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Group Hospital Indemnity Plan Pays benefits for hospitalization ABJ23902X-1 Page 1 of 4 group hospital indemnity plan Group Hospital Indemnity coverage from Allstate Benefits pays cash benefits for expenses associated with a hospital stay due to sickness or injury, plus emergency room services for accidental injuries. Being hospitalized is something everyone may experience in their lifetime. When it does happen, having the right supplemental hospitalization coverage in place can help offer peace of mind. Most major medical insurance plans only pay a portion of the hospital bills. Our coverage helps pick up where other insurance leaves off and provide cash to help cover the expenses. Our hospital confinement coverage helps offer peace of mind when you are hospitalized. Below is an example of how benefits are paid.* Group Hospital Indemnity Plan While in the emergency room the employee was examined by a physician who recommended admittance to the hospital intensive care unit. After one day in intensive care the employee was moved to an in-patient hospital room for a 3-day hospital stay. Several days later the employee was going out to dinner, was in a car accident, and rushed to the hospital emergency room. During the 3-day hospital stay the employee had several tests performed and was visited by the admitting physician. At the end of the 3-day stay the employee was released. Employee selected the Employee incurred expenses for services and treatment in the hospital. In addition to what major medical insurance paid, our hospital confinement benefits paid for: Benefits for 4-day Hospital Stay First Day Confinement $1,100 Daily Confinement $ 300 Intensive Care $100 Emergency Room $500 Total Benefits: $2,000 meeting your needs your benefit coverage† Our hospital confinement coverage helps offer peace of mind when a sickness or injury occurs. The following benefits will pay for services and treatments due to sickness or injury, unless otherwise noted for you and/or a covered family member. Treatment must be received in the U.S. or its territories. • Coverage that is guaranteed issue; there are no medical exams or tests to take • Benefits that correspond with hospital and emergency room treatment • Affordable premiums • Coverage for employee, employee + spouse/domestic partner, employee + child(ren) and family • Benefits paid directly to you, unless you assign them to someone else • Portable coverage To Enroll: Please contact the American Red Cross Benefits Service Center (1-877-860-7526) or online at http://resources.hewitt.com/redcross Page 2 of 4 ABJ23902X-1 Initial Hospital Confinement - Pays when you are hospital confined for the first time after your effective date. Paid once per year per covered person. Not paid for a newborn child’s initial hospitalization after birth. Daily Hospital Confinement - Pays after the first day of admittance as an inpatient, up to 29 days, for the first continuous hospital confinement in a year. For the second and any following confinements in a year, pays for each day, up to 30 days. Hospital Intensive Care - Pays when you are confined in a hospital intensive-care unit up to 60 days for each continuous hospital confinement. This benefit is paid in addition to the Initial Hospital Confinement benefit and Daily Hospital Confinement benefit. Emergency Treatment Center (Outpatient Emergency Accident) Pays emergency treatment services for injuries requiring medical or surgical treatment after your effective date. Paid once per accident, per covered person. *Your individual experience may vary. †Pays stated amounts for sickness or injury only. Benefit amounts are shown on pages 2a. See page 3 for limits and conditions. coverage specifications Conditions and Limits - We pay benefits as stated for service and treatment administered or received by the covered person while coverage is in force, for the care and treatment of sickness or injury when recommended by a physician. Any loss not stated in the provisions is not covered. Treatment must be received in the United States or its territories. Your Eligibility - Your employer decides who is eligible for your group (such as length of service and hours worked each week). Issue ages are 18 and over. Dependent Eligibility/Termination - (a) Coverage may include you, your spouse or domestic partner, and your children, and domestic partner’s children. (b) Coverage for children ends upon your death or when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. (c) Spouse coverage ends upon valid decree of divorce or your death. (d) Domestic partner coverage ends upon termination of domestic partnership or your death. When Coverage Ends - Coverage under the policy ends on the earliest of: (a) the date the policy is canceled; (b) the last day of the period for which you made any required contributions; (c) the last day of the month you are in active employment, except as provided under the “Temporary Layoff, Leave of Absence, or Family and Medical