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Basic Group Term Life InsuranceandBasic AD&D InsuranceA guide toyour benefitsYou've made a good decision in choosing Anthem LifePlan Sponsor:Policy:Class:Class Description:Capital Area Health Consortium Inc.AL0000643701All Eligible Employeesanthem.comLife and Disability products are underwritten by Anthem Life Insurance Company. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
Benefits GuideSection ContentsSection I. - Your Certificate of CoverageSection II. - Value Added ServicesNote: The Value Added additional services are not a part of Your Certificate of Coverage anddo not modify your insured benefits.The Value Added Services are provided based on negotiated agreements between the insurancecompany and certain service providers. Although the insurance company endeavors to makethese services available to all policyholders and certificateholders as described below,modifications to Our agreements with service providers may require that services be periodicallymodified or terminated. Such modification or termination of services may be made based oncost to the insurer, availability of services, or other business reasons at the discretion of theinsurer or service providers.1.Resource Advisor2.SpecialOffers Discounts3.Travel AssistanceThis Group, on behalf of itself and its participants, hereby expressly acknowledges its understanding thispolicy constitutes a contract solely between this Group and Anthem Life Insurance Company, which is anindependent corporation operating under a license from the Blue Cross and Blue Shield Association, anassociation of independent Blue Cross and Blue Shield Plans, (the “Association”) permitting Anthem LifeInsurance Company to use the Blue Cross and/or Blue Shield Service Mark in Connecticut and thatAnthem Life Insurance Company is not contracting as the agent of the Association. This Group furtheracknowledges and agrees that it has not entered into this policy based upon representations by any personother than Anthem Life Insurance Company and that no person, entity, or organization other than AnthemLife Insurance Company shall be held accountable or liable to this Group for any of Anthem LifeInsurance Company’s obligations to the Group created under this policy. This paragraph shall not createany additional obligations whatsoever on the part of Anthem Life Insurance Company other than thoseobligations created under other provisions of this agreement.Guide to BenefitsContents
Section I.Your Certificate of CoverageBasic Group Term LifeandBasic Accidental Death and DismembermentInsuranceAnthem Life Insurance CompanyMain Administrative OfficePost Office Box 182361Columbus, Ohio 43218-23611 (800) 551-7265LBO A 0105 CLBO A 0105 C Life / AD&D CertPage 1Anthem Life Insurance Company
Important Notice Regarding Accelerated Death BenefitsThis Certificate contains an Accelerated Death Benefit provision within the LifeInsurance section. Benefits are payable as shown on the Schedule. Please refer to theAccelerated Death Benefit provision of this Certificate for a complete benefit description.This Accelerated Death Benefit is NOT a long term care policy or a nursing homeinsurance policy. You may use the Accelerated Death Benefit for any purpose. TheAccelerated Death Benefit may be taxable. As with all tax matters, You should consult apersonal tax advisor to determine the tax consequences prior to making an election forthis benefit.LIFE INSURANCE WILL BE REDUCED IF AN ACCELERATED DEATHBENEFIT IS PAID.RECEIPT OF ACCELERATED DEATH BENEFITS MAY AFFECTELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS SUCH AS, BUT NOTLIMITED TO, MEDICAID. Because the Accelerated Death Benefit is part of thisCertificate, You may be required to receive and spend all of the available funds from theCertificate prior to becoming eligible for public assistance programs.LBO A 0105 C Life / AD&D CertPage 2Anthem Life Insurance Company
IntroductionAnthem Life Insurance Company certifies that it has issued a Group Policy insuringcertain eligible employees of the Plan Sponsor.This Certificate describes the benefits provided as of the effective date. For purposes ofeffective dates and ending dates under the Policy, all days begin at 12:01 a.m. and end at12:00 midnight at the Plan Sponsor’s address.Certain terms of the Group Policy which affect Your insurance are contained in thefollowing pages. Anthem Life has written this Certificate in plain English. However, afew terms and provisions are written as required by insurance law. Anthem Life urgesYou to read Your Certificate carefully and keep it in a safe place.If the terms and provisions of the