Transcription
STANDARD INSURANCE COMPANYA Stock Life Insurance Company900 SW Fifth AvenuePortland, Oregon 97204-1282(503) 321-7000GROUP ACCIDENT INSURANCE CERTIFICATEPolicyholder:School Board of Brevard County, FloridaEmployer(s):School Board of Brevard County, FloridaGroup Policy Number:759084-BGroup Policy Effective Date:01/01/2022State Of Issue:FloridaThe Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by theterms of the Group Policy. If your insurance is changed by an amendment to the Group Policy, we will providethe Policyholder or Employer with a revised Certificate or other notice that will be available to you.Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet therequirements set out in this Certificate."You" and "your" mean the Member. "We", "us" and "our" mean Standard Insurance Company. Other definedterms appear with the initial letters capitalized. Section and provision headings, and references to them, appearin boldface type.Your Certificate describes the insurance under the Group Policy. Please read your Certificate carefully.You may call Standard Insurance Company at (800) 368-1135 to make inquiries, obtain information, orrequest assistance in resolving problems concerning coverage.THIS CERTIFICATE IS ISSUED UNDER A LIMITED BENEFIT POLICY THAT PROVIDES ACCIDENTINSURANCE BENEFITS AND IT DOES NOT PAY BENEFITS FOR LOSS FROM SICKNESS. THE POLICYUNDER WHICH THIS CERTIFICATE IS ISSUED DOES NOT PROVIDE COMPREHENSIVE HEALTHINSURANCE COVERAGE. IT IS NOT INTENDED TO SATISFY THE INDIVIDUAL MANDATE OF THEAFFORDABLE CARE ACT (ACA) OR PROVIDE THE MINIMUM ESSENTIAL COVERAGE REQUIRED BYTHE ACA (OFTEN REFERRED TO AS “MAJOR MEDICAL COVERAGE”). IT DOES NOT PROVIDECOVERAGE FOR HOSPITAL, SURGICAL, OR MAJOR MEDICAL EXPENSES.THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR MEDICARE,REVIEW THE “GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE” AVAILABLE FROM US.STANDARD INSURANCE COMPANYByGC0614-ACC FLORIDA
Table of ContentsCOVERAGE FEATURES . 1Employer(s) . 1Member. 1Class(es). 1Work (Occupational) Accident Covered . 1Eligibility Waiting Period . 1Premium Contributions . 1Table Of Accident Insurance Benefit Amounts . 2Additional Features . 6ELIGIBILITY AND ENROLLMENT . 7Becoming Insured . 7When Your Insurance Becomes Effective . 7Changes in Your Insurance . 7Active Work Requirement . 7When Your Insurance Ends . 7CHILD INSURANCE . 8Eligibility for Child Insurance . 8When Child Insurance Becomes Effective . 8Changes in Child Insurance . 9When Child Insurance Ends . 9SPOUSE INSURANCE. 9Eligibility for Spouse Insurance . 9When Spouse Insurance Becomes Effective . 9Changes in Spouse Insurance . 9When Spouse Insurance Ends . 9ACCIDENT INSURANCE BENEFITS . 10Insuring Clause . 10Emergency Care Benefits . 10Air Ambulance Benefit . 10Blood, Plasma, and Platelet Benefit . 10Emergency Dental Benefit . 10GC0614-ACC FLORIDA759084-B
Emergency Room Benefit. 10Ground Ambulance Benefit . 10Initial Care Visit Benefit . 11Major Diagnostic Exam Benefit . 11Outpatient X-Ray Benefit . 11Urgent Care Benefit . 11Specific Injury Benefits . 12Burn Benefit . 12Coma Benefit . 12Concussion Benefit . 12Dislocation Benefit . 12Eye Injury Benefit . 12Fracture Benefit . 13Laceration Benefit . 13Skin Graft Benefit . 13Surgical Benefits . 13Abdominal and Thoracic Surgery Benefit . 13Knee Cartilage Benefit . 13Ruptured Disc Benefit . 14Surgical Facility Benefit . 14Tendon, Ligament, and Rotator Cuff Surgery Benefit . 14Hospital Benefits . 14Critical Care Unit Admission Benefit . 14Daily Critical Care Unit Confinement Benefit . 15Daily Hospital Confinement Benefit . 15Daily Rehabilitation Facility Benefit . 15Hospital Admission Benefit . 15Follow Up Care Benefits . 16Appliance Benefit . 16Chiropractic Care Benefit . 16Follow Up Care Benefit . 16Hearing Device Benefit . 16Prosthesis Benefit . 17Therapy Services Benefit . 17GC0614-ACC FLORIDA759084-B
