Travel health, medical and international health insurance for global travel, living and study

Global Citizen
A Participating Provider
Major Medical Plan


CERTIFICATE OF COVERAGE

This Plan is a Participating Provider Plan for major medical care.

Under this Plan, UniCare pays certain benefits at higher payment percentages when the services of a Participating Provider are used.

Covered Expenses for the services of a Non-Participating Provider will be paid according to the in-network benefit when it is in connection with a Medical Emergency.

The Insurance Coverage Area is any place that is anywhere in the world.

Table of Contents

  BCR 105 01/04

I. Introduction

About This Plan
This Certificate of Coverage is issued by UniCare Life & Health Insurance Company ("Insurer").

In this Plan, "Insurer" means the UniCare Life & Health Insurance Company. The "Eligible Participant" is the person who meets the eligibility criteria of this Certificate. The term "Insured Person," means the Eligible Participant and any Insured Dependents.

The benefits of this Plan are provided only for those services that the Insurer determines are Medically Necessary and for which the Insured Person has benefits. The fact that a Physician prescribes or orders a service does not, by itself, mean that the service is Medically Necessary or that the service is a Covered Expense. If the Eligible Participant has any questions about whether services are covered he/she should consult this Certificate of Coverage or telephone the Insurer at the number shown on his/her identification card.

This Certificate of Coverage contains many important terms (such as "Medically Necessary" and "Covered Expense") that are defined in Section III and capitalized throughout the Certificate of Coverage. The Eligible Participant may wish to consult Section III for the meanings of these words as they pertain to this Certificate of Coverage before reading through this Certificate of Coverage.

The Insurer has issued a Policy to the Group identified on the Eligible Participant's identification card. The benefits and services listed in this Certificate of Coverage will be provided for Insured Persons for a covered Illness, Injury, or condition, subject to all of the terms and conditions of the Policy.

Choice of Hospital and Physician: Nothing contained in this Plan restricts or interferes with the Eligible Participant's right to select the Hospital or Physician of the Eligible Participant's choice. Also, nothing in this Plan restricts the Eligible Participant's right to receive, at his/her expense, any treatment not covered in this Plan.

Use of Administrator: The Insurer may use a third party administrator to perform certain of its duties on its behalf. The Group and the Insured Participant will be notified of the use of an administrator.

BCR 135.1 01/04

Benefit Overview Matrix
Following is a very brief description of the benefit schedule of the Plan. This should be used only as a quick reference tool. The entire Certificate of Coverage sets forth, in detail, the rights and obligations of both the Eligible Participant and the Insurer. It is, therefore, important that THE ENTIRE CERTIFICATE OF COVERAGE BE READ CAREFULLY!

The benefits outlined in the following table show the payment percentages for Covered Expenses AFTER the Eligible Participant has satisfied any Deductibles and prior to satisfaction of his/her Out-of-Pocket Maximum. Covered Expenses for Participating Providers are based on the Insurer's Negotiated Rate. Participating Providers have agreed to accept the Negotiated Rate as payment in full. Covered Expenses for Non-Participating Providers are based on Reasonable Charges which may be less than actual billed charges. Non-Participating Providers can bill the Eligible Participant for amounts exceeding Covered Expenses. The Eligible Participant's personal financial cost may be considerably higher when he/she uses a Non-Participating Provider.

PLEASE NOTE: THIS CERTIFICATE PROVIDES DIFFERENT BENEFITS IN THE U.S. FROM THOSE LISTED IN THE BENEFIT OVERVIEW MATRIX. PLEASE SEE ATTACHMENT A FOR THESE VARIATIONS. The percentages indicated in "First Level Payment" and "Second Level" segments in the "Out of Pocket" section of Attachment A apply to all benefits in the Benefit Overview Matrix when Covered Expenses delivered in the U.S. unless otherwise stated.

Deductible:
The Eligible Participant's Annual Deductible is $0/$250/$500/$1,000/$2,500/$10,000/$25,000 per Insured Person per Year AS CHOSEN BY THE ELIGIBLE PARTICIPANT.
The Eligible Participant's Annual Deductible is as stated in Attachment A per Insured Person per Year for Covered Expenses incurred in the U.S.

After the Deductible is satisfied, benefits are paid for Covered Expenses as follows:

BCR 136 04/03

II. Who is eligible for coverage?

Eligible Participants and their Eligible Dependents are the only people qualified to be covered by the Policy. The following section describes who qualifies as an Eligible Participant or Eligible Dependent, as well as information on when and who to enroll and when coverage begins and ends.

Who is Eligible to Enroll Under This Plan? An Eligible Participant:

1. Is a member of a Group covered under the Policy.
2. Has submitted an enrollment form, if applicable, and the premium to the Insurer.

Eligible Member
An Eligible Member is a bona fide member in good-standing of a membership Group.

1. unmarried natural child, stepchild or legally adopted child who has not yet reached age 19;
2. own or spouse's own unmarried child, of any age, enrolled prior to age 26, who is incapable of self support due to continuing mental retardation or physical disability and who is chiefly dependent on the Eligible Participant. The Insurer requires written proof from a Physician of such disability and dependency within 31 days of the child's 26th birthday and annually thereafter.
3. unmarried child, from their 19th to their 22nd birthday who is a full-time student attending an accredited college, university, vocational or technical school, and who is fully dependent upon the Eligible Participant for support. The Insurer may require proof of student status, but not more than once a Year;
4. grandchild, niece or nephew who otherwise qualifies as a dependent child, if: (i) the child is under the primary care of the Insured Participant; and (ii) the legal guardian of the child, if other than the Insured Participant, is not covered by an accident or sickness policy.
   
   The term "primary care" means that the Insured Participant provides food, clothing and shelter on a regular and continuous basis during the time that public schools are in regular session.

1. resident of the U.S.
2. under Age 75.

