Standard Security Life/HR/Rider - Y
STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK
(a New York Stock Life and Health Insurance Company)
("We", "Us", "Our")
POLICY RIDER
RIDER NUMBER: 01
EFFECTIVE DATE: January 1, 2014
POLICY NUMBER: C-SSL-IHCRS-00114-14
POLICYHOLDER: City of Carmel
The parties shall refer to the Policy for the definitions of the terminology used in this Rider.
As of the Effective Date and regardless of anything in the Policy to the contrary, this Rider.changes the....
Policy as follows:
1. Loss or Losses in SECTION 1 –DEFINITIONS is amended to include the following:
Loss or Losses includes any Payment required to be.made by the Plan to comply with CIGNA
provider contract provisions, whether or not such Payment complies with the provisions of the
Plan.
2. In the event the CIGNA provider contract requires re-pricing of any Loss after the Benefit Period
has expired, such re-priced Loss will be deemed Paid during the Benefit Period and eligible for
reimbursement under the Policy, subject to all terms, conditions, limitations and exclusions of the
Policy.
For a re-priced Loss to be reimbursable under this provision: •
1. The re-pricing must take place no later than six months following the original Payment of
such Loss;
2. The re-priced Loss must be Paid within 30 days following the re-pricing;and
3. We must be notified by You in writing within 30 days of the date you become aware of the re-
pricing.
The Policy is changed only as stated in this Rider. All provisions not changed by this Rider shall apply.
62?—rjor Kazdas---7-
David T. Kettig Adam C. Vandervoort
President Secretary
AGREED:
Policyholder: City of Carmel
Signature:_
,Print,Name:_ Signature Page Attached
;Title:
Date:
SL2004-R 11/22/13
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CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
J es Brainard, Presiding Officer Date ///V/7
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Mary An i urke, Board Member Date
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Lori Wad ri, aoard Member Date
ATTEST:
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Tana Cordray, 4, C, Clerk-Treasurer Date