Connecticut General Life Insurance Company In consideration of the application, copy of which is attached hereto and made a part hereof, and the payment of the premium hereinafter stated, the Company and agrees that, subject to the provisions, conditions, limitations and exclusions contained herein, if the Insured shall be confined in a hospital while insured under this Policy, the Company will pay to the insured an amount equal to 75% of the Covered Expenses, as defined below, after first deducting from such expenses the Deductible Amount shown above, and subject to a maximum payment of $5,000. Covered Expenses shall include (1) charges made by the hospital for room and board and nece hospital services and supplies, (2) charges for treatment by any duly licensed physion, for medical supplies and for full-time during services by a trained nurse other than a memb e Insured's family, provided such charges are incurred during the period of hospital confinement e for treatment of the condition requiring bospital confinement and are incurred within the six months period immediately following confinement, and (9) charges by a duly licensed physician or botal for diagnosis or treatment of the condition requiring hospital confinement incurred within the two months' period preceding such confinement, but not in the aggregate more than $200, provided, however, that Covered Expenses shall clude only charges for care and treatment prescribed by the attending physician as necessary and such charges shall not exceed the regular and customary charges therefor. Two or more successive hospital contents for the same cause separated by an interval of less than six months shall be considered as one period of hospital confinement and only one Deductible Amount shall apply. MAXIMUM PAYMENT The maximum amount payable for expenses incurred by the Insured in connection with the same or related cau shall be $5,000, irrespecting of the number of separate hospital confinements. DEFINITIONS HOSPITAL. The term hospital means a legally constituted hospital providing facilities for the care and treatment, medical and surgical, of both sick and injured patients. CONFINEMENT. Confinement in a hospital means confinement for a period of at least eighteen consecutive hours. EXCLUSIONS The insurance under this Policy does not cover, and no payment shall be made for, expenses incurred in connecting with 1. pregnancy, childbirth or miscarriage. 2. intentionally self-inflicted injuries or attempted suicide, whether sane or insane, 3. confinement in any Federal hospital, 4. treatment of nervous or mental disease or disorder except charges incurred while confined in a general hospital not specializing in the treatment of nervous or mental diseases or disorders, 5. dental work, except charges made necessary by injury to natural teeth, 6. injuries sustained as a result of travel or flight in any aircraft if the Insured is a pilot or member of the crew or if the aircraft is being operated for aviation training. 7. disease contracted or injuries sustained as a result of war, declared or undeclared, or any act of war, 8. disease contracted or injuries sustained while in the military, naval or other armed service of any country. and the pro rata unearned premium for any period during which the Insured is in such service will be returned to the Insured upon request. 9. cosmetic surgery, unless occasioned by accidental injury. MM 2358 2-15-62 2000 POLICY PROVISIONS Entire Contract; Changes: This Policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this Policy shall be valid until approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this Policy or to waive any of its provisions. Time Limit on Certain Defenses: (a) After three years from the date of issue of this Policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such Policy shall be used to void the Policy or to deny a claim for loss incurred after the expiration of such three year period. (b) No claim for loss incurred after three years from the date of issue of this Policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this Policy. Grace Period: Unless not less than five days prior to the premium due date the Company has delivered to the Insured or has mailed to his last address as shown by the records of the Company written notice of its intention not to renew this Policy beyond the period for which the premium has been accepted, a grace period of thirty-one days will be granted for the payment of each premium falling due after the first premium, during which grace period the Policy shall continue in force subject to the right of the Company to cancel in accordance with the cancellation provision hereof. Reinstatement: If any renewal premium be not paid within the time granted the Insured for payment, a subsequent acceptance of premium by the Company or by any agent duly authorized by the Company to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the Policy; provided, however, that if the Company or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the Policy will be reinstated upon approval of such application by the Company or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the Company has previously notified the Insured in writing of its disapproval of such application. The reinstated Policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the Insured and Company shall have the same rights thereunder as they had under the Policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement. Notice of Claim: Written notice of claim must be given to the Company within twenty days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Insured to the Company at Hartford, Connecticut, or to any authorized agent of the Company, with information sufficient to identify the Insured, shall be deemed notice to the Company. Claim Forms: The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this Policy as to proof of loss upon submitting, within the time fixed in the Policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Proofs of Loss: Written proof of loss must be furnished to the Company at its said office within ninety days after the date of the loss for which claim is made. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Time of Payment of Claims: All indemnities payable under this Policy will be paid immediately upon receipt of due written proof of loss. Payment of Claims: All indemnities of this Policy will be payable to the Insured and any accrued indemnities unpaid at the Insured's death will be payable to the estate of the Insured. Physical Examinations: The Company at its own expense shall have the right and opportunity, to examine the person of the Insured when and as often as it may reasonably require during the pendency of a claim hereunder. Legal Actions: No action at law or in equity shall be brought to recover on this Policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this Policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. Cancellation: The Company may cancel this Policy at any time by written notice delivered to the Insured, or mailed to his last address as shown by the records of the Company, stating when, not less than five days thereafter, such cancellation shall be effective; and after the Policy has been continued beyond its original term the Insured may cancel this Policy at any time by written notice delivered or mailed to the Company, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the Company will return promptly the unearned portion of any premium paid. If the Insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the Insured resided when the Policy was issued. If the Company cancels, the earned premium shall be computed pro rata, Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation. Conformity With State Statutes: Any provision of this Policy which, on its effective date, is in conflict with the statutes of the state in which the Insured resides on such date is hereby amended to conform to the minimum requirements of such statutes. Assignment: No assignment of interest under this Policy shall be binding upon the Company unless and until the original or a duplicate thereof is filed at the Home Office of the Company, which does not assume any responsibility for the validity thereof. Renewal: Subject to the consent of the Company, this Policy may be renewed from term to term by the payment of the premium at the Company's premium rate in force at the time of renewals. In Witness Whereof, The Connecticut General Life Insurance Company has caused this Policy to be signed by its President and a Secretary but it shall not be binding upon the Company unless countersigned by a duly authorized representative of the Company. A. The Society will pay benefits equal to Three Quarters of the Covered Charges in excess of $500 which are incurred on behalf of a Covered Person as a result of an accident or a sickness; provided 1. Covered Charges of at least $500 are incurred for such accident or sickness within a sixty-day period and while this policy is in force; and 2. Benefits will be payable only with respect to those Covered Charges which are incurred (a) within a year from the beginning of the sixty-day period, and (b) within any further period during which the Covered Person is continuously confined as a registered bed patient in a hospital if the confinement commenced prior to the expiration of such year; and 3. The total benefit payable under this policy, including renewals thereof, with respect to any one accident or sickness and all recurrences and related conditions shall not exceed $7500; and 4. The payment of any benefits shall be subject to the exceptions under the provision, Charges Not Covered, and to the further provisions of this policy. B. If Covered Charges are incurred with respect to the same accident or sickness while this policy is in force and after the period for which benefits are payable under Section A of this provision and if the Benefit Limit has not been exceeded, further payments will be made in accordance with the terms of such Section A as if it were a new accident or sickness, except that the maximum payable under this policy, including renewals thereof, with respect to a Covered Person as a result of any one accident or sickness and all recurrences and related conditions shall in no event exceed $7500. C. If Covered Charges are incurred on behalf of two or more Covered Persons as a result of the same accident, the Covered Charges will be combined in determining the beginning of the sixty-day period for each Covered Person, and only one Deductible Amount will be applied in computing benefits payable. In other respects the terms of Section A of this provision will apply to each Covered Person separately. D. Payment of the Benefit Limit with respect to Covered Charges incurred on behalf of a Covered Person as the result of one accident