1. Any person who qualifies as an Eligible Participant of the Group on the day prior to the Effective Date of the Policy, or any person who has continued group coverage with the Group under applicable federal or state law on the date immediately preceding the Effective Date of the Policy, is eligible as of the Effective Date of the Policy. The application, if applicable, for this Eligible Participant should be submitted with the Group application.
2. The Effective Date for a participant who becomes eligible after the Effective Date of the Policy will be the first of the month following the Waiting Period (the Initial Eligibility Date), provided the Insurer receives a fully completed application prior to the Initial Eligibility Date. The Effective Date will be the first of the month following the date the Insurer approves the application.
3. If a person meets the above definition of an Eligible Dependent on the date the Eligible Participant is qualified to apply for the Plan, then the Eligible Dependent qualifies to apply at the same time that the Eligible Participant applies, and should be included on the Eligible Participant's application.
4. For a person who becomes an Eligible Dependent after the date the Eligible Participant's coverage begins, the Eligible Dependent is qualified to apply for the Plan within 31 days following the date he/she meets the above definition of an Eligible Dependent. Coverage for the Eligible Dependent will become effective in accordance with the following provisions subject to approval by the Insurer:
   1. Newborn Children: Coverage will be automatic for the first 31 days following the birth of an Insured Participant's Newborn child. To continue coverage beyond 31 days, the Newborn child must be enrolled within 31 days of birth.
   2. Court Ordered Coverage for a Dependent: If a court has ordered an Insured Participant to provide coverage for an Eligible Dependent who is a spouse or minor child, coverage will be automatic for the first 31 days following the date on which the court order is issued. To continue coverage beyond 31 days, an Insured Participant must enroll the Eligible Dependent within that 31-day period.
   3. Adopted Children: An Insured Participant's adopted child is automatically covered for Illness or Injury for 31 days from either the date of placement of the child in the home, or the date of the final decree of adoption, whichever is earlier. To continue coverage beyond 31 days, an Insured Participant must enroll the adopted child within 31 days from either the date of placement or the final decree of adoption.
   4. Other Dependents: A written application must be received within 31 days of the date that a person first qualifies as an Eligible Dependent. Coverage will become effective on the first day of the month following date of approval.
5. If the application is not received within the time frames outlined above, the Eligible Participant/Dependent will become a Late Enrollee. The Late Enrollee may become covered for Participant and/or Dependent coverage only if he or she submits an application within the 31-day Annual Open Enrollment Period that ends each Year on the anniversary of the Effective Date of the Policy. A Late Enrollee may not enroll at any time other than during the Annual Open Enrollment Period. A Late Enrollee's coverage must be approved by the Insurer in writing and will become effective on the first day of the month following the date the Insurer receives and approves the application.

Notification of Eligibility Change

1. Any person who does not satisfy the eligibility requirements is not covered by the Plan and has no right to any of the benefits provided under the Plan.
2. The Group and/or the Insured Participant must notify the Insurer within 31 days of any change that affects an individual's eligibility under the Plan, including the additional requirements for an Eligible Participant and Eligible Dependents.

1. the last day of the month after the date the Insured Participant no longer meets the definition of an Eligible Participant;
2. the end of the last period for which premium payment has been made to the Insurer;
3. the date the Policy terminates;
4. the date the Lifetime Maximum Benefit of the Plan has been exhausted;
5. the date of fraud or misrepresentation of a material fact by the Insured Participant, except as indicated in the Time Limit on Certain Defenses provision.

1. the date the Insured Participant's Insured Dependent no longer meets the definition of an Eligible Dependent as defined in the Plan;
2. the end of the period for which premium payment has been made to the Insurer;
3. the date the Policy terminates;
4. the date the Insured Participant's coverage terminates (unless due to exhaustion of the Lifetime Maximum Benefits);
5. the date the Insured Dependent's Lifetime Maximum Benefit is exhausted;
6. the date of fraud or misrepresentation of material fact by the Insured Dependent, except as indicated in the Time Limit on Certain Defenses provision.

1. for non-payment of premium;
2. on the date of fraud or intentional misrepresentation of a material fact by the Group, except as indicated in the Time Limit on Certain Defenses provision;
3. on any premium due date for any of the following reasons. The Insurer must give the Group written notice of cancellation at least 30 days in advance if termination is due to:
   1. failure to maintain the required minimum premium contribution;
   2. failure to provide required information or documentation related to the Group Health Benefit Plan upon request;
   3. failure to maintain status as a Group as defined in the Definitions (Section III) provision.
4. on any premium due date if the Insurer is also canceling all Group Health Benefit Plans in the state or in a geographic Service Area. The Insurer must give the Group written notice of cancellation:
   1. at least 180 days in advance; and
   2. again at least 30 days in advance.

1. the date payment of the maximum benefit occurs;
2. the date the Insured Person ceases to be Totally Disabled; or
3. the end of 90 days following the date of termination.

BCR 122 04/03

III. Definitions

The following definitions contain the meanings of key terms used in this Plan. Throughout this Plan, the terms defined appear with the first letter of each word in capital letters.

Accidental Injury means an accidental bodily Injury sustained by an Insured Person which is the direct cause of a loss independent of disease, bodily infirmity, or any other cause.

Age means the Insured Person's attained age.

Alcoholism means a disorder characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning, also termed alcohol abuse or, if tolerance or withdrawal is present, alcohol dependence.

Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It also must meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

Authorization means that the Insurer has approved specific services performed by specific providers as Covered Services prior to the services being rendered. Authorized services are subject to all other limitations and conditions of this Plan. Authorization is required before certain services are eligible for maximum benefits.

Certificate of Coverage is the document issued to each Eligible Participant outlining the benefits under the group Policy.

Coinsurance is the percentage of Covered Expenses the Insured Person is responsible for paying (after the applicable Deductible is satisfied and/or Copayment paid). Coinsurance does not include charges for services that are not Covered Services or charges in excess of Covered Expenses. These charges are the Insured Person's responsibility and are not included in the Coinsurance calculation.

Complications of Pregnancy are conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from the pregnancy, but are adversely affected by the pregnancy, including, but not limited to acute nephritis, nephrosis, cardiac decompression, missed abortion, pre-eclampsia, intrauterine fetal growth retardation, and similar medical and surgical conditions of comparable severity. Complications of Pregnancy also include termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible. Complications of Pregnancy do not include elective abortion, elective cesarean section, false labor, occasional spotting, morning sickness, physician prescribed rest during the period of pregnancy, hyperemesis gravidarium, and similar conditions associated with the management of a difficult pregnancy not constituting a distinct complication of pregnancy.

A Continuing Hospital Confinement means consecutive days of in-hospital service received as an inpatient, or successive confinements for the same diagnosis, when discharge from and readmission to the Hospital occurs within 24 hours.

