Medical Bridge 3000 – Hospital Confinement Indemnity Insurance

Can you afford the out-of-pocket costs not covered by your health insurance?

How will you cover all of your medical expenses?

As major medical plans move toward larger deductibles and higher co-payments, you may be left with more gaps to fill.

Colonial Life’s Hospital Confinement Indemnity Insurance plan can help you fill those gaps and help protect against those out-of-pocket expenses that occur when it comes to you or your family members’ healthcare.

Benefits of this plan include:

Blood test for triglycerides Colonoscopy or Virtual Colonoscopy PSA (blood test for prostate cancer)
Breast ultrasound Fasting blood glucose Serum protein electrophoresis (blood test for myeloma)
CA 15-3 (blood test for breast cancer) Flexible sigmoidoscopy CA 125 (blood test for ovarian cancer)
Hemoccult stool analysis Serum cholesterol test for HDL and LDL CEA (blood test for colon cancer)
Mammography Stress test on a bicycle or treadmill Chest x-ray Pap smear or Thin Prep Pap Thermography

The following benefits are payable due to a covered accident or covered sickness:

More than six in ten adults who report problems paying medical bills are covered by health insurance.*

Wouldn’t you feel better knowing that you or your family have the added protection that Colonial Life can provide to help fill those unexpected gaps?

With This Plan:

Consider the following:

75% percent of individuals declaring personal bankruptcy for medical reasons in 2001 were insured at the onset of their illness.**

The Colonial Advantage

Medical Bridge 3000 – Plan 2 Benefit Amount Options & Monthly Premiums

CA Hospital Confinement $500 Outpatient Surgery Tier 1 $750 Outpatient Surgery Tier 2 $1,500

Age Employee EE & Spouse EE & Dependent Children EE, Spouse & Dependent Children
17-49 15.60 33.40 26.45 40.45
50-59 21.55 45.90 32.00 52.10
60-64 28.15 61.05 39.20 66.30
65-74 37.05 80.40 51.60 87.20

CC Hospital Confinement $1,500 Outpatient Surgery Tier 1 $750 Outpatient Surgery Tier 2 $1,500

Age Employee EE & Spouse EE & Dependent Children EE, Spouse & Dependent Children
17-49 26.40 56.70 45.05 68.65
50-59 36.55 78.10 54.40 88.60
60-64 47.65 103.85 66.80 112.60
65-74 62.75 136.60 87.80 148.10

COLONIAL LIFE 1200 Colonial Life Boulevard, P.O. Box 1365 Columbia, South Carolina 29202 (800) 325-4368 A Stock Company LIMITED BENEFIT HOSPITAL CONFINEMENT INDEMNITY INSURANCE - OUTLINE OF COVERAGE (Applicable to Policy form MB3000-NC) BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company. Premiums vary depending on your level of coverage.

Read your policy carefully. Your outline provides a very brief description of the important features of your policy. This is not an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of both you and us. It is, therefore, important that you READ YOUR POLICY CAREFULLY. Renewability. Your policy is guaranteed renewable as long as you pay the premiums when they are due or within the grace period. The premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued. Limited Benefit Coverage. Your policy does not provide coverage for basic hospital, basic medical-surgical or major medical expenses.

Benefits

Hospital Confinement Benefit Amount: $__________ per confinement
We will pay this benefit if any covered person incurs charges for and is confined due to a covered accident or covered sickness. The confinement to a hospital must begin while the policy is in force.
We will pay this benefit once per confinement. If a covered person is confined and is discharged and confined again for the same or related condition within 90 days of discharge, we will treat this later confinement as a continuation of the previous confinement. If more than 90 days have passed between the periods of hospital confinement, we will treat this later confinement as a new and separate confinement.

Outpatient Surgical Procedure Benefit

Tier 1 Surgical Procedures $__________ per covered procedure

Tier 2 Surgical Procedures $__________ per covered procedure

Calendar Year Maximum $__________ per covered person for all covered surgical procedures combined

We will pay this benefit if any covered person incurs charges for and requires a surgical procedure due to a covered accident or covered sickness, and he is not confined in a hospital at the time of the procedure. The procedure must be performed by a doctor in a hospital or ambulatory surgical center. We will pay this benefit once per covered outpatient surgical procedure. We will pay this benefit for only one outpatient surgical procedure performed at the same time even if caused by more than one accident or sickness. In that event, we will pay the benefit that has the highest dollar value. The surgical procedure must occur while the policy is in force.
Ambulatory Surgical Center means a place which:

Surgical Procedure means the cutting into the skin or other organ to accomplish any of the following goals

The following will not be considered a surgical procedure for the purposes of the policy;

To determine the amount payable for a surgical procedure, located the procedure in one of the tiers shown in the Surgical Schedule below and refer to the benefit amount in the Policy Schedule for the tier in which the procedure appears.

