement Income Security Act of 1974 (ERISA), as amended.
3. We must approve a change in Administrator prior to its occurrence.
SL2004 6 01/10/12
SECTION 8 GENERAL PROVISIONS
Entire Contract
This Policy, Your Application, Your Disclosure Statement and a copy of the Plan constitute the entire
contract between the parties. No change in the Plan, made after the Effective Date, shall have any effect on
benefits payable under this Policy, unless a copy of such change has been submitted to and accepted in
writing by one of Our officers or Our authorized representative.
In the event of a conflict in between the Plan and this Policy, the terms and provisions of this Policy will
govern.
This Policy does not create any right or legal relationship whatsoever between Us and a Covered Person or
beneficiaries under the Plan. We shall not have any responsibility or obligation under this Policy to directly
reimburse any Covered Person, or provider of professional or medical services for any benefits which are
provided under the terms of the Plan. Our only liability under this Policy is to You. Only one of Our officers
may change this Policy. No change shall be valid unless the change is agreed to by Our President, Vice
President or Secretary in writing.
Other Insurance
The insurance coverage provided by this Policy shall be excess over any other valid group health, excess
insurance, or group indemnity coverage unless such other coverage is specifically issued to be in excess of
the insurance provided by this Policy.
Notice
For the purpose of any notice required under this Policy, notice to the Administrator is notice to You, and
conversely, notice to You is notice to the Administrator.
Examination Of Records
Your books and records, and the books and records of all of Your agents and representatives pertaining to
the Plan and/or insurance provided by this Policy shall be available to Us and Our representatives during
Your regular business hours for inspection and audit.
Amendments To The Plan
Amendments to the Plan are not covered under this Policy unless We have accepted the proposed change
in writing; and You have agreed to pay any additional premium or to accept a higher Aggregate Monthly
Factor(s) as a result of the Plan change.
Clerical Error
Clerical error will not invalidate insurance otherwise in effect nor continue insurance validly terminated. A
clerical error does not include intentional acts or the failure to comply with the Plan or this Policy.
If an error is discovered, an equitable adjustment in premium will be made. If a premium and/or factor(s)
adjustment involves the return of unearned premium, the amount of the return will be limited to the premium
for the twelve month period which precedes the date that We receive proof that such an adjustment should
be made.
Conformity With State Statutes
If any provision of this Policy or its Effective Date conflicts with any applicable law, the provision will be
deemed to conform with the minimum requirements of such law.
Assignment
Your interest under this Policy is not assignable and any attempt to assign Your interest shall be null and
void.
Non Participating
You are not entitled to share in Our surplus earnings.
Notice Of Potential Claim
You shall give Us a written notice of any potential claim within thirty (30) days of the date You become
aware of the existence of facts which would reasonably suggest the possibility that expenses covered under
SL2004 7 01/10/12
the Plan will be Incurred for which benefits may be payable under this Policy, and is equivalent to or
exceeds the lesser of $25,000, or fifty percent of the Specific Deductible amount.
This notice shall include:
1. name of the Covered Person;
2. date of accident or onset of sickness;
3. nature of injury or sickness; and
4. estimated total cost of claim.
Your failure to furnish written notice of a potential claim within thirty (30) days shall not invalidate or reduce
the claim if it was not reasonably possible to give such notice within such time; provided that written notice is
furnished to Us as soon as reasonably possible.
Claims
We shall have the sole authority to reimburse, or deny reimbursement of, Paid claims which exceed any
Aggregate Attachment Point or Specific Deductible amount. Reimbursement of claims shall be
administered by Us or Our authorized representative. Claims and proof of loss must be submitted within
thirty (30) days after You have Paid Eligible Expenses on behalf of any Covered Person. We are not
obligated to reimburse a claim submitted after such period. However, We will reimburse such claim in the
event You show that timely submission was not possible, and You made the submission as soon as
possible. In no event will We reimburse claims submitted more than one year after proof of loss was
otherwise due.
All benefits will be paid to You as they become payable under this Policy.
Any objection, notice of legal action, or complaint, which is received on a claim processed by You or Your
Administrator and on which it reasonably appears that benefits will be payable under this Policy, shall be
brought to Our immediate attention.
Advanced Funding For Specific Excess Loss Insurance
The following provision applies if Advanced Funding is elected as indicated in the Schedule.