Copayment is the dollar amount of Covered Expenses the Insured Person is responsible for paying. Copayment does not include charges for services that are not Covered Services or charges in excess of Covered Expenses.

Cosmetic and Reconstructive Surgery. Cosmetic Surgery is performed to change the appearance of otherwise normal looking characteristics or features of the patient's body. A physical feature or characteristic is normal looking when the average person would consider that feature or characteristic to be within the range of usual variations of normal human appearance. Reconstructive Surgery is surgery to correct the appearance of abnormal looking features or characteristics of the body caused by birth defects, Injury, tumors, or infection. A feature or characteristic of the body is abnormal looking when an average person would consider it to be outside the range of general variations of normal human appearance. Note: Cosmetic Surgery does not become Reconstructive Surgery because of psychological or psychiatric reasons.

Country of Assignment means the country for which the Eligible Participant has a valid passport and, if required, a visa, and in which he/she is working and/or residing.

Course of Treatment is a planned, structured, and organized sequence of treatment procedures based on an individualized evaluation to restore or improve health function, or to promote chemical free status. A Course of Treatment is complete when the patient has finished a series of treatments without a lapse in treatment or has been medically discharged. If the Insured Person begins a series of treatments, it will count as one course of treatment, reducing the available benefits, even if the patient fails to comply with the treatment program for a period of 30 days.

Covered Expenses are the expenses incurred for Covered Services. Covered Expenses for Covered Services received from Participating Providers will not exceed the Negotiated Rate. Covered Expenses for Covered Services received from Non-Participating Providers will not exceed Reasonable Charges. In addition, Covered Expenses may be limited by other specific maximums described in this Plan under Section IV, How the Plan Works and Section V, Benefits - What the Plan Pays. Covered Expenses are subject to applicable Deductibles, penalties and other benefit limits. An expense is incurred on the date the Insured Person receives the service or supply.

Covered Services are Medically Necessary services or supplies that are listed in the benefit sections of this Plan, and for which the Insured Person is entitled to receive benefits.

Creditable Coverage means coverage provided under:

1. a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 101 et seq.);
2. a group health benefit plan provided by a health insurance carrier or health maintenance organization;
3. an individual health insurance policy or evidence of coverage;
4. Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1395c et seq.);
5. Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s);
6. Chapter 55, Title 10, United States Code (10 U.S.C. Section 1071 et seq.);
7. A medical program of the Indian Health Service or of a tribal organization;
8. A state or political subdivision health benefits risk pool;
9. A health plan offered under Chapter 89, Title 5, United States Code (5 U.S.C. Section 8901 et seq.)
10. A public health plan as defined by federal regulations;
11. A health benefit plan under Section 5 (e), Peace Corps Act (22 U.S.C. Section 2504 (e)).

1. Its use is mainly limited to laboratory and/or research; or
2. it has not been given approval for marketing by the United States Food & Drug Administration at the time it is furnished and such approval is required by law; or
3. reliable evidence shows it is the subject of ongoing phase I, II or III clinical trials or under study to determine if maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the state or means of treatment or diagnosis; or
4. reliable evidence shows that the consensus of the opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the stated means of treatment of diagnosis; or
5. reliable evidence shows that it is not generally approved or used by Physicians in the medical community; or
6. it does not have final approval from the appropriate governmental regulatory body.

1. accident-only, credit or disability insurance coverages;
2. specified disease coverage or other limited benefit policies;
3. long-term care, dental care, or vision care coverages;
4. coverage provided by a single service health maintenance organization;
5. insurance coverage issued as a supplement to liability insurance;
6. insurance coverage arising out of a workers' compensation system or similar statutory system;
7. automobile medical payment insurance coverage;
8. jointly managed trusts authorized under 29 U.S.C. Section 141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157;
9. hospital confinement indemnity coverage; or
10. reinsurance contracts issued on a stop-loss, quota share, or similar basis.

1. be licensed as a hospital and operated pursuant to law; and
2. be primarily engaged in providing or operating (either on its premises or in facilities available to the hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed physicians) medical, diagnostic, and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and
3. provide 24 hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and
4. be an institution which maintains and operates a minimum of five beds; and
5. have X-ray and laboratory facilities either on the premises or available on a contractual prearranged basis; and
6. maintain permanent medical history records.

1. conceive after sexual relations without contraceptives for the period of one year; or
2. maintain a pregnancy until fetal viability.

1. Permanently placing the Insured Person's health in jeopardy, or
2. Causing other serious medical consequences; or
3. Causing serious impairment to bodily functions; or
4. Causing serious and permanent dysfunction of any bodily organ or part.

1. Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition.
2. Provided for the diagnosis or direct care and treatment of the medical condition.
3. Within standards of good medical practice within the organized community.
4. Not primarily for the patient's, the Physician's, or another provider's convenience.
5. The most appropriate supply or level of service that can safely be provided. For Hospital stays, this means acute care as an inpatient is necessary due to the kind of services the Insured Person is receiving or the severity of the Insured Person's condition and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.

1. History (gathering of information on an Illness or Injury).
2. Examination.
3. Medical Decision Making (the Physician's diagnosis and plan of treatment).

1. The actual charge.
2. Specialty training, work value factors, practice costs, regional geographic factors and inflation factors.
3. The amount charged for the same or comparable services or supplies in the same region or in other parts of the country.
4. Consideration of new procedures, services or supplies in comparison to commonly used procedures, services or supplies.
5. The Average Wholesale Price for Pharmaceuticals.

1. As applied to Insured Participant, any period of time during the Insured Participant's lifetime in which he/she is unable to perform substantially all the duties required by his/her usual occupation, provided the disability commences within twelve (12) months from the date the disabling condition occurred;
2. As applied to a Dependent, not being able to perform the normal activities of a like person of the same age and sex.

BCR 112.1 01/04

IV. How the Plan Works

The Insured Person's Plan pays a portion of his/her Covered Expenses after he/she meets his/her Deductible each Year. This section describes the Deductible and Copayments and discusses steps he/she should take to ensure that he/she receives the highest level of benefits available to him/her under this Plan. See Definitions (Section III) for a definition of Covered Expenses and Covered Services.