Certificate (issued to You) are different from the Policy(issued to the Plan Sponsor), the Policy will govern. Your coverage may be cancelled orchanged in whole or in part under the terms and provisions of the Policy.The Group Policy was issued in the state of Connecticut. Its laws and rules will governin resolving any questions about the Group Policy, except to the extent that the Policymay be governed by the Employee Retirement Income Security Act of 1974, as amended(ERISA).While You remain insured, this booklet is Your Certificate of insurance. It replaces anyprior booklet or Certificate given to You for the types of insurance described here. It isvoid and of no effect if You are not entitled to or have ceased to be entitled to theinsurance coverage. Many of the provisions of this Certificate are interrelated, and Youshould read the entire Certificate to get a full understanding of Your coverage. ThisCertificate also contains exclusions, so please be sure to read this Certificate carefully.Anthem Life Insurance CompanyAdministrative OfficeP.O. Box 182361Columbus, OH 43215-2361Michael A. WoznyPresidentFraud: Any person who knowingly and with intent to injure, defraud or deceive any insurancecompany files a statement of claim or an application containing any false, incomplete, ormisleading information is guilty of a crime and may be subject to criminal and civil penalties.LBO A 0105 C Life / AD&D CertPage 3Anthem Life Insurance Company
—TABLE OF CONTENTS—Introduction. 3Schedule of Benefits. 5Basic Life Insurance.5Basic Accidental Death and Dismemberment Insurance. 6Definitions. 7When Insurance Begins and Ends. 11Basic Insurance Eligibility.11Effective Date of Insurance. 12Age Reductions for Your Basic Coverage. 13Changes in Insurance.14Proof of Insurability.15Coverage Provisions. 18Waiver of Life Insurance Premium Benefit During Your Total Disability.18Accelerated Death Benefit for Basic Life.22Conversion of Life Insurance . 24Accidental Death and Dismemberment Insurance Benefits.26Exclusions for Accidental Death & Dismemberment. 29Additional Benefit for Exposure and Disappearance. 34Additional Benefit for Home Alteration and Vehicle Modification.35General Provisions. 36Claims and Payment Provisions.39Beneficiary Provisions.40LBO A 0105 C Life / AD&D CertPage 4Anthem Life Insurance Company
Schedule of BenefitsAbout This ScheduleThis Schedule of Benefits shows highlights of the coverage available under the GroupPolicy. Final interpretation of all provisions and coverages will be governed by theGroup Policy on file with Anthem Life Insurance Company at its Administrative Office.The amounts of Your insurance are determined by this schedule. You are not insured forany type of coverage for which You have not paid the required premium.Basic Life InsuranceAmount of Your Basic Life Insurance:An amount equal to 1 times Your Annual Earnings, rounded to the next higher 1000, if not already a multiple thereof, to a maximum of 50,000.All Benefits terminate at retirement.Your amount of Basic Life Insurance will be subject to any reductions listed in the AgeReductions provision of this Certificate.LBO A 0105 C Life / AD&D CertPage 5Anthem Life Insurance Company
Basic Accidental Death and Dismemberment InsuranceAmount of Your Basic Accidental Death and Dismemberment InsurancePrincipal Sum:An amount equal to 3 times Your AnnualEarnings, rounded to the next higher 1000, ifnot already a multiple thereof, to a maximum of 150,000.Your amount of Basic Accidental Death and Dismemberment Insurance will be subject toany reductions listed in the Age Reductions provision of this Certificate.Basic Accidental Death and Dismemberment Insurance Coverage is 24-hour.Additional Benefits:·Child Education·Common Carrier·Repatriation·Seat Belt and Air BagSpecific information regarding the Policy and its terms may be obtained from the PlanSponsor. The provisions, terms and conditions listed in any Policy document, includingbut not limited to this Certificate may be modified, amended, or changed at any time.Consent from any Insured or beneficiary is not required for such modification,amendment, or change.LBO A 0105 C 1LBO A 0105 C Life / AD&D CertPage 6Anthem Life Insurance Company