Leave of Absence” provision; (d) the date you are no longer in an eligible class; (e) the date your class is no longer eligible. Continuation of Coverage - You may be eligible to continue coverage when coverage under the policy ends. You have 30 days after coverage under the policy ends to let us know if you wish to continue coverage. Group Hospital Confinement Exclusions and Limitations Benefits are not paid for: (a) injury or sickness incurred before the effective date, subject to the Time Limit on Certain Defenses provision; (b) any act of war or participation in a riot, insurrection or rebellion; (c) suicide or attempted suicide; (d) participation in aeronautics unless a fare-paying passenger on a licensed common-carrier aircraft; (e) injury while engaging in an illegal occupation or committing or attempting an assault or felony; (f) cosmetic dentistry or plastic surgery, except to treat an injury or correct a disorder or normal body function; (g) self inflicted injury; (h) a newborn child’s routine nursing or well baby care; (i) hospitalization beginning before the effective date; (j) the reversal of a tubal ligation or vasectomy; (k) artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician services, unless required by law; (l) driving in any race or speed test or testing any motorized vehicle on any racetrack or speedway. Hospital Intensive Care - A Hospital Intensive Care Unit means a hospital area of special care, including cardiac and coronary care units, surgical intensive care units or cardiovascular intensive care units, which at the time of admission are separate and apart from the surgical recovery room, or other rooms, beds or wards normally used for patient confinement. In addition, such a unit must provide the following: (a) 24 hour continuous nursing care and attendance by nurses assigned to the unit on a full-time basis; (b) direction and/or supervision by a full-time physician director or a standing “intensive care” committee of the medical staff; (c) special medical apparatus used to treat the critically ill. The following do not qualify as Hospital Intensive Care Units: (a) progressive care units; (b) sub-acute intensive care units; (c) intermediate care units; (d) private rooms with monitoring; (e) step-down units; or (f) any other lesser care treatment units. Nurse means any one of the following who is not a member of the covered person’s immediate family: (a) licensed practical nurse (L.P.N.); (b) licensed vocational nurse (L.V.N.); or (c) graduate registered nurse (R.N.). Emergency Treatment Center (Outpatient Emergency Accident) - Emergency treatment center means the emergency room of a hospital and ambulatory surgical centers, and satellite emergency centers of a hospital. Ambulatory surgical center means a licensed surgical center consisting of an operating room, facilities for the administration of general anesthesia and a post surgery recovery room in which the patient is admitted to, and discharged from, within a period of less than 24 hours. ABJ23902X-1 Page 3 of 4 Rev. 10/15. This material is valid as long as information remains current, but in no event later than July 1, 2016. Group Hospital Confinement benefits provided by policy form GHCPNC, or state variations thereof. Coverage is provided by supplemental, limited benefit insurance. This is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer’s Guide available from Allstate Benefits. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the policyholder (employer) and the insurance company. For complete details, go to: http://www. allstatebenefits.com/americanredcross/ Underwritten by American Heritage Life Insurance Company. This is a brief overview of the benefits available under the Group Voluntary Policy issued by Allstate Benefits. Details of the insurance,including exclusions, restrictions and other provisions are included in the certificates issued. This coverage does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. The American Red Cross Group Hospital Indemnity Plan is sitused in North Carolina. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2015 Allstate Insurance Company. www.allstate.com or allstatebenefits.com. Page 4 of 4 ABJ23902X-1 group hospital indemnity plan BASE BENEFITS Initial Hospitalization Confinement (paid once per year) PLAN $1,100 1 Daily Hospital Confinement2 $100 $100 Hospital Intensive Care3 Emergency Treatment Center (Outpatient Emergency Accident) (paid once per accident)1 1 per covered person. 2 up to 30 days maximum. 3 up to 60 days maximum. $500 premiums MODE Semi-Monthly EE EE + SP EE + CH F $8.99$17.99 $11.67 $20.66 EE = Employee; EE + SP = Employee + Spouse/Domestic Partner; EE + CH = Employee + Child(ren); and F = Family Issue ages: 18 and over if Actively at Work This insert is for use in: NC This insert is part of brochure ABJ23902X-1 and is not to be used on its own. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2015 Allstate Insurance Company. www.allstate.com or allstatebenefits.com. ABJ23902X-1-Insert-ARC Page 2a