The benefits described in the following sections are provided for Covered Expenses incurred by the Insured Person while covered under this Plan. An expense is incurred on the date the Insured Person receives the service or supply for which the charge is made. These benefits are subject to all provisions of this Plan, which may limit benefits or result in benefits not being payable.

Either the Insured Person or the provider of service must claim benefits by sending the Insurer properly completed claim forms itemizing the services or supplies received and the charges.

Benefits
This Benefits section shows the maximum Covered Expense for each type of provider.

No benefits are payable unless the Insured Person's coverage is in force at the time services are rendered, and the payment of benefits is subject to all the terms, conditions, limitations and exclusions of this Plan.

Participating Hospitals, Participating Physicians and Other Participating Providers.
Covered Expenses for Participating Providers are based on the Insurer's Negotiated Rate. Participating Providers have agreed NOT to charge the Eligible Participant and the Insurer more than the Insurer's Negotiated Rates. In addition, Participating Providers will file claims with the Insurer for the Eligible Participant.

Non-Participating Hospitals, Non-Participating Physicians, and Other Non-Participating Providers.
The amount that will be treated as a Covered Expense for services provided by a Non-Participating Provider will not exceed the lesser of actual billed charges, eligible billed charges as outlined in the Hospital's Service Item Master Manual, or a Reasonable Charge as determined by the Insurer.

Hospitals, Physicians, and Other Providers.
The amount that will be treated as a Covered Expense for services provided by a Provider will not exceed the lesser of actual billed charges, eligible billed charges as outlined in the Hospital's Service Item Master Manual, or a Reasonable Charge as determined by the Insurer.

Exception: If Medicare is the primary payer, Covered Expense does not include any charge:

1. By a Hospital in excess of the approved amount as determined by Medicare; or
2. By a Physician or other provider, in excess of the lesser of the maximum Covered Expense stated above; or
   1. For providers who accept Medicare assignment, the approved amount as determined by Medicare; or
   2. For providers who do not accept Medicare assignment, the limiting charge as determined by Medicare.

1. When the services are not available through Participating Providers; or
2. When the services are for a Medical Emergency with benefits provided as follows:
   
   Hospital
   Initial services for a Medical Emergency will be paid at in-network benefit levels. Thereafter, payment will be reduced to out of network levels if the Insured Person is not transferred to a Participating Hospital as soon as his/her medical condition permits.
   
   Physician or other provider
   Covered Expense will be paid at in-network benefit levels for initial care for a Medical Emergency.

Deductibles
Deductibles are prescribed amounts of Covered Expenses the Eligible Participant must pay before benefits are available. The Annual Deductible applies to all Covered Expenses. A complete description of each Deductible follows. Only Covered Expenses are applied to any Deductible. Any expenses the Insured Person incurs in addition to Covered Expenses are never applied to any Deductible.

Deductibles will be credited on the Insurer's files in the order in which the Insured Person's claims are processed, not necessarily in the order in which he/she receives the service or supply.

If the Insured Person submits a claim for services which have a maximum payment limit and his/her Annual Deductible is not satisfied, the Insurer will only apply the allowed per visit, per day, or per event amount (whichever applies) toward any applicable Deductible.

Annual Deductible
The Insured Person's Annual Deductible is $0/$250/$500/$1,000/$2,500/$10,000/$25,000 per Insured Person per Year. This Deductible is the amount of Covered Expenses the Insured Participant and other Insured Persons must pay for any Covered Services incurred for services received from either Participating or Non-Participating Providers each Year before any benefits are available. The Annual Deductible does not apply to those Office Visits for which a Copayment is required.

Out-of-Pocket Maximums
The Out-of-Pocket Maximum is the amount of Copayment each Insured Person incurs for Covered Expenses in a Year. The Out-of-Pocket Maximum does not include any amounts in excess of Covered Expenses, Prescription Drug Deductible or Copayments, Annual Deductible, amounts applied to any penalties, or any amounts in excess of other benefit limits of this Plan.

The in network (Participating Providers) Out-of-Pocket Maximum is $2,000/$3,000/$4,000/$8,000/$10,000/$10,000/$10,000 per Insured Person per Year.

The out of network (Non-Participating Providers) Out-of Pocket Maximum is $2,000/$3,000/$4,000/$8,000/$10,000/$10,000/$10,000 per Insured Person per Year.

Once the in network (Participating Providers) Out-of-Pocket Maximum is met, the Insurer will pay 100% of Reasonable Charges for Non-Participating Providers for the remainder of the Year.

Once the out of network (Non-Participating Provider) Out-of-Pocket Maximum is met, the Insurer will pay 100% of Reasonable Charges for Non-Participating Providers for the remainder of the Year.

Plan Payment
After the Insured Participant satisfies any required Deductible, payment of Covered Expenses is provided as defined below:

Limited Benefits
Regardless of the Insured Person's Out-of-Pocket Maximum, the Insurer pays:

1. Up to: (i) 100% for 20 days per Year for inpatient treatment; and (ii) 80% for the first 30 visits for outpatient treatment of Mental, Emotional or Functional Nervous Disorders.
2. Up to: (i) 100% for up to 12 days per Year for detoxification; and (ii) 80% for up to 30 visits per Year for outpatient treatment of Alcoholism or Drug Abuse.
3. Up to $30 per visit for services for Physical and/or Occupational Therapy/Medicine limited to combined maximum of 12 visits per Year for first and second level payments combined.

1. The balance of the Covered Expense after the Insured Person pays a $10 Copayment for Office Visits to Participating Providers.
2. 100% of Covered Expenses for routine pap smears and annual mammograms obtained from either a Participating or Non-Participating Provider.
3. 100% of Covered Expense for Office Visits to Non-Participating Providers.
4. 100% of Covered Expense for all other Covered Services obtained from a Participating Provider. The Insured Person pays 0% of the Covered Expense. Participating Providers will not charge more than the Negotiated Rate.
5. 100% of Covered Expense for all other Covered Services obtained from a Non-Participating Provider. The Insured Person pays 0% of the Covered Expense, plus any amount in excess of the Covered Expense.

1. 100% of the Negotiated Rate for all other Covered Expenses obtained from a Participating Provider.
2. 100% of the Reasonable Charge for Covered Expenses for routine pap smears and annual mammograms obtained from a Non Participating Provider.
3. 100% of the Reasonable Charges for all other Covered Expenses obtained from a Non-Participating Provider.

