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
Major Medical
is designed to
provide health
insurance
against the big
medical and hospital bills incurred by a
serious accident or illness-bills above
and beyond those normally covered by
basic hospital-surgical-medical plans, such
as New York 65 Basic, Blue Cross-Blue
Shield, and others. It's offered as a vital
addition to any of these basic plans.

For example, assuming you have New
York 65 Regular Basic (or the equiva-
lent benefits under another basic plan*)
this is how New York 65 Major Medical
works:

After the Basic has paid room and board
benefits for the first 31 days of hospitali-
zation, New York 65 Major Medical
picks up and extends this benefit.

After benefits for "other hospital serv-
ices and supplies" have been paid by the
Basic, the Major Medical picks up and
continues to pay 80% of such charges.
And after the Basic has paid benefits

for 31 days of convalescent nursing
home care, New York 65 Major Medical
steps in to extend this benefit through
another 60 days.

As pointed out in the schedule below,
the Major Medical plan pays a maximum
benefit for all these charges up to $3,600
for each confinement.

New York 65 Major Medical also pro-
vides benefits covering Other Medical Ex-
penses (doctor bills, nursing services,
drugs, X-Rays, etc.). The plan starts pay-
ing for these charges after you pay a
yearly $75 cash deductible and after the
program's Basic hospital-surgical-medical
benefits, or their equivalent, have been
used up. New York 65 Major Medical then
pays 80% of the benefits shown below, up
to a maximum of $10,000 over your life-
time.

Just think how vitally important New
York 65 Major Medical protection could
be to you! And it costs only $9 a month!
*You are eligible for the Major Medical
plan alone, whether or not you have basic
coverage. However, if you have no basic
coverage, you should be prepared to meet
the equivalent of New York 65 Regular
Basic benefits out of your own pocket.

EXPENSES NOT COVERED

UNDER NEW YORK 65

Expenses during the first 6 months of your
insurance- or during any period of hos-
pital confinement commencing in the first
6 months- for any condition for which
you received treatment or diagnosis during
the 90 days before your New York 65 in-
surance became effective.

Other principal exclusions are: injuries
and diseases covered by Workmen's Com-
pensation; care for mental and nervous
conditions outside a hospital; dental care;
eye examinations and glasses; hearing
aids; diseases or injuries arising out of
any war; expenses for services and sup-
plies furnished without charge by any gov-
ernment; expenses which you would have
no obligation to pay if you did not have
insurance.

Benefits under New York 65 are subject to
reduction if you have benefits under other
hospital, surgical or medical plans.

HERE'S HOW NEW YORK 65 MIGHT BENEFIT YOU!

NEW YORK 65
REGULAR BASIC

($10 a Month)

Pays Benefits Up to 31 Days For

• Hospital room/board up to $18 a day
• Miscellaneous hospital charges up to $150

• Doctors fees in hospital (non-surgical) up to
$145.

$6 per day, first week-$5 per day, second
week-$4 per day, thereafter

Convalescent nursing home charges up to
$7.50 a day following at least 5 days hospital
confinement.

PLUS: Surgery, in or out of a hospital, and Radiation
Therapy for Malignancy according to a schedule,
up to $250.

Same plan available on Optional basis at a cost
of $8 per month with room and board benefits
limited to $12 per day.

The important benefits and limitations of New York
65 are presented in this folder. Complete details
are given in the Certificate Booklet you will receive
shortly after you enroll.

HOSPITAL AND CONVALESCENT NURSING HOME BENEFITS
(Maximum Benefit $3600 FOR ANY ONE CONFINEMENT)

■ Hospital room and board benefits up to $18 a day after the first 31 days of confinement.
exceed $150.
Benefits for other hospital services and supplies at 80% of the amount by which expenses

▪ Convalescent nursing home benefits up to $7.50 per day for a maximum of 60 days following
at least 5 days hospital confinement.

(NOTE: After you've been out of a hospital or convalescent nursing home for 90 days, you're
entitled to a new maximum benefit of $3600 for any future confinement.)

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
expense equal to the excess of the established Blue Shield fees in your community for
families with maximum yearly income of $6,000 over the benefits payable under other plans
for these services. If you have no basic coverage for surgery or doctor fees in hospital,
you should be prepared to meet the equivalent of New York 65 Basic benefits out of your
own pocket.

■ Private duty nursing services by registered professional nurses, registered visiting nurses, or
licensed practical nurses, not in excess of charges of $1,000 in any calendar year.
Drugs and medicines which require a doctor's prescription.

■ Diagnostic x-ray and laboratory examination and out-patient diagnostic services
■ Physiotherapy

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
respiratory paralysis

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