DefinitionsBelow, the definitions of the Policy are discussed. Where these terms are used inthis Certificate, unless specified otherwise, they have the meaning explained here.Accident or Accidental means accidental bodily Injury which is sustained independentlyof disease, Illness, or bodily infirmity.Actively at Work means that You are performing the normal duties of Your ownoccupation, and working Your normal hours. You must be working at least the minimumnumber of required hours per week to meet the definition of eligible employee for thePlan Sponsor on a permanent full-time basis and must be paid regular earnings.Your work site must be:··at the Plan Sponsor’s usual place of business; orat a location to which the Plan Sponsor’s business requires You to travel.You are not considered Actively at Work when You are off work or lose time due toIllness, Injury, Leave of Absence, strike or layoff. Paid days off will count as Actively atWork if You were fully capable of performing the normal duties of Your own occupationduring the paid days off, provided that You were Actively at Work on the last workingday prior to the paid days off.Additional Benefit or Additional Provision means an addendum to the Policy whichincreases or limits coverage for a specified set of conditions. The provisions, limitations,and exclusions in the entire Policy will apply unless specifically stated otherwise in theAdditional Benefit or Additional Provision.Annual Earnings means Your annual gross base earnings in effect from the PlanSponsor. It does not include commissions, bonuses, overtime pay, and extracompensation.Annual Earnings will be calculated based on the lesser of Your Annual Earnings ascalculated above or the premium amount actually received by Us.Certificate means this document which provides a description of the coverage availableunder the Policy.Child(ren) means Your natural Child, legally adopted Child, or stepchild provided suchChild is at least 15 days old and has not yet reached the age limit as described below:A Child’s coverage will end on the end of the calendar month in which the Child attainsage 26.*LBO A 0105 C Life / AD&D CertPage 7Anthem Life Insurance Company
*The attainment of any maximum age specified above will not terminate the insuranceof a Child if at the time the Child is:1. Incapable of self-support by reason of mental or physical handicap; and2. Unmarried and dependent on You for support and maintenance.Coverage for the Child will terminate under this provision if:1. The Child ceases to meet the above conditions; or2. The Child’s coverage would cease under the Policy for a reason other than thelimiting age.Proof that the Child meets the required conditions must be given to Us within 31 daysof its request. Proof shall not be required more than once a year after such Dependentattains the age of 27. Any required premium payment must be paid in accordancewith the terms of the Policy.Claimant means a person who has filed a claim for benefits under the Policy, as anInsured or as the beneficiary of an Insured.Class means a grouping of Insureds based on criteria agreed on between the Plan Sponsorand Us.Contributory means that You pay all or a portion of the premium for the coverage.Eligible Employee means a person who meets all of the following:····is a regular full-time employee of the Plan Sponsor, working for pay on ascheduled normal work week of at least 30 hours required per week by Ouragreement with the employer; andis performing work at the Plan Sponsor’s usual place of business, except forduties of a kind that must be done elsewhere; andis in a covered Class named under the Policy; andis a legal citizen or legal resident of the United States or Canada. In the caseof a legal resident, the person will become ineligible for insurance if he or sheleaves the United States or Canada for one hundred eighty (180) or moreconsecutive days.Temporary, seasonal, or contract employees are not included as Eligible Employeesunder the Policy.Eligibility Waiting Period means the continuous length of time You must serve in aneligible Class to reach Your eligibility date and begin Your coverage.Guaranteed Issue Amount means an amount of insurance for which We do not requireProof of Insurability.Illness means:· a sickness that impairs an Insured’s normal functioning of mind or body; and· the pregnancy, childbirth and related medical conditions of an Insured.LBO A 0105 C Life / AD&D CertPage 8Anthem Life Insurance Company