When a claim has been submitted to Us for reimbursement under Specific Excess Loss Insurance in
compliance with all other terms and conditions of this Policy, You may request in writing, and We will
consider advancing to You, the remaining eligible unpaid balance of the claim.
Advanced Funding is available only if approved by Us, and is subject to the following requirements:
1. The Specific Deductible amount must be paid in full by You prior to any claims being considered
for Advanced Funding. Payment of the Specific Deductible must be made at least ten (10)
business days prior to the end of the Specific Benefit Period.
2. The claim amount must be equal to or greater than $1,000.
3. Claims submitted for Advanced Funding must have been fully processed according to the terms
of the Plan and must be ready for Payment.
4. Normal Specific claim audit procedures will be implemented prior to any checks being issued by
Us.
5. Your payment for Eligible Expenses must be released to the provider within five (5) days of
receiving the reimbursement check from Us. If these payments are not made within five (5) days,
the reimbursement check must be returned to Us.
6. Any portion of the reimbursement check not used to reimburse Eligible Expenses, due to
additional discounts or any other reason, must be returned to Us within five (5) days.
7. All initial or subsequent Advance Funding claim requests must be received by the Company ten
(10) business days prior to the end of the Specific Benefit Period. Any requests received after that
date, are not eligible for Advance Funding and therefore, must be fully Paid by the Plan in order
to be eligible for reimbursement under this Policy.
SL2004 8 01/10/12
Legal Action
No legal action to recover any benefits may be brought until sixty (60) days after the date that written
request for reimbursement has been given to Us. No legal action may be brought more than three years
after the Incurred date of the Loss for which benefits are claimed.
Renewal
At the end of a Policy Year, a subsequent Policy Year may be agreed to by You and Us. We may request a
new Disclosure Form or additional information before approving a subsequent Policy Year. We will issue to
you a new Policy face page and a new Schedule to show the coverage and terms in effect during each
subsequent Policy Year. If, within ninety (90) days after the proposed Effective Date of the Renewal, We do
not receive from You:
1) a signed copy of the Disclosure Form and additional information, if requested by Us; and
2) a signed copy of the Renewal Schedule,
any Renewal premium submitted to Us will be refunded and coverage will be automatically null and void
retroactive to the proposed Effective Date.
Subrogation
You shall pursue any and all valid claims against third parties arising out of any occurrence resulting in a
Loss payment under the Plan in accordance with applicable law. You shall account for any amounts
recovered. Should You fail to pursue any valid claims against third parties for good cause and We then
become liable to make payment to You under the terms and conditions of the Policy, then We shall be
subrogated to all of Your rights to the proceeds of a third party settlement or satisfied judgment; but only to
the extent that said settlement or judgment specifically allocates a portion thereof to Eligible Expenses
Incurred by a Covered Person prior to the date of settlement or judgment. You shall take such action,
furnish such information and assistance, and execute such papers as We may require to facilitate
enforcement of Our rights, and shall take no action prejudicing Our rights and interests under this Policy.
Any amounts that We recover shall be used to pay Our expenses of collection, and to reimburse Us for any
amount that We may have paid, or become liable to pay, to You under the terms of this Policy. All
remaining amounts shall be paid to You.
Medicare
This Policy does not provide benefits for any Loss for which payment has been made or would have been
made, if application has been made or eligibility maintained, under Part A or Part B of Medicare on behalf of
a Covered Person. However, if a Covered Person is eligible for Medicare but has a right to be enrolled
under the Plan, such exclusion shall not apply.
Reinstatement
We may agree at Our sole option and without prejudice to Our rights under this Policy to reinstate
coverage as of the effective date of cancellation, on receipt and approval of written request for
reinstatement and any and all other material and /or information as We may request, including but not
limited to all outstanding premiums plus interest due from the effective date of reinstatement at a rate of
not less than 1.5% per month compounded monthly. No insurance shall be reinstated until We confirm
such reinstatement to You in writing and any premiums have been paid.
Liability And Indemnification
Except as specifically provided in any rider or endorsement, attached to and forming part of the Policy,
We have no obligation to any third party. Our liability under this Policy is limited to reimbursing You,
pursuant to the terms of this Policy, for payments You make on behalf of Covered Persons for expenses
covered under the Plan. You hold Us harmless for damages, of any kind, which are not caused by Our
own acts or omissions. We are not responsible for any liability You assume under any contract of
agreement other than the Plan.
SL2004 9 01/10/12