Additional Benefits . 17Health Maintenance Screening Benefit . 17Lodging Benefit . 18Transportation Benefit . 18Youth Organized Sports Benefit . 18AD&D Benefits . 19Accidental Death Benefit . 19Accidental Dismemberment Benefit . 19Accidental Impairment Benefit . 20Value Added AD&D Benefits . 20Air Bag Benefit . 20Common Carrier Accidental Death Benefit . 21Helmet Benefit . 21Line Of Duty Benefit . 21Repatriation Benefit . 22Seat Belt Benefit . 22EXCLUSIONS . 22ADDITIONAL FEATURES. 23Reinstatement. 23Continuity of Coverage . 23Continuation of Insurance (Portability) for the Member . 24Extension of Benefits . 24CLAIMS . 25Filing a Claim . 25Time Limits on Filing Proof Of Loss. 25Proof Of Loss . 25Investigation of Claim . 25Notice of Decision on Claim . 25Review Procedure . 25Time of Payment. 26Reimbursement . 26Unpaid Premium . 26BENEFIT PAYMENT AND BENEFICIARY PROVISIONS . 26GC0614-ACC FLORIDA759084-B
Payment of Benefits . 26Naming a Beneficiary . 27Simultaneous Death Provision . 27No Surviving Beneficiary . 27GENERAL PROVISIONS . 28Assignment . 28Time Limits on Legal Actions . 28Incontestability of Insurance . 28Clerical Error . 28Agency . 28Misstatement of Age . 28DEFINITIONS . 29GC0614-ACC FLORIDA759084-B
INDEX OF DEFINED TERMSInpatient, 31Accident or Accidental, 29Active Work, Actively At Work, 7Admitted, 29Air Bag System, 21Ambulance (Ground or Air), 29Ambulatory Surgical Center, 29Appliance, 16Automobile, 29Knee Cartilage, 14Laceration, 13Limb, 31Line Of Duty, 21Loss Of Hearing, 20Loss Of Sight, 20Beneficiary, 27Mental Disorder, 31Moderate Loss Of Hearing, 17Calendar Year, 29Child, 29Child Safety Seat, 22Chip Fracture, 13Chiropractor, 16Coma, 12Common Carrier, 21Concussion, 12Confinement or Confined, 29Covered Accident, 30Critical Care Unit (CCU), 30Dentist, 10Dependent(s), 30Dislocated, 12Dislocation, 12Eligibility Waiting Period, 30Emergency Room, 30Employer, 30Nurse Practitioner, 31Occupational Therapist, 31Organized Sport Event, 19Outpatient, 31Paraplegia, 20Physical Therapist, 31Physician, 31Physician Assistant, 31Pregnancy, 32Prior Plan, 32Proof Of Loss, 25Public Safety Officer, 22Quadriplegia, 20Rehabilitation Facility, 32Follow Up Care, 16Fracture, 13Group Policy, 30Health Care Provider, 30Health Maintenance Screening Procedures, 17Health Service Facility or Facilities, 30Hearing Device, 16Helmet, 21Hemiplegia, 20Hospital, 31Initial Care, 31Injury or Injuries, 31GC0614-ACC FLORIDASeat Belt System, 22Sickness, 32Speech Therapist, 32Spouse, 32Substance Abuse, 32Triplegia, 20Uniplegia, 20Urgent Care Facility, 32War, 22759084-B
COVERAGE FEATURESEmployer(s)School Board of Brevard County, FloridaMemberYou are a Member if you are all of the following: A regular employee of the Employer working in the United States. Actively At Work more than 25 hours each week. A citizen or resident of the United States.You are not a Member if you are: A temporary or seasonal employee. A full time member of the armed forces of any country. A leased employee. An independent contractor.Class(es)All MembersWork (Occupational) Accident Covered:YesEligibility Waiting PeriodIf you are a Member on the Group Policy Effective Date, you are eligible on that date.If you become a Member after the Group Policy Effective Date, you are eligible on the 46th day from Date ofHire.Premium ContributionsFor you or your Dependents:ContributoryContributory means you pay all or part of the premium for insurance.GC0614-ACC FLORIDA-1-759084-B
Table Of Accident Insurance Benefit AmountsEmergency Care BenefitsAir Ambulance Benefit 800Blood, Plasma, and Platelet Benefit 300Emergency Dental BenefitCrown 200Extraction 100Emergency Room Benefit 500Ground Ambulance Benefit 300Initial Care Visit Benefit 500Major Diagnostic Exam Benefit 300Outpatient X-Ray Benefit 300Urgent Care Benefit 500Specific Injury BenefitsBurn Benefit2nd degree burn less than or equalto 15% of body surface 2002nd degree burn greater than 15%of body surface 1,0003 rd degree burn less than or equalto 15% of body surface 5,0003rd degree burn greater than 15%of body surface 10,000Coma Benefit 7,500Concussion Benefit 500Dislocation BenefitNon-surgicalSurgicalAnkle 800 1,600Collarbone (sternocalvicular) 800 1,600Collarbone (acromio andseparation) 400 800Elbow 800 1,600Finger(s) 150 300Foot (not including toe(s)) 800 1,600Hand (not including finger(s)) 800 1,600Hip 2,500 5,000Knee (not including kneecap) 900 1,800GC0614-ACC FLORIDA-2-759084-B
