Download outline of coverage for policy form 5km, 5kn, and 5ko

OUTLINE OF COVERAGE FOR POLICY FORM 5KM, 5KN, AND 5KO
LIBERTY NATIONAL LIFE INSURANCE COMPANY
P.O. Box 2612 • Birmingham, AL 35202 • Telephone (205) 325-4979
LIMITED BENEFIT INSURANCE--CANCER AND SPECIFIED DISEASE COVERAGE
(Please keep for your records)
NOTICE: This notice is to advise You that should any complaints arise or if
You need to obtain information regarding this insurance You may contact the following:
Consumer Service Department • Telephone 205-325-4979
Liberty National Life Insurance Company • P.O. Box 2612 * Birmingham, Alabama 35202
READ YOUR POLICY CAREFULLY-- This outline of coverage provides a very brief description of the important features of
your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth
in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR
POLICY CAREFULLY.
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FAMILY-- If family coverage is selected, this policy covers the proposed insured, insured’s spouse named in the
application for this policy and insured’s children, legally adopted children, and stepchildren provided such children,
adopted children, or stepchildren (1) are less than 21 years of age, (2) are unmarried, and (3) either reside in your
household or are dependent upon you for their support. Coverage on mentally or physically incapacitated children may
continue even longer. Coverage on full-time students may continue to age 25.
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SINGLE PARENT-- If single parent coverage is selected, this policy covers the proposed insured, insured’s children, legally
adopted children, and stepchildren provided such children, adopted children, or stepchildren (1) are less than 21 years of
age, (2) are unmarried, and (3) either reside in your household or are dependent upon you for their support. Coverage on
mentally or physically incapacitated children may continue even longer. Coverage on full-time students may continue to
age 25.
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INDIVIDUAL-- This policy covers the proposed insured.
CANCER AND DREAD DISEASE POLICY-- This policy insures person(s) covered under the policy against losses due to hospital
confinement and other specified expenses you incur resulting from treatment of cancer and other specified diseases which first
manifest themselves 30 or more days after the effective date of this policy.
FIRST OCCURRENCE BENEFIT-- Liberty National’s Cancer Policy will pay a one-time benefit of $3,500 when cancer (except nonmelanoma skin cancer) is manifested after the 30-day waiting period.
HOSPITAL CONFINEMENT BENEFIT-- $250 per day for the first 90 days and $600 per day thereafter. No maximum number
of days.
DREAD DISEASE BENEFIT-- Pays Hospital Confinement Benefit for certain specified diseases.
OUTPATIENT SURGERY BENEFIT-- We will pay $250 per day covering charges by hospital or ambulatory surgical center for
surgical procedures as an outpatient.
RADIATION THERAPY AND CHEMOTHERAPY DRUG BENEFIT-- This cancer policy will pay a maximum to $500 per day hospital
and physician charges for radiation therapy and chemotherapy and the professional administration thereof.
PRESCRIPTION CHEMOTHERAPY DRUG BENEFIT-- A maximum yearly payment of $10,000 will be paid for the expense of antineoplastic drugs prescribed by a physician to be self-administered, or administered by someone who is not a physician or nurse.
NEW OR EXPERIMENTAL TREATMENT BENEFIT-- We will cover new or experimental treatment for cancer under the regular
schedule of benefits, provided the treatment is approved by the American Medical Association; is administered in the continental
United States by a licensed physician; and you incur a charge for such treatment.
BLOOD TRANSFUSION BENEFIT-- We will pay up to $500 per day for blood or blood components, administration and processing
of blood or plasma. Cross matching, laboratory tests, supplies or blood subsequently replaced by a donor are not covered.
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TRANSPORTATION BENEFIT-- We will pay the amount charged for the covered insured and one attendant for transportation
by commercial aircraft, bus or professional ambulance, exclusive of air ambulance, to and from any hospital or clinic in the
continental United States for specialized treatment deemed necessary by a physician where similar services are not available in
the city where you live. We will reimburse you $.25 per mile for travel more than100 miles away (one way) in your personal car.
Maximum benefit will be six round trips in a consecutive 12-month period.
SURGICAL BENEFIT-- The maximum payment for any one surgical procedure will be the amount shown in the surgical schedule.
Payments for surgical procedures not listed in the surgical schedule will be determined by us on a consistent basis with the
surgical schedule with a minimum payment of $25 and a maximum payment of $2,000.
ANESTHETIST BENEFIT-- We will pay you the lesser of the amount charged for the administration of anesthesia or 25% of the
amount payable for the surgery.
ATTENDING PHYSICIAN BENEFIT-- We will pay a maximum payment of $35 per day for physician’s services (other than the
operating surgeon).
PRIVATE NURSE BENEFIT-- We will pay a maximum payment of $75 per day to a graduate registered nurse or licensed practical
nurse exclusive of general hospital nursing care.
PROSTHESIS BENEFIT-- We will pay up to $750 for a surgically implanted or external prosthesis with a lifetime limit of
two devices.
HOSPICE BENEFIT-- A maximum benefit of $75 will be payable for hospice service, a visit from a representative of a hospice, and
treatment at a hospice center if cancer treatments are no longer beneficial and life expectancy is six months or less. This benefit
will not be payable if the insured is confined to a hospital.
INCOME REPLACEMENT BENEFIT-- $100 per week for disability due to cancer after 14-day elimination period. Benefits cease
after the earlier of: (a) a lifetime maximum of 26 completed weeks of disability. Only covered persons who are gainfully employed
when the disability begins are eligible for this benefit.
FIRST DIAGNOSIS-- The first time a Covered Person is diagnosed as having internal cancer or malignant melanoma (this excludes
all other Skin Cancer); provided the diagnosis is after the waiting period and while this policy is in force with respect to the
covered person.
WAITING PERIOD-- No benefit is payable if cancer first manifests itself before the policy has been in force for 30 days from the
effective date shown in the policy schedule. Cancer is first manifested when symptoms exist.
CANCELLATION-- You may cancel this policy at any time by written notice delivered or mailed to us, effective upon receipt of
such notice or on such later date as may be specified in such notice. In the event of such cancellation, or the death of the insured,
we will return the unearned portion of premiums paid for any period from the moment of such cancellation or death. Cancellation
shall be without prejudice to any claim originating prior to the effective date of cancellation.
EXCEPTIONS-- This policy does not cover medical treatment: (1) for any disease, sickness or incapacity other than cancer or
specified dread disease; (2) for which no charge is normally made in the absence of insurance; (3) under any governmental plan
except through U.S. governmental hospitals; (4) outside the United States; (5) not accepted or approved by the American Medical
Association; (6) by the use of drugs not approved by the Federal Drug Administration for use in the treatment of cancer; (7) for
cancer manifested before this policy has been in force 30 days, coverage will apply to losses commencing after two years from
the effective date and no First Occurrence Benefit will be paid; or (8) if you are confined to a U.S. Government hospital, only the
Hospital Confinement and, if applicable, the First Occurrence Benefits will be paid.
GUARANTEED RENEWABLE; PREMIUMS SUBJECT TO CHANGE-- Your policy is guaranteed renewable for life. You may renew
this contract by paying each renewal premium as it falls due or during the grace period. We cannot cancel or refuse to renew your
policy. We reserve the right to change premium rates. A change in the rates will apply to all policies of this form issued by us and
in force in the state where you live. If we can change the rates, your premium will be determined by your age on the effective date
of this policy. If we change the rates, we will write you 45 days or more before the change at the address shown in our records. We
will not restrict or limit your policy in any other way while it is in force.
This outline of coverage is only a brief summary and is not the contract of insurance. Please refer to the policy for further
policy provisions.
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