or sickness and all recurrences and related conditions shall not preclude the payment of additional benefits with respect to Covered Charges incurred on behalf of the same Covered Person arising from a different and entirely unrelated accident or sickness. The provisions of the subsequent pages hereof form a part of this policy. This policy is executed at the Home Office of the Society in New York on the Date of Issue. BY No. 6101 SPECIMEN Secretary SPECIMEN SPECIMEN President Assistant Registrar MAJOR MEDICAL EXPENSE POLICY Renewable Only With the Consent of the Society, as Set Forth in the Provision, Renewal, on Page 3 COVERED CHARGES Covered Charges shall consist of the charges for the following services, supplies and treatments furnished, to the extent prescribed as necessary by the attending physician, but in no event shall Covered Charges exceed the regular and customary charges for such services, supplies and treatments: A. Medical or surgical treatment by a physician. B. Hospital room and board, drugs and medications for use while the Covered Person is confined in a hospital, and other medical and surgical services and supplies provided by a hospital. C. Private duty nursing service by a registered nurse. D. Other services, supplies and treatments, as follows: 1. 2. 3. 4. local ambulance service; artificial limbs or eyes; casts, splints, trusses, braces or crutches; oxygen and the rental of equipment for the administration thereof, the rental of a wheel chair, a hospital-type bed, an iron lung or other mechanical equipment required for the treatment of respiratory paralysis; 5. 6. x-ray services; A. Charges incurred for or in the course of maternity confinement or prenatal or postnatal care shall not be covered under this policy, except that in the case of any complication incident to pregnancy other than a surgical procedure for delivery of a child or children, the Society will pay benefits calculated in accordance with the Benefits provision but based only on the amounts of charges in excess of those which would have been incurred in the absence of such camplication, as determined on the basis of the regular and customary charges therefor. B. Charges shall not be covered under this policy if such charges are incurred for services, supplies, or treatment 1. not recommended and approved by a legally qualified physician, or 3. resulting from war, declared or undeclared, including armed aggression resisted by the armed forces of any country, international organization or combination of countries, or 6. for nervous or mental disease or disorder; or for injury or disease with respect to which benefits are payable under any Workmen's Compensation or Occupational Disease Act or Law. C. Charges shall not be covered under this policy for dentistry or dental x-rays, except as required because of accidental injury of sound, natural teeth occurning while this policy is in force; cosmetic surgery, unless occasioned by accidental injury occurring while this policy is in force or by a cosgenital anomaly in a child born while this policy is in force; 1. 6. drugs and medications which are purchased for use while the Covered Person is not confined in a hospital eye refractions, eye glasses or the fitting thereof; DEFINITIONS COVERED PERSON: A Covered Person is any person so named on the first page of this policy, the spouse or any child of the Insured added by amendment, and, from date of birth, a child born to the Insured while this policy is in Jurce The Insured shall be a Covered Person only if his name is included in the list of Covered Persons. A person will continue to be a Covered Person while this policy is in force, provided that: A. B. A child born to the Insured while no other children are Covered Persons will cease to be a Covered Person on the premium due date next following the date of his birth unless (i) written notice of his birth is received by the Society prior to such premium due date, and (1) this policy is renewed by payment of a prestom which includes the premium charge for such child A person shall cease to be a Covered Person at the end of the period of coverage in which occur (1) ht sixty-fifth birthday, in the case of an adult, and (ii) the earlier of his eighteenth birthday or date of mar riage, in the case of a child. C. If a Covered Person becomes a member of the military, naval, or air forces of any country, the Insured may request that such person cease to be a Covered Person as of the date of entry into such forces, and in that event the Society will allow a refund of any unearned premium. INSURED: The Insured hereunder shall be the person so designated on the first page of this policy until such per son's death, and thereafter the Insured shall be the surviving spouse, if any, of such person, provided such spouse is then a Covered Person. If on any renewal premium due date, there is no person then occupying the status of Insured, this policy shall terminate on such renewal premium due date. Subject to the Society's approval, the Insured may mait any change under this policy permitted by the Society, without the consent of any other person referred in in this posty HOSPITALI A hospital is defined as a legally constituted and operated institution having organized facilities for the care and treatment of sick and injured persons, including facilities for diagnosis and surgery, and providing twentyfour hour nursing service and medical supervision. |