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Copyright 2014 HCCUA. All Rights Reserved
Plan Overview1Congratulations on becoming a HCCUA Member. This handbookis an overview of your HCCUA GAP plan, which includes insuredbenefits underwritten by Unified Life Insurance Company as well asnon-insured benefits designed to help you live a happier, healthierlife. Included is a CERTIFICATE of COVERAGE. Please review itcarefully prior to seeking medical care. If any of the benefits, terms,conditions, limitations or exclusions of coverage in this overviewdiffer from the benefits as described in the Certificate of Coverage,the Certificate of Coverage shall control and take precedence. Please note that this plan is NOT a major medical coverageplan. Lack of major medical coverage or other minimumessential coverage may result in an additional payment withyour taxes. This GAP plan is specifically designed to supplement majormedical coverage. Benefits under the plan are limited to specified maximum amountsshown in your schedule of benefits and certificate for your plan. The information in this handbook is a brief description of importantfeatures of this insurance coverage; it is not a contract of insurance. Included with your membership packet you will also find a guide tothe non-insurance benefits you receive as a member of HCCUA,including Prescription Advocacy, access to Telemedicine services,Licensed Clinical Counseling, Roadside Assistance, and much more.866-227-5400 Member Services www.HCCUAMedChoice.com
Plan BenefitsCOVERAGEWhile this plan is not a major medical plan, it does provide significant paymentsrelated to: Accidental DismembermentAccidental DeathAccident Medical Expense*Depending upon state law Critical Illness*Doctor’s Visits/HospitalConfinement****Depending upon plan purchased.HOW THE PLAN WORKSThis plan will pay according to the summary of benefits for any covered incident asdefined on the certificate of coverage. Please note: You may choose to use this planin addition to a primary health insurance OR can use this stand alone.HOW TO FILE A CLAIM***1. Call member services to request a claim form: 866-227-54002. Fill out claim form and send back to CHP:CHP Claims Department2077 Roosevelt AvenueSpringfield, MA 01104CHP Claims Department Fax: 1-413-733-46123. Benefits will be paid within 45 days of receipt of a payable claim***Please refer to your Certificate(s) of coverage for complete information on filing a claim.2
Plan Benefits3BenefitPremierPremierPlusIssue Document Policy Title(Title of Document from rightfooter):ACCIDENTALDEATH ANDDISMEMBERMENTINSURANCEACCIDENTALDEATH ANDDISMEMBERMENTINSURANCEACCIDENTALDEATH ANDDISMEMBERMENTINSURANCEACCIDENTALDEATH ANDDISMEMBERMENTINSURANCEBenefit Reduction atage 70 and 75Benefit Reduction atage 70 and 75Benefit Reduction atage 70 and 75Benefit Reduction atage 70 and 75(HCCUA 2014 iGAP)(HCCUA 2014 iGAP)(HCCUA 2014 iGAP)(HCCUA 2014 iGAP)(All Benefits below underwrittenby Unified Life InsuranceCompany)PLUS:Group Accident and sicknesshospital indemnity insurance(HCCUA 2013 iGAP LM)Enhanced EnhancedPlusDoctor’s Office Visits - The planwill pay the Doctor’s Office VisitBenefit, shown on the CertificateSchedule, for any day a CoveredPerson incurs charges for andrequires a Doctor’s office visit dueto injuries received in a CoveredAccident or due to a CoveredSickness. The visit must occur ona day that the coverage is in force.There is a 30 day waiting periodfor sickness.N/AHospital Confinement Benefits- The plan will pay the amountshown on the Certificate Schedulefor each day the CoveredPerson is confined, up to theHospital Confinement MaximumBenefit shown on the CertificateSchedule. The visit must occur ona day that the coverage is in force.There is a 30 day waiting periodfor sickness.N/A3 days perpolicy yearN/A3 days perpolicy yearAccidental Dismemberment: The plan will pay out 100% ofthe principal sum to the namedinsured for the Loss of: Bothhands or both feet, sight of botheyes, one hand and one foot,one hand and the sight of oneeye, one foot and the sight of oneeye. The plan will pay out 50% ofthe principal sum to the namedinsured for the Loss of: one handOR one foot, sight of one eye.Loss must be due to a coveredaccident that occurred whilecoverage is in force. 10,000 10,000 10,000 10,000 50 per visit2 per policyyearN/A 100 per day 50 per visit2 per policyyear 100 per day866-227-5400 Member Services www.HCCUAMedChoice.com
866-227-5400 Member Services www.HCCUA.orgBenefit(All Benefits below underwrittenby Unified Life InsuranceCompany)Accidental Death: - The planwill pay out 200% of the principalsum for the named insured eligibledependents for loss of life due toa covered accident that occurredwhile coverage is in force.Accident Excess MedicalExpense Benefit - The insurancecompany may pay up to thebenefit amount for eligible medicalexpense related to the accidentif an insured person suffers froma covered injury and receivestreatment within 30 days of theCovered Accident.Critical Illness The plan willpay out 100% of the benefit tothe named insured for any of thefollowing events: Heart Attack,Invasive Cancer (diagnosis morethan 30 days after effective date),End-Stage Renal Failure, Stroke,or Major Organ Transplant. Theplan will pay out 25% of thebenefit to the named insured forCancer In Situ (diagnosis morethan 30 days from effective date.The plan will pay out 10% of thebenefit to the named insured forInvasive Cancer (diagnosed within30 days from effective date).The plan will pay out 2.5% of thebenefit to the named insured forInvasive Cancer (diagnosed within30 days from effective date) . PremierPremierPlusEnhanced EnhancedPlus 10,000 10,000 10,000 10,000Principle SumPrinciple SumPrinciple SumPrinciple Sum 3,500 witha 250deductible 3,500 witha 250deductible 7,000 witha 250deductible 7,000 witha 250deductible 5,000 5,000 10,000 10,000per originaldiagnosis, percoverd personper originaldiagnosis, percoverd personper originaldiagnosis, percoverd personper originaldiagnosis, percoverd personThere is a 12 month waiting period for pre-existing conditions on all plan benefits.Please note, this is a summary of your benefits. Please refer to the certificate ofinsurance for full benefit details4
Notes5NOTES:866-227-5400 Member Services www.HCCUAMedChoice.com
866-227-5400 Member Services www.HCCUA.org6
Gap (11/7)
Congratulations on becoming a HCCUA Member. This handbook . is an overview of your HCCUA GAP plan, which includes insured . benefits underwritten by Unified Life Insurance Company as well as non-insured benefits designed to help you live a happier, healthier . life. Included is a CE
