Group Health Insurance Policy Issued pursuant to Section 221-a MAJOR MEDICAL EXPENSE BENEFITS designed to supplement New York 65 Basic Benefits or similar benefits which you may have obtained elsewhere. NON-DUPLICATION OF BENEFITS Benefits under New York 65 Plans are subject to reduction if you have benefits under any other hospital, surgical, or medical plan. If, for any reason, after examining this Certificate Booklet, you are not satisfied with this insurance, then within ten (10) days after receipt of this booklet, you may return it to: New York 65 101 West 51st Street New York 19, N. Y. Your insurance will then be void from the beginning and any premium paid will be returned. Read this entire Certificate Booklet carefully. It contains the benefit provisions which are a part of the New York 65 Group Health Insurance Policy held by the New York 65 Health Insurance Association. This Certificate Booklet is subject to the terms, provisions and conditions of such policy. Keep this Certificate Booklet in a safe place. Highlights Of Your New York 65 Plan A more detailed description appears Basic Hospital, In-Hospital Medical, Convalescent Nursing Home, and Surgical Expense Benefits Regular (a) Hospital room and board benefits up to $18 a day for a maximum of 31 days. (b) Other hospital service benefits for services during the first 31 days of confinement, up to $150. (c) Benefits for doctors' visits for non-surgical care in the hospi tal. (d) Convalescent nursing home benefits up to $7.50 a day for a maximum of 31 days. (e) Surgical expense benefits. NOTE: The Optional Basic Plan provides a maximum benefit for hospital room and board of $12 a day. WHO IS ELIGIBLE? You are eligible for this insurance if your principal place of residence is in the State of New York and 1. you have attained your 65th birth- 2. you are the wife or husband of a No person who has not attained his or her 65th birthday will become covered under any New York 65 Plan unless and until his or her spouse is covered. EFFECTIVE DATE OF INSURANCE If you enroll during an enrollment period specified by the Association, your insurance will become effective on the date of receipt by the Association of your completed enrollment form together with your first required monthly premium except as provided in the next two paragraphs. If you are confined in a hospital or convalescent nursing home on the date your insurance would otherwise become effective, or were so confined on any day within the 31-day period immediately preceding that date, YOUR INSURANCE WILL BECOME EFFECTIVE ON THE FIRST DAY FOLLOWING A CONTINUOUS PERIOD OF 31 DAYS DURING WHICH YOU WERE NOT SO CONFINED EXCEPT AS PROVIDED IN THE NEXT PARAGRAPH. If your insurance would otherwise become effective on the 29th, 30th or 31st of any month, it will become effective on the 1st day of the next month. In no event will the effective date be earlier than October 15, 1962. The Association will send you premium cards for premiums becoming due after your insurance becomes effective. Each monthly premium is due on the date specified on the card for that month and payment thereof on or before the due date will continue the insurance in force until the next succeeding monthly due date. However, a grace period of ten days will be granted for the payment of each monthly premium falling due after the first monthly premium, during which grace period your insurance shall continue in force. If you pay premiums in advance, send the premium card for each premium you pay. Make checks or money orders payable to New York 65 and mail them together with your premium cards for the premiums you are paying to: New York 65 Box 6500, General Post Office New York 1, N. Y. The Association reserves the right to change the premium rates upon appropriate notice. BASIC HOSPITAL, IN-HOSPITAL MEDICAL, CONVALESCENT NURSING HOME, AND SURGICAL EXPENSE BENEFITS IN-HOSPITAL BENEFITS A. Hospital Expense Benefits If, while insured, you become confined as an inpatient in a hospital on account of an injury or sickness, the Plan will pay an amount equal to the daily room and board charge made to you by the hospital for each of the first 31 days of any one period of hospital confinement, up to $18 per day under the Regular Basic Plan; or $12 per day under the Optional Basic Plan. If, while insured, you receive in a hospital (a) treatment on any day of confinement for which room and board benefits are payable, or (b) emergency treatment on account of an injury suffered in an accident and within 24 hours after the time of the accident, or (c) treatment in connection with and within 24 hours after a surgical procedure, the Plan will pay the actual amounts charged to you by the hospital for necessary hospital services and supplies furnished in connection with such treatment during any one period of hospital confinement, up to $150. B. In-Hospital Medical Expense Benefits-For Doctors' Visits for Non-Surgical Care in the Hospital If, while insured, you become confined in a hospital for reasons other than surgery, and receive, on any day of such confinement for which room and board benefits are payable, necessary services of a doctor which are neither surgical services nor related to surgical services, the Plan will pay the actual amounts charged to you for such services, up to $6 for each of the first seven days, $5 for each of the next seven days, and $4 for each of the next seventeen days, of any one period of hospital confinement. For the purpose of determining in-hospital benefits payable, successive periods of hospital confinement, regardless of cause, which commence while you are insured will be considered as one period of hospital confinement unless between such periods of confinement there were at least 90 consecutive days during which you were not confined in a hospital or a convalescent nursing home. |