Independent Medical Exam means an examination by a Physician of the appropriatespecialty for Your or Your Insured Dependent’s condition at Our expense. Suchexamination, scheduled by Us, may be used for the purpose of determining eligibility forinsurance or benefits, including eligibility under the Additional Benefits, if any,associated with the Policy.Injury means bodily harm which is the direct result of an Accident and not related to anyother cause.Insured means an individual covered under the Policy.Leave of Absence means an arrangement where You and the Plan Sponsor agree thatYou will not be Actively at Work for a specific period of time and You are expected to beActively at Work at the end of that period. Refer to When Your Insurance Ends todetermine how long Your coverage can be continued during a Leave of Absence.Physician means:··a person licensed to practice medicine in the jurisdiction where such servicesare performed; orany other person whose services must be treated as a Physician’s for thepurposes of the Policy according to applicable law. Each such person must belicensed in the jurisdiction where he or she performs the service and must actwithin the scope of that license. He or she must also be certified and/orregistered if required by such jurisdiction.Physician does not include:····You.Your Spouse.Anyone employed by the Plan Sponsor, or any business partner of You or thePlan Sponsor.Any member of Your immediate family, including Your and/or YourSpouse’s:- Parents;- Children (natural, step, or adopted);- Siblings;- Grandparents;- Grandchildren;- In-Laws.Plan Sponsor means the employer or other organization that has entered into anagreement with Us as outlined in the Policy.Policy or Group Policy means the policy issued by Us and the Plan Sponsor anddescribed in this Certificate.LBO A 0105 C Life / AD&D CertPage 9Anthem Life Insurance Company
Prior Plan means the plan providing similar insurance benefits carried by the PlanSponsor on the day before the Policy’s effective date with Us.Proof means evidence satisfactory to Us that the terms and provisions of the Policy havebeen met. Proof may include but is not limited to: questionnaires, physical exams, orWritten documentation and records as required by Us. Proof must be received by Us atOur Administrative Office. All Proof must be given at Your expense (or that of Yourrepresentative or beneficiary), unless otherwise specifically provided by the terms of thePolicy. If any additional Proof is reasonably required by Us, an Insured may be requiredto give Us authorization to obtain such additional Proof. The following are some specifictypes of Proof referenced under the Policy:Proof of Claim means evidence satisfactory to Us that a person has satisfied theconditions and requirements for a benefit. Proof of Claim must establish:···the nature and extent of the loss or condition;Our obligation to pay the claim under the Policy;the Claimant’s right to receive payment.Proof of Insurability means evidence satisfactory to Us of a person’s health and otherinformation related to insurability which enables Us to determine whether the person canbecome insured, or is eligible for an increase in coverage.Sign or Signed means the use by a person of a symbol or method with the presentintention to authenticate a record. Such authentication may be executed and/ortransmitted by paper or electronic media, provided it is acceptable to Us and consistentwith applicable law.We, Us, and Our mean the insurer, Anthem Life Insurance Company.Written and Writing means a record which is on or transmitted by paper or electronicmedia which is acceptable to Us and consistent with applicable law.You and Your means an Eligible Employee.Other terms are defined elsewhere under the Policy.LBO A 0105 C 2LBO A 0105 C Life / AD&D CertPage 10Anthem Life Insurance Company
When Insurance Begins and EndsThis section tells how You may become insured.Obtaining InsuranceTo obtain insurance under the Policy, You must be an Eligible Employee and be Activelyat Work.EnrollmentIf you contribute to the cost of your Coverage:You must apply for Your insurance if the coverage is Contributory.An application for You to become insured must be completed on a form approved for thatpurpose by Us. The Plan Sponsor must send the completed application to Us at OurAdministrative Office. If Proof of Insurability is required for any coverage, thecompleted Proof of Insurability statement must be sent to us at our Administrative Office.If you do not contribute to the cost of your Coverage:You must enroll for Your insurance if the coverage is not Contributory.An enrollment form for You to become insured must be completed on a form approvedfor that purpose by Us. The Plan Sponsor must send the completed enrollment form toUs at Our Administrative Office.Basic Insurance EligibilityIf You are an Eligible Employee on the Effective Date of the Policy, You are eligible forBasic Life insurance on the date provided You have completed the Eligibility Waiting
Accelerated Death Benefit provision of this Certificate for a complete benefit description. This Accelerated Death Benefit is NOT a long term care policy or a nursing home insurance policy. You may use the Accelerated Death Benefit for any purpose. The Accelerated Death Benefit may