Lower jaw 800 1,600Rib 150 300Shoulder 800 1,600Spine 400 800Toe(s) 150 300Wrist 800 1,600Partial Dislocation25% of the non-surgical amount payable for thespecific dislocation amount shown aboveEye Injury Benefit 200Fracture BenefitNon-surgicalSurgicalAnkle 550 1,100Arm (elbow to wrist) 550 1,100Arm (shoulder to elbow) 550 1,100Bones of face (other than lower jawor nose) 500 1,000Coccyx 500 1,000Collarbone 550 1,100Elbow 550 1,100Finger(s) 100 200Foot (not including toe(s)) 550 1,100Hand (not including finger(s)) 550 1,100Hip 2,500 5,000Kneecap 550 1,100Leg (knee to ankle) 1,200 2,400Leg (hip to knee) 2,000 4,000Lower jaw 550 1,100Nose 500 1,000Pelvis 1,200 2,400Rib 400 800Shoulder blade 550 1,100Depressed 4,000 8,000Non-depressed 1,500 3,000Sternum 550 1,100Toe(s) 100 200Vertebrae 500 1,000Vertebral Column 1,200 2,400SkullGC0614-ACC FLORIDA-3-759084-B
Wrist 550 1,100Chip Fracture25% of the non-surgical amount payable for thespecific fracture shown aboveLaceration BenefitLess than 2 inches combinedlength for all lacerations 752-6 inches combined length for alllacerations 200Over 6 inches combined length forall lacerations 500Skin Graft Benefit25% of Burn BenefitSurgical BenefitsAbdominal and Thoracic SurgeryBenefitExploratory surgery (bothlaparoscopic and open) 200Laparoscopic surgical repair 750Open surgical repair 1,500Knee Cartilage BenefitExploratory surgery 200One surgical repair 750Ruptured Disc Benefit 750Surgical Facility Benefit 150Tendon, Ligament, and Rotator CuffSurgery BenefitExploratory of any of the above 200Repair of one of the above 750Repair of more than one of theabove 1,000Hospital BenefitsCritical Care Unit Admission Benefit 2,000Daily Critical Care Unit ConfinementBenefit 600 per dayDaily Hospital Confinement Benefit 600 per dayDaily Rehabilitation Facility Benefit 100 per dayHospital Admission Benefit 2,000Follow Up Care BenefitsGC0614-ACC FLORIDA-4-759084-B
Appliance Benefit 500Chiropractic Care Benefit 100 per dayFollow Up Care Benefit 350 per dayHearing Device Benefit 500Prosthesis BenefitOne Prosthetic 500More than one Prosthetic 1,000Therapy Services Benefit 350 per dayAdditional BenefitsHealth Maintenance ScreeningBenefit 50 per dayLodging Benefit 175 per dayTransportation Benefit 1,000 per dayYouth Organized Sports Benefit25% of total Covered Accident benefits payable forChildAccidental Death and Dismemberment (AD&D) BenefitsAccidental Death Benefit (AD Benefit)For you: 150,000For your Spouse: 75,000For your Child(ren): 37,500Accidental Dismemberment BenefitOne hand or one foot15% of AD BenefitBoth hands or feet30% of AD BenefitOne hand and one foot30% of AD BenefitOne finger or toe2% of AD BenefitMore than one finger or toe5% of AD BenefitAccidental Impairment BenefitLoss Of HearingOne ear15% of AD BenefitBoth ears30% of AD BenefitLoss Of SightOne eye15% of AD BenefitBoth eyes30% of AD BenefitGC0614-ACC FLORIDA-5-759084-B
Hemiplegia30% of AD BenefitParaplegia30% of AD BenefitQuadriplegia50% of AD BenefitTriplegia30% of AD BenefitUniplegia15% of AD BenefitValue Added AD&D BenefitsAir Bag Benefit10% of AD BenefitCommon Carrier Accidental DeathBenefit100% of AD BenefitHelmet Benefit10% of AD BenefitLine Of Duty Benefit100% of AD&D BenefitRepatriation Benefit10% of AD BenefitSeat Belt Benefit10% of AD BenefitAdditional FeaturesReinstatementContinuity of CoverageContinuation of Insurance (Portability) for the MemberExtension of BenefitsGC0614-ACC FLORIDA-6-759084-B
ELIGIBILITY AND ENROLLMENTBecoming InsuredTo become insured you must: Be a Member. Complete your Eligibility Waiting Period. Meet the requirements shown in When Your Insurance Becomes Effective and Active WorkRequirement.When Your Insurance Becomes EffectiveThe Coverage Features states whether insurance is Contributory or Noncontributory. Subject to the ActiveWork Requirement, your insurance becomes effective as follows:Contributory InsuranceYou must apply in writing for Contributory insurance and agree to pay premiums. Contributory insurancebecomes effective on:The date you become eligible if you apply on or before that date.The first day of the calendar month coinciding with or next following the date you apply, if youapply after you become eligible.Changes in Your InsuranceSubject to the Active Work Requirement, you may apply in writing for any increase in your insurance, forwhich you are eligible.Increases become effective the latest of:The first day of the calendar month coinciding