1. not counted towards the Insured Person's Out-of-Pocket Maximum.
2. not eligible for benefit payments.

Non-Emergency Outpatient Hospital emergency room services: There will be a $50 penalty per visit, unless the visit results in an inpatient admission into that Hospital immediately following the emergency room visit.

BCR 366 04/03

V. Benefits: What the Plan Pays

Before this Participating Provider Plan pays for any benefits, the Insured Person must satisfy his/her Annual Deductible and any Other Deductibles that may apply. After the Eligible Participant satisfies the appropriate Deductibles, the Insurer will begin paying for Covered Services as described in this section.

The benefits described in this section will be paid for Covered Expenses incurred on the date the Insured Person receives the service or supply for which the charge is made. These benefits are subject to all terms, conditions, exclusions, and limitations of this Plan. All services are paid at percentages indicated and subject to limits outlined in Section IV, How the Plan Works.

Following is a general description of the supplies and services for which the Insured Person's Participating Provider Plan will pay benefits, if such supplies and services are Medically Necessary:

Services and Supplies Provided by a Hospital
For any eligible condition other than for Mental, Emotional or Functional Nervous Disorders, Alcoholism or Drug Abuse, the Insurer will pay indicated benefits on Covered Expenses for:

1. Inpatient services and supplies provided by the Hospital except private room charges above the prevailing two-bed room rate of the facility.
2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.

1. Services must be those which are regularly provided and billed by the Hospital.
2. Services are provided only for the number of days required to treat the Insured Person's Illness or Injury

1. Services of a Physician.
2. Services of an anesthesiologist or an anesthetist.
3. Outpatient diagnostic radiology and laboratory services.
4. Cervical cancer screening tests and the Office Visit associated with those tests when ordered by the Insured Person's Physician, nurse practitioner or certified nurse midwife. (The laboratory and x-ray charges related to cervical screenings are not subject to the deductible/coinsurance provisions, although the deductible and coinsurance provisions do apply to the office visit.)
5. Mammogram examinations, limited to one baseline mammogram and an annual mammography examination upon the recommendation of the Insured Person's physician. (Mammograms are not subject to the deductible /coinsurance provisions.)
6. Prostate Specific Antigen tests and the Office Visit associated with this test when ordered by the Insured Person's Physician or nurse practitioner.
7. Radiation therapy and hemodialysis treatment.
8. Surgical implants.
9. Artificial limbs or eyes.
10. The first pair of contact lenses or the first pair of eyeglasses when required as a result of eye surgery.
11. Self-Administered injectable drugs.
12. Syringes when dispensed with self-administered injectable drugs (except insulin).
13. Blood transfusions, including blood processing and the cost of unreplaced blood and blood products.
14. Services for the detection and prevention of osteoporosis for qualified individuals.
15. Rental or purchase of medical equipment and/or supplies that are all of the following:
    1. ordered by a Physician;
    2. of no further use when medical need ends;
    3. usable only by the patient;
    4. not primarily for the Insured Person's comfort or hygiene;
    5. not for environmental control;
    6. not for exercise; and
    7. manufactured specifically for medical use.
    Note: Medical equipment and supplies must meet all of the above guidelines in order to be eligible for benefits under this Plan. The fact that a Physician prescribes or orders equipment or supplies does not necessarily qualify the equipment or supply for payment.
    The Insurer determines whether the item meets these conditions.
    Rental charges that exceed the reasonable purchase price of the equipment are not covered. All durable medical equipment used in Infusion Therapy will be excluded under this Plan except where specifically stated under the benefit for Infusion Therapy.
16. Colorectal cancer screenings: Colorectal screenings shall be in compliance with the American Cancer Society colorectal cancer screening guidelines.

1. Base charge, mileage and non-reusable supplies of a licensed ambulance company for ground or air service for transportation to and from a Hospital or Skilled Nursing Facility.
2. Monitoring, electrocardiograms (EKGs or ECGs), cardiac defibrillation, cardiopulmonary resuscitation (CPR) and administration of oxygen and intravenous (IV) solutions in connection with ambulance service. An appropriate licensed person must render the services.

1. Up to 12 days per calendar year, for detoxification treatment;
2. 80% of up to 30 outpatient treatment visits in an outpatient treatment facility per calendar year.

1. 20 days of inpatient or residential treatment in a hospital or non-hospital residential facility per calendar year; and
2. 80% of charges incurred for the first 30 outpatient visits in a calendar year.

1. Services must be for the treatment of a Mental, Emotional or Functional Nervous Disorder, Alcoholism or Drug Abuse that can be improved by standard medical practice. Covered expenses are subject to all the provisions of the group Policy that would apply to any other illness.
2. The Insured Person must be under the direct care and treatment of a Physician for the condition being treated. The physician must certify that such Insured Person is suffering from Mental, Emotional or Functional Nervous Disorders, Alcoholism or Drug Abuse.
3. Services must be those which are regularly provided and billed by a Hospital.
4. Services are provided only for the number of days required to treat the Insured Person's condition.
5. Services must be received in a Hospital, Day Care Center or Non-hospital residential facility.

1. services must be received during the 6 months following the date of Injury;
2. no benefits are available to replace or repair existing dental prostheses even if damaged in an eligible Accidental Injury;
3. damage to natural teeth due to chewing or biting is not considered an Accidental Injury under this Plan; and
4. the same as any injury at 100% of Covered Expenses up to $1,000 per Year maximum per Insured Person and $200 per tooth.

1. Childhood immunizations and routine physical examination associated with the immunization, including Physician services.
2. Medically appropriate laboratory tests, procedures and radiology services in connection with the examination.
3. Routine hearing and vision tests and Physician services in connection with those tests.

1. measurements, sensory screening, neuro-psychiatric evaluation and developmental screening, including unlimited visits for minor children up to age 12 years and 3 visits per Year for minor children ages 12 years up to 18 years of age; and
2. hereditary and metabolic screening at birth, urinalysis, tuberculin tests, hemacrit, hemoglobin and other appropriate blood tests, including tests to screen for sickle hemoglobinopathy, as recommended by a physician

1. An Insured Person who receives the organ or tissue.
2. An Insured Person who donates the organ or tissue.
3. An organ or tissue donor who is not an Insured Person, if the organ or tissue recipient is an Insured Person. Benefits are payable only after benefits have been paid for the Insured Person's expenses, and then only to the extent benefits are available under the recipient's Plan.