If the specific procedure is not listed in the Surgical Schedule, we will use the Current Procedural Terminology (CPT) Code provided by the covered person’s doctor and a current relative value scale to determine the tier of the procedure.

We will pay for only one surgical procedure for the same covered accident or same covered sickness in a 90-day time period. If a covered person receives a subsequent surgical procedure for the same covered accident or same covered sickness, we will pay an additional benefit only if the subsequent procedure was performed more than 90 days after the last covered procedure was performed.

We will pay no more than the Calendar Year Maximum for the Outpatient Surgical Procedure Benefit shown.

If any covered person has an outpatient surgical procedure and is confined as a result of complications from the surgery within 90 days following the surgery, we will pay only the Hospital Confinement Benefit and not pay the Outpatient Surgical Procedure Benefit.

If we have already paid the Outpatient Surgical Procedure Benefit, we will deduct the Outpatient Surgical Procedure Benefit amount paid from any Hospital Confinement Benefit that is payable.

Tier 1 Surgical Procedures

Tier 2 Surgical Procedures

Wellness Benefit Amount: $50 per test, one test per calendar year if named insured coverage; two tests per calendar year if named insured and spouse coverage, one-parent family coverage or two-parent family coverage

We will pay this benefit if any covered person incurs charged for and has one of the wellness tests listed below performed while the policy is in force. We will pay the amount shown for one of the following wellness tests:

We will pay up to the maximum number of tests shown.

Rehabilitation Unit Benefit Amount: $100 per day up to 15 days per confinement with a 30 day maximum per covered person per calendar year

We will pay this benefit if any covered person incurs charges for and is transferred to a rehabilitation unit immediately after a period of hospital confinement due to a covered accident or covered sickness. We will pay the amount shown for each day of confinement in a rehabilitation unit, up to the maximum number of days shown.

Confinement to a rehabilitation unit must begin while the policy is in force.

Waiver of Premium Benefit After you have been confined to a hospital due to a covered accident or covered sickness for more than 30 continuous days while the policy is in force, we will waive the premium for the policy and any attached riders for as long as you remain confined to a hospital or rehabilitation unit.

You must pay all premiums to keep the policy and any attached rider(s) in force until you have been confined to a hospital for more than 30 continuous days and the waiver becomes effective. You must send us written notice as soon as you are no longer confined to a hospital or rehabilitation unit. We will assume you are no longer confined to a hospital or rehabilitation unit if:

You must pay all premiums to keep the policy in force beginning with the first premium due after you are no longer confined to a hospital or rehabilitation unit.

The Waiver of Premium Benefit does not apply to any period that you are confined to a hospital or rehabilitation unit due to an accident, sickness or condition which is excluded by name or specific description. The benefit does not apply to your spouse or to your children. We will waive premiums only if you, the named insured, are confined to a hospital for more than 30 continuous days. However, if this is a named insured and spouse, one-parent family policy or a two-parent family policy, we will waive premiums on all family members insured by the policy.

Definitions - Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily infirmity, illness, infection, or any other abnormal physical condition. Calendar Year means the period beginning on the effective date of coverage shown on the Policy Schedule and ending on December 31 of the same year. Thereafter, it is the period beginning on January 1 and ending on December 31 of each following year. Confined or Confinement means the assignment to a bed as a resident inpatient in a hospital on the advice of a physician or, for purposes of the hospital confinement benefit only, confinement in an observation unit within a hospital for a period of no less than 20 continuous hours on the advice of a physician. Covered Accident means an accident which occurs on or after the effective date of the policy, occurs while the policy is in force, and is not excluded by name or specific description in the policy. Covered Sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an accident, which occurs on or after the effective date of the policy, occurs while the policy is in force, and is not excluded by name or specific description in the policy. Covered sickness also included complications of pregnancy of a covered dependent child and pregnancy or complications of pregnancy of a covered spouse or named insured. Dependent Children means any natural children, step-children, legally adopted children, foster children, children for whom the named insured is required by court or administrative order to provide coverage or children placed into your custody for adoption who are unmarried and younger than age 26. Doctor or Physician means a person who is licensed by the state to practice a healing art and performs services for a covered person which are allowed by his license. For purposes of this definition, Doctor or Physician does not include any covered person or anyone related to any covered person by blood or marriage, a business or professional partner of any covered person, or any person who has a financial affiliation or a business interest with any covered person. Emergency Room means a specified area within a hospital which is designated for the emergency care of accidental injuries or sicknesses. This area must be staffed and equipped to handle trauma, be supervised and provide treatment by physicians and provide care seven days per week, 24 hours per day. Hospital means a place that is run according to law on a full-time basis, provides overnight care of injured and sick people, is supervised by a doctor, has full-time nurses supervised by a registered nurse, and has at its locations or uses on a pre-arranged basis: X-ray equipment, a laboratory and an operating room where surgical where surgical operations take place. A hospital is not a nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a rehabilitation unit, a place for alcoholics or drug addicts or an assisted living facility. Observation Unit means a specified area within a hospital, apart from the emergency room, where a patient can be monitored following outpatient surgery or treatment in the emergency room by a physician and which is under the direct supervision of a physician or registered nurse, is staffed by nurses assigned specifically to that unit and provides care seven days per week, 24 hours per day. Pre-existing Condition means any covered person having sickness or physical condition for which he was treated, had medical testing, received medical advice or had taken medication within 12 months before the effective date of the policy. Rehabilitation Unit means an appropriately licensed facility that provides rehabilitation care services on an inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by sickness or accidental injury to achieve the highest possible functional ability. Services are provided by or under the supervision of an organized staff of physicians. The rehabilitation unit may be part of a hospital or a freestanding facility. A rehabilitation unit is not a nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a hospice care facility, a place for alcoholics or drug addicts, or an assisted living facility.

What is Not Covered We will not pay benefits for injuries received in accidents or for sicknesses which are caused by:

  1. Any covered person’s addiction to alcohol or drugs, except for drugs taken as prescribed by his doctor.
  2. Any covered person’s treatment for dental care or dental procedures, unless treatment is the result of a covered accident. However, treatment involving any bone or joint of the jaw, face or hear will be covered so long as the care or procedure is necessary to treat a condition which prevents normal functioning of the particular bone or joint involved and the condition is caused by congenital deformity, disease or traumatic injury.
  3. Any covered person undergoing elective procedures or cosmetic surgery. This includes procedures for complications arising from elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child or reconstructive surgery related to a covered sickness or injuries received in a covered accident.
  4. Any covered person participating or attempting to participate in an illegal activity.
  5. Any pregnancy of a dependent child, including services rendered to her child after birth. However, complications of pregnancy of a dependent child will be covered to the same extent as any other covered sickness. Complications of pregnancy are those conditions, requiring treatment, whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or caused by pregnancy. These include, but are not limited to, acute nephritis, nephrosis, cardiac decomposition, missed abortion, miscarriage, non-elective Cesarean, non-elective abortion and similar medical and surgical conditions of comparable severity. Complications of pregnancy do not include false labor, morning sickness, hyperemesis gravidarum and similar conditions associated with the management of a difficult pregnancy.
  6. Any covered person having a psychiatric or psychological condition including but not limited to affective disorders, neuroses, anxiety, stress and adjustment reactions. However, Alzheimer’s Disease and other organic senile dementias are covered under the policy.
  7. Any covered person committing or trying to commit suicide or injuring himself intentionally, whether he is sane or not.
  8. Any covered person’s involvement in any period of armed conflict, even if it is not declared.

Well Baby Care Limitation - We will not pay benefits for hospital confinement of a newborn child following his birth unless he is injured or sick.

Pre-existing Condition Limitation - We will not pay benefits for Hospital Confinement, Rehabilitation Unit Confinement or Outpatient Surgical Procedure for any covered person when such loss results from a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Policy Schedule.

*USA Today/Kaiser Family Foundation/Harvard School of Public Health Health Care Costs Survey (conducted April 25-June 9, 2005)

**Illness and Injury as Contributors to Bankruptcy,” February 2005 Issue of Health Affairs

Copyright © 2007 Pierce Group Benefits, LLC. All Right Reserved.
This website highlights the voluntary benefits offered through your employer for the current plan year. This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet. Please meet with your Colonial Representative during the Open Enrollment Period to verify the information contained within this booklet as well as your own policy information.