with or next following the date you apply for theincrease.Decreases become effective on the later of:The first day of the calendar month coinciding with or next following the date of change in your Class.The first day of the calendar month coinciding with or next following the date the Policyholder orEmployer receives your written request for the decrease.Active Work RequirementIf you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before thescheduled effective date of your insurance under the Group Policy, your insurance will not become effectiveuntil the day after you complete 1 full day(s) of Active Work as an eligible Member.Active Work and Actively At Work mean performing the material duties of your own occupation at yourEmployer's usual place of business.You will also meet the Active Work requirement if you meet all of the requirements shown below:You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day.You were Actively At Work on your last scheduled work day before the date of your absence.You were capable of Active Work on the day before the scheduled effective date of your insurance.When Your Insurance EndsGC0614-ACC FLORIDA-7-759084-B
Insurance ends automatically on the earliest of the following:For Contributory insurance, the date you notify your Employer or Policyholder in writing that coverageis to be terminated.The date the last period ends for which the premium was paid for your insurance.The date the Group Policy or your Employer's coverage under the Group Policy terminates.The first day of the calendar month following the date your employment terminates, unless youcontinue your insurance under the Continuation of Insurance (Portability) for the Memberprovision.The date you cease to be a Member. However, if you cease to be a Member because you are notworking the required minimum number of hours, your insurance will be continued with payment ofpremium:During the first 60 day(s) of a temporary or indefinite administrative leave of absence.During any other scheduled leave of absence approved by your Employer in advance and inwriting and lasting not more than 60 day(s).During a leave of absence which is required by the federal or a state-mandated family ormedical leave act or law.CHILD INSURANCEEligibility for Child InsuranceYou become eligible to insure your Child(ren) on the later of:The date your insurance becomes effective if you have a Child on that date.The date you first acquire a Child, if you are insured on that date.A Member may not be insured as both a Member and a Child. A Child may not be insured by more than oneMember.For Contributory Child insurance, if you do not have Child insurance at the time you acquire a newborn oradopted Child, you must: (1) notify us within 31 days from the date of birth or placement; (2) apply in writingwithin that 31-day time period; and (3) agree to pay the required premium for your Child insurance. If notice isgiven within that 31-day period, no additional premium may be charged for that 31-day period. If you applywithin that time period, your Child insurance will continue beyond those 31 days, subject to payment ofpremium. If you: (1) do not apply for Child insurance within that 31-day time period but do apply in writingwithin 60 days from the date of birth or placement; and (2) agree to pay premium for the Child insurance fromthe date of birth or placement; then (3) insurance will become effective on the date of birth or placementWhen Child Insurance Becomes EffectiveThe Coverage Features states whether your Child insurance is Contributory or Noncontributory. You mustapply in writing for Contributory Child insurance and agree to pay premiums.Contributory Child insurance becomes effective on the latest of:The date your insurance becomes effective if you have a Child on that date and you have applied forChild insurance.GC0614-ACC FLORIDA-8-759084-B
The first day of the calendar month coinciding
Portland, Oregon 97204-1282 (503) 321-7000 GROUP ACCIDENT INSURANCE CERTIFICATE Policyholder: School Board of Brevard County, Florida Employer(s): School Board of Brevard County, Florida Group Policy Number: 759084-B Group Policy Effective Date: 01/01/2022 . Chiropractic Care Benefit 100 per day Follow Up Care Benefit 350 per day