1. Reconstruction of the breast on which the mastectomy has been performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance;
3. Prostheses; and
4. Treatment for physical complications of all stages of mastectomy, including lymphedemas.

Loss	Benefit
Loss of life	100% of the Principal Sum
Loss of one hand	50% of the Principal Sum
Loss of one foot	50% of the Principal Sum
Loss of sight in one eye	50% of the Principal Sum

Loss of one hand or loss of one foot means the actual severance through or above the wrist or ankle joints. Loss of the sight of one eye means the entire and irrecoverable loss of sight in that eye.

If more than one of the losses stated above is due to the same Accident, the Insurer will pay 100% of the Principal Sum. In no event will the Insurer pay more than the Principal Sum for loss to the Insured Person due to any one Accident.

The Principal Sum is stated in Benefit Overview Matrix.

There is no coverage for loss of life or dismemberment for or arising from an Accident in the Insured Person's Home Country.

Repatriation Of Remains Benefit
If an Insured Person dies, the Insurer will pay the necessary expenses actually incurred, up to the Maximum Limit shown in the Benefit Overview Matrix, for the repatriation of the Insured Person's remains to his/her Home Country. This benefit covers the legal minimum requirements for the transportation of the remains. It does not include the transportation of anyone accompanying the body or visitation or funeral expenses. Any expenses for repatriation of remains require the Insurer's prior approval.

If an Injury or a Sickness results in the Insured Person's loss of life outside the U.S., the Insurer will pay the Reasonable Expense incurred for cremation or for preparation of the body for burial in, and for transportation of the body to the U.S. up to the maximum stated for this benefit in the Benefit Overview Matrix. Payment of this benefit is subject to the Limitations and Conditions on Eligibility for Benefits.

No benefit is payable if the death occurs after the Termination Date. However, if the Insured Person is Hospital Confined on the Termination Date, eligibility for this benefit continues until the earlier of the date the Insured Person's Confinement ends or 31 days after the Termination Date. The Insurer will not pay any claims under this provision unless the expense has been approved by the Insurer before the body is prepared for transportation.

Medical Evacuation Benefit
If a Insured Person sustains an Injury or suffers a sudden Sickness while traveling outside the U.S., the Insurer will pay the Medically Necessary expenses incurred, up to the Lifetime Maximum Limit for all medical evacuations shown in the Benefit Overview Matrix, for a medical evacuation to the nearest Hospital, appropriate medical facility or back to the U.S. Transportation must be by the most direct and economical route. However, before the Insurer makes any payment, it requires written certification by the attending Physician that the evacuation is Medically Necessary.
The Insurer will pay Reasonable Charges for escort services if the Insured Person is a minor or if the Insured Person is disabled during a trip and an escort is recommended in writing by the attending Physician and approved by the Insurer. Any expenses for medical evacuation require the Insurer's prior approval.

With respect to this provision only, the following is in lieu of the Policy's Extension of Benefits provision: No benefits are payable for Covered Expenses incurred after the date the Insured Persons insurance under the Policy terminates. However, if on the date of termination the Insured Person is Hospital Confined, then coverage under this benefit provision continues until the earlier of the date the Hospital Confinement ends or the end of the 31st day after the date of termination.

Bedside Visit Benefit
If the Insured Person is Hospital Confined due to an Injury or Sickness for more than 7 days while traveling outside the U.S., the Insurer will pay up to a maximum benefit of $2,500 for the cost of one economy round trip air fare ticket to the place of the Hospital Confinement for one person designated by the Insured Person. With respect to any one trip, this benefit is payable only once for that trip, regardless of the number of Insured Persons on that trip. No more than one (1) visit may be made during any 12-month period. No benefits are payable under this provision prior to the end of the 7-day Hospital Confinement. No benefits are payable unless the trip is approved in advance by the Insurer.

BCR 368 04/03

VI. Exclusions and Limitations: What the Plan does not pay for

Excluded Services
The Participating Provider Plan does not provide benefits for:

1. Any amounts in excess of maximum amounts of Covered Expenses stated in this Plan.
2. Services not specifically listed in this Plan as Covered Services.
3. Services or supplies that are not Medically Necessary as defined by the Insurer.
4. Services or supplies that the Insurer considers to be Experimental or Investigative.
5. Services received before the Effective Date of coverage or during an inpatient stay that began before that Effective Date of Coverage.
6. Services received after coverage ends unless an extension of benefits applies as specifically stated under Extension of Benefits in the 'Who is Eligible for Coverage' section of this Plan.
7. Services for which the Insured Person has no legal obligation to pay or for which no charge would be made if he/she did not have a health policy or insurance coverage.
8. Services for any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, even if the Insured Person does not claim those benefits.
9. Conditions caused by or contributed by: (a) An act of war; (b) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) An Insured Person participating in the military service of any country; (d) An Insured Person participating in an insurrection, rebellion, or riot; (e) Services received for any condition caused by an Insured Person's commission of, or attempt to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation; (f) An Insured Person, age 19 or older, being under the influence of illegal narcotics or non-prescribed controlled substances unless administered on the advice of a Physician.
10. Any services provided by a local, state or federal government agency except when payment under this Plan is expressly required by federal or state law.
11. Professional services received or supplies purchased from the Insured Person, a person who lives in the Insured Person's home or who is related to the Insured Person by blood, marriage or adoption, or the Insured Person's employer.
12. Inpatient or outpatient services of a private duty nurse.
13. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
14. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
15. Treatment of Mental, Emotional of Functional Nervous Disorders (including nicotine use) or psychological testing except as specifically stated in this Plan. However, medical conditions that are caused by behavior of the Insured Person and that may be associated with these mental conditions are not subject to these limitations.
16. Treatment of Drug, alcohol, or other substance addiction or abuse, except as specifically stated in this Plan.
17. Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under Dental Care for an Accidental Injury in the Benefits section of this Plan.
18. Dental and orthodontic services for Temporomandibular Joint Dysfunction.
19. Orthodontic Services, braces and other orthodontic appliances.
20. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
21. Hearing aids.
22. Routine hearing tests except as provided under Preventive and Primary Care.
23. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan.
24. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
25. Outpatient speech therapy.
26. Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician.
27. Any intentionally self-inflicted Injury or Illness. This exclusion does not apply to the Medical Evacuation Benefit, to the Repatriation of Remains Benefit and to the Bedside Visit Benefit.
28. Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a newborn child, or to Medically Necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
29. Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
30. Treatment of sexual dysfunction or inadequacy.
31. All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated under Benefits, What the Plan Pays For Sterilization.
32. All contraceptive services and supplies, including but not limited to, all consultations, examinations, evaluations, medications, medical, laboratory, devices, or surgical procedures unless stated otherwise.
33. Cryopreservation of sperm or eggs.
34. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
35. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method of treatment.
36. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated under the Professional and other Services and Preventive and Primary Care sections of this Plan.
37. Charges by a provider for telephone consultations.
38. Items which are furnished primarily for the Eligible Participant's personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).
39. Educational services except as specifically provided or arranged by the Insurer.
40. Nutritional counseling or food supplements.
41. Durable medical equipment not specifically listed as Covered Services in the Covered Services or Infusion Therapy sections of this Plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.
42. Any services received on or within 6 months after the Effective Date of coverage if they are related to a Pre-existing Condition as defined in the Definitions section.
43. Physical and/or Occupational Therapy/Medicine, except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine.
44. All Infusion Therapy together with any associated supplies, Drugs or professional services are excluded except as specifically provided under the benefit for Infusion Therapy described in this Plan.
45. Growth Hormone Treatment.
46. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet.
47. Charges for which the Insurer is unable to determine the Insurer's liability because the Eligible Participant or an Insured Person failed, within 60 days, or as soon as reasonably possible to (a) authorize the Insurer to receive all the medical records and information the Insurer requested or, (b) provide the Insurer with information the Insurer requested regarding the circumstances of the claim or other insurance coverage.
48. Charges for the services of a standby Physician.
49. Charges for animal to human organ transplants.

