Short Term Major Medical
Questions? Contact your independent insurance agent toll-free 1(800) 849-0953
HERE'S HOW THE PLAN WORKS
You select the Benefit Period that best suits your temporary needs:
|30 Days||120 Days|
|60 Days||150 Days|
|90 Days||180 Days|
Select the Benefit Period Deductible:
Following deductible satisfaction, the plan pays the next $5,000 of Covered Expenses at 80% and additional Covered Expenses at 100%, up to the Lifetime Maximum Benefit of $1,000,000.
Without health insurance protection, a sickness or injury could financially devastate you and your family
Protect yourself and your family from the unexpected!
American Health Shield
Short Term Medical Insurance provides affordable, essential, easy-to-understand coverage that is designed for persons that are temporarily without health insurance.
You may purchase coverage for periods as short as 30 days or up to 180 days; you have the option to pay premium in monthly "pay as you go" installments or one lump-sum; you can select the plan deductible that best suits your needs; and you have the freedom to choose your own healthcare providers and facilities.
COVERED EXPENSE HIGHLIGHTS
+ Services of licensed Physicians, Registered
+ Hospital room and board and general nursing Nurses, Surgeons, Assistant
Surgeon, and care while confined in a semi-private room Anesthetist
+ Intensive care
+ Prescription drugs (up to $500) and injections + Chemotherapy and radiation
+ X-rays and laboratory tests + Physiotherapy
+ Ground ambulance service
+ Pre-admission testing + Braces and appliances
+ Hospital emergency room + Detailed information about these and
+ Hospital services including outpatient department additional Covered Expenses
is listed in the or ambulatory surgical facility services Policy or Certificate.
This plan provides benefits based on Usual and Customary Charges, defined as the lesser of: 1) the actual charge; 2) what the provider would accept for the same service or supply in the absence of insurance; or 3) the reasonable charge as deter- mined by the Company, based on factors such as: a) the most common charge for the same or comparable service or supply in a com- munity similar to where the service or supply is furnished; b) charging protocols and billing practices generally accepted by the med- ical community or specialty; or c) inflation trends by geographic region.
COVERAGE EFFECTIVE DATE
The earliest coverage can begin (if approved) is 12:01am on the day after the U.S. Postmark date stamped on the envelope in which the fully completed application and correct plan cost are received by Co-ordinated Benefit Plans, Inc. (a later effec- tive date may be requested by the applicant). If the U.S. Postmark date is not legible or present, coverage will be effec- tive on the day after the fully completed application and cor- rect plan cost are received by Co-ordinated Benefit Plans, Inc.
American Health Shield - Short Term Medical is not renewable nor intended to be permanent coverage. However, if your temporary need for Short Term Medical Insurance continues beyond your Benefit Period, you may apply for an additional Benefit Period. There is no continuous coverage between the previous Benefit Period and a subsequent Benefit Period. Any condition or symptom which may have occurred under a previous Benefit Period will be treated as a pre-existing condition under a subsequent Benefit Period. In no event will the Company issue successive Benefit Periods totaling more than 365 days.
NOTE: If you reside in CO, GA, or UT, you may not apply for an additional Benefit Period. In MN, state law limits coverage to a maximum of 185 days in any 365 day period. I=
COVERAGE TERMlNATION DATE
Coverage will terminate on the earlier of: 1) the Benefit Period termination date; 2) the last day of the period through which the plan cost is paid; 3) the date the Insured Person attains age 65 or becomes Medicare eligible; or 4) if a dependent child, the date on which his/her eligibility terminates.
Extension of Benefits - If an Insured incurs medical expenses after the Termination Date from a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Medical Expenses for such Injury or Sickness will continue to be paid as long as the condition continues: 1) When
Hospital Confined on the Termination Date, not to exceed 90 days after the Termination Date; or 2) When not Hospital Confined on the Termination Date, not to exceed 30 days after the Termination Date. The Insured Person must: a) have met his or her Deductible during the Benefit Period; and b) be being treated for complications of or follow-up treatment for an Injury or Sickness which commenced during the Benefit Period.
The total payments made in respect to the Insured for such condition both before and after the Termination Date will never exceed the Maximum Benefit. After this "Extension of Benefits After Termination" provision has been exhausted, all benefits cease to exist, and under no circumstances will further payments be made.
This brochure provides general information about the American Health Shield - Short Term Medical Insurance plan. It is not a contract. The complete terms, provisions and conditions of coverage are described in the Policy or Certificate issued by The Chesapeake Life Insurance Company.
Money Back Guarantee - Once you receive your Policy or Certificate, carefully review all information. If you are not satisfied for any reason, return the Policy or Certificate (within 10 days of delivery) with your written request for cancellation to Co-ordinated Benefit Plans, Inc. Coverage will be cancelled as of the effective date and you'll receive a full refund - no questions asked!
You and your spouse (to 64 and 11 months) and your unmarried dependent children (between age 15 days to age 19 or 23 if a full-time student) that live with you may apply for coverage. To be considered for coverage, proposed Insureds must not:
a) have other hospital, major medical, health, governmental, or medical insurance coverage in force that will not terminate prior to the Effective Date of the plan;
b) be pregnant or the expectant father of an unborn child on the Effective Date; c) have been declined for insurance due to health reasons; d) have received consultation or treatment, within the past five years, for any conditions identified on the application; and NOTE: Child(ren) only coverage is available. Contact Co-ordinat- ed Benefit Plans, Inc. for application and rating procedures. . Non- US citizens and persons traveling outside the United States of America are not eligible for coverage.
HOW DO I APPLY?
1. Fully complete, sign and date the Short Term Medical Insurance Application (application is valid for 30 days from the Proposed Insured's signature date).
2. Calculate the plan cost for all persons to be insured (refer to the enclosed rate chart for plan costs and rating procedures). Plan cost can be paid by check, money order, or credit card (MasterCard or Visa).
3. Mail the application, with your payment, to Co-ordinated Benefit Plans, Inc. If you wish to charge the plan cost to your MasterCard or Visa, complete the Payment By Credit Card Authorization and fax both sides of your application to 1-714-279-1990
If you have any questions or need assistance in completing the application or calculating plan cost, please contact your independent insurance agent toll-free 1-800-849-0953
In the event of Injury or Sickness, the Insured should:
1) Contact their Physician or Hospital
2) Complete a claim form, attach medical and hospital bills, and mail to the claims address
listed on the Insured's insurance ID card.
Toll-free assistance numbers are listed on the Insured's insurance 10 card, should the Insured or a healthcare provider need assistance.
ABOUT THE INSURER
American Health Shield - Short Term Medical, under Policy Forms STP-01 and STP-INO-01, is underwritten by The Chesapeake Life Insurance Company (a UICI Company). Founded in 1956, Chesapeake Life has protected millions of insureds and earned a "Excellent" rating from A.M. Best Company (as of 10/22/2002).