IT'S EASY TO FILE YOUR CLAIM FOR NEW YORK 65 BENEFITS Making a claim for New York 65 benefits is simple. As you'll see inside this folder, after you have given the essential information needed in Section A the Insured's Statement you need only sign your name opposite the arrows in the other Sections. This authorizes release of information to New York 65, or assigns benefit payments to the hospital, convalescent nursing home, physician or surgeon, as the case may be. You'll note that the New York 65 Claim Form comes in two Parts. Part One covers hospital and nursing home benefits, and Part Two covers surgical, medical and miscellaneous expenses. If your claim requires that both Parts be filled in, you merely separate these at the perforation leaving Part One with the hospital or convalescent nursing home to complete and mail to New York 65. Part Two may then be handed to your doctor, laboratory or nurse for similar attention and action. Generally, the two Parts of the form will be filled in separately and mailed to New York 65 at different times. Therefore, upon mailing its benefit check, New York 65 will also mail you another blank Claim Form so you won't have to wait for all bills to come in, or wait to fill in all Sections of the form before filing for benefits under any particular other Section. For example, suppose you have been in a hospital and your doctor has recommended that you complete your recovery in a convalescent nursing home. As soon as you are ready to leave the hospital, you should complete "A. Insured's Statement" on Part One of the form and ask the hospital to complete "B. Hospital Statement," and mail this to New York 65. When New York 65 mails a check for the hospital benefit to you, it will at the same time mail you another blank claim form. When you are ready to leave the convalescent nursing home, you will thus have another Part One which you and the nursing home may use to file claim for the expenses incurred in the nursing home. Similarly, Part Two may be handed to your doctor or surgeon for completion and for mailing to New York 65. Again, another blank form will be sent to you by New York 65, and you will have it available for any other claim need that might arise, such as diagnostic x-ray and laboratory examination. Promotional Folder for Special Enrollment Opportunities in New York 65 SPECIAL ENROLLMENT OPPORTUNITIES IN HOW NEW YORK 65 WORKS... HOW THE MAJOR MEDICAL PLAN GIVES YOU PROTECTION TO HELP YOU PAY REALLY BIG MEDICAL BILLS NEW YORK 65 HEALTH INSURANCE New York 65 For example, assuming you have New After the Basic has paid room and board After benefits for "other hospital serv- for 31 days of convalescent nursing As pointed out in the schedule below, New York 65 Major Medical also pro- Just think how vitally important New EXPENSES NOT COVERED UNDER NEW YORK 65 Expenses during the first 6 months of your Other principal exclusions are: injuries Benefits under New York 65 are subject to HERE'S HOW NEW YORK 65 MIGHT BENEFIT YOU! NEW YORK 65 ($10 a Month) Pays Benefits Up to 31 Days For • Hospital room/board up to $18 a day • Doctors fees in hospital (non-surgical) up to $6 per day, first week-$5 per day, second Convalescent nursing home charges up to PLUS: Surgery, in or out of a hospital, and Radiation Same plan available on Optional basis at a cost The important benefits and limitations of New York HOSPITAL AND CONVALESCENT NURSING HOME BENEFITS ■ Hospital room and board benefits up to $18 a day after the first 31 days of confinement. ▪ Convalescent nursing home benefits up to $7.50 per day for a maximum of 60 days following (NOTE: After you've been out of a hospital or convalescent nursing home for 90 days, you're OTHER MEDICAL EXPENSE BENEFITS (Maximum Benefit $10,000 DURING YOUR LIFETIME) Benefits for the following medical expenses at 80% of the amount by which expenses exceed $75 in a calendar year: with maximum ■ Doctor's medical and surgical services for home, office or in-hospital care ■ Private duty nursing services by registered professional nurses, registered visiting nurses, or ■ Diagnostic x-ray and laboratory examination and out-patient diagnostic services Anesthetics ... I artificial limbs and eyes trusses and crutches Oxygen and rental of equipment for its administration ■ Rental of radium and radioactive isotopes Blood and blood plasma Rental of a wheel-chair, hospital-type bed, iron lung, or other equipment for the treatment of Local ambulance service to or from a hospital or convalescent nursing home BENEFITS UNDER NEW YORK 65 ARE SUBJECT TO REDUCTION IF YOU HAVE OTHER HOSPITAL, SURGICAL OR MEDICAL INSURANCE |