BCR 369 04/03

OPTIONAL BENEFITS THAT CAN BE CHOSEN BY THE ELIGIBLE PARTICIPANT:

VII. Prescription Drug Benefits

Reimbursement
Many Prescription Drugs are available in Generic form, which is more cost effective for the Insured Person. It may be to the Eligible Participant's advantage to ask the Insured Person's Physician to prescribe and the Insured Person's pharmacist to dispense Generic Drugs whenever possible.

The amount reimbursed by the Insurer for claims for Prescription Drugs is separate from and will not be applied toward any coinsurance amount described in the Covered Services section of this Plan.

When the Insured Person Goes to a Pharmacy.
If the Insured Person purchases a Prescription Drug from a Pharmacy, he/she will be responsible for the Copayment stated below as well as any charge which exceeds the Reasonable Charge of the Drug. He/she will need to have the pharmacist complete his/her portion of the Prescription Drug Claim Form. The Insured Person will pay the pharmacist for the Prescription, complete the Insured Person's portion of the Prescription Claim Form and then submit the Eligible Participant's claim to the Insurer for reimbursement within 15 months of the date of purchase. If the Insured Person has not satisfied his/her Deductible at the time his/her claim is submitted, the amount the Insured Person paid for the Prescription may be applied toward his/her Deductible amount. The Insured Person's Prescription is considered purchased on the date he/she receives the Drug for which the charge is made. The completed claim form should be submitted to the address included on the Prescription Claim Form.

When the Insured Person has his/her Prescription filled at a Pharmacy, he/she will be reimbursed at the following rate for each covered Prescription and/or refill after the Insured Person's deductible is satisfied:

1. For Generic Prescription Drugs, you pay a $10 Copayment per Prescription, plus any amount over Reasonable Charges.
2. For Brand Name Prescription Drugs, you pay a $25 Copayment per Prescription, plus any amount over Reasonable Charges.

1. Drugs and medications not requiring a Prescription, except insulin.
2. Self-administered injectable drugs, except insulin.
3. Non-medical substances or items.
4. Contraceptive Drugs and certain devices prescribed for birth control, Drugs and medications used to induce non-spontaneous abortions.
5. Dietary supplements, cosmetics, health or beauty aids.
6. Any vitamin, mineral, herb or botanical product which is believed to have health benefits, but does not have Food and Drug Administration (FDA) approved indication to treat, diagnose or cure a medical condition.
7. Drugs taken while the Eligible Participant are in a Hospital, Skilled Nursing Facility, rest home, sanitarium, convalescent hospital or similar facility.
8. Any Drug labeled "Caution, limited by federal law to investigational use" or Non-FDA approved investigational Drugs, any Drug or medication prescribed for experimental indications (such as progesterone suppositories).
9. Syringes and/or needles, except those dispensed for use with insulin.
10. Durable medical equipment, devices, appliances and supplies.
11. Immunizing agents, biological sera, blood, blood products or blood plasma.
12. Oxygen.
13. Professional charges in connection with administering, injecting or dispensing of Drugs.
14. Drugs and medications dispensed or administered in an outpatient setting, including but not limited to outpatient hospital facilities and doctor's offices.
15. Drugs used for cosmetic purposes.
16. Drugs used for the primary purpose of treating infertility.
17. Anorexiants or Drugs associated with weight loss.
18. Allergy desensitization products, allergy serum.
19. All Infusion Therapy is excluded under this Plan except as specifically stated in the Covered Services section.
20. Drugs for treatment of a condition, Illness, or Injury for which benefits are excluded or limited by a Preexisting Condition, or other contract limitation.
21. Growth Hormone Treatment.
22. Over the counter medications and Prescription Drugs with a non-prescription (over the counter) chemical and dose equivalent.

BCR 301 04/03

VIII. General Provisions

Third Party Liability
No benefits are payable for any Illness, Injury, or other condition for which a third party may be liable or legally responsible by reason of negligence, an intentional act, or breach of any legal obligation on the part of such third party. Nevertheless, the Insurer will advance the benefits of this Plan to the Insured Person subject to the following:

1. The Insured Participant agrees to advise the Insurer, in writing, within 60 days of any Insured Person's claim against the third party and to take such action, to provide such information and assistance, and to execute such paper as the Insurer may require to facilitate enforcement of the claim. The Insured Participant and Insured Person also agree to take no action that may prejudice the Insurer's rights or interests under this Plan. Failure to provide notice of a claim or to cooperate with the Insurer, or actions that prejudice the Insurer's rights or interests, will be material breach of this Plan and will result in the Insured Participant being personally responsible for reimbursing the Insurer.
2. The Insurer will automatically have a lien, to the extent of benefits advanced, upon any recovery that any Insured Person receives from the third party, the third party's insurer, or the third party's guarantor. Recovery may be by settlement, judgment or otherwise. The lien will be in the amount of benefits paid by the Insurer under this Plan for the treatment of the Illness, disease, Injury or condition for which the third party is liable.

1. Group, blanket or franchise insurance coverage, except blanket student accident coverage;
2. Group service plan contract, group practice, group individual practice and other group prepayment coverages;
3. Group coverage under labor management trustee plans, union benefit organization plans, employer organization plans, employee benefit organization plans, or self-insured employee benefit plans.

1. A plan which has no Coordination of Benefits provision pays before a plan which has a Coordination of Benefits provision.
2. A plan which covers the Eligible Participant as an Insured Employee pays before a plan that covers the Eligible Participant as an Insured Dependent.
3. For a dependent child covered under plans of two parents, the plan of the parent whose birthday falls earlier in the Year pays before the plan of the parent whose birthday falls later in the Year. But if one plan does not have a birthday rule provision, the provisions of that plan determine the order of benefits.
   
   Exception to Rule 3: For a dependent child of parents who are divorced or separated, the following rules will be used in place of Rule 3:
   1. If the parent with custody of that child for whom a claim has been made has not remarried, then the plan of the parent with custody that covers that child as an Insured Dependent pays first.
   2. If the parent with custody of the child for whom a claim has been made has remarried, then the order in which benefits are paid will be as follows:
      1. The plan which covers the child as an Insured Dependent of the parent with custody.
      2. The plan which covers the child as an Insured Dependent of the stepparent (married to the parent with custody).
      3. The plan which covered the child as an Insured Dependent of the parent without custody.
      4. The plan which covers the child as an Insured Dependent of the stepparent (married to the parent without custody).
   3. Regardless of (A) and (B) above, if there is a court decree which establishes a parent's financial responsibility for that child's health care coverage, a plan which covers that child as an Insured Dependent of that parent pays first.
4. The plan covering the Insured Participant as a laid-off or retired employee or as an Insured Dependent of a laid-off or retired participant pays after a plan covering the Insured Participant as other than a laid-off or retired participant or the Insured Dependent of such a person. But if either plan does not have a provision regarding laid-off or retired participant, Rule 6 applies.
5. If an Insured Person whose coverage is provided under a right of continuation pursuant to federal or state law is also covered under another plan, the following shall be the order of benefit determination:
   1. First the benefits of a plan covering the Insured Person as an Employee, member or subscriber or dependent.
   2. Second the benefits under the continuation coverage.
6. When the above rules do not establish the order of payment, the plan on which the Insured Person has been enrolled the longest pays first unless two of the plans have the same effective date.

1. Insured Persons who are receiving treatment for end-stage renal disease following the first 30 months such Insured Persons are entitled to end-stage renal disease benefits under Medicare, regardless of group size.
2. Insured Persons who are entitled to Medicare benefits as disabled persons, unless the Insured Persons have a current employment status, as determined by Medicare rules, through a Group of 100 or more employees (subject to COBRA legislation).
3. Insured Persons who are entitled to Medicare for any other reason, unless the Insured Persons have a current employment status, as determined by Medicare rules, through a Group of 20 or more employees (subject to COBRA legislation).

1. Entire Contract and Changes: The entire contract between the Group and the Insurer is as stated in the Policy and the entire contract between the Insured Participant and the Insurer is as stated in the Certificate of Coverage including the endorsements, application, and the attached papers, if any. No change in the Policy or Certificate of Coverage shall be effective until approved by one of the Insurer's officers. This approval must be noted on or attached to the Certificate of Coverage. No agent may change the Policy or waive any of its provisions.
2. Payment of Premiums: Premiums are payable in advance. Premiums must be paid monthly including any contributions the Insured Participant must make. The Insurer may change the premium rates from time to time. The Insurer must give the Group written notice of any premium rate change at least 30 days prior to the change. The Insurer may not increase premiums without first providing written notification to the Group at least 30 days prior to the date the increase is to take effect, with the exception of retroactive premium rate increases related to fraud or the intentional misrepresentation of a material fact.
3. Grace Period: There is a Grace Period of 31 days allowed for the payment of each premium after the first premium.
4. Representations: All statements made by the Insured Participant or the Group shall be considered representations and not warranties. The Insurer must provide the Insured Participant or the Group with a copy of any statements used to contest coverage.
5. Time Limit on Certain Defenses/Misstatements on the Application: After two years from the Effective Date of the Policy, the Insurer will not contest the validity of the Policy. After two years from the Insured Participant's Effective Date of Coverage, no misstatements on the Eligible Participant's application may be used to:
   1. void this coverage, or
   2. deny any claim for loss incurred or disability that starts after the 2 year period.
      The above does not apply to fraudulent misstatements.
6. Legal Actions: The Insured Person cannot file a lawsuit before 60 days after the Insurer has been given written proof of loss. No action can be brought after 3 years from the time that proof is required to be given.
7. Conformity With State Statutes: If any provision of this Plan which, on its Effective Date, is in conflict with the statutes of the state in which the Policyholder resides, it is amended to conform to the minimum requirements of those statutes.
8. Provision in Event of Partial Invalidity: If any provision or any word, term, clause, or part of any provision of this Plan shall be invalid for any reason, the same shall be ineffective, but the remainder of this Plan and of the provision shall not be affected and shall remain in full force and effect.
9. The Claims Process

1. acknowledge receipt of the claim;
2. begin any investigation of the claim;
3. specify the information the Eligible Participant must provide to file proof of loss. (The Insurer can request additional information during the investigation if necessary.)
4. send the Insured Person any forms the Insurer require for filing proof of loss. If the Insurer does not send the forms within this time period, the Insured Person can file proof of loss by giving the Insurer a letter describing the occurrence, the nature and the extent of the Insured Person's claim. The Insured Person must give the Insurer this letter within the time period for filing proof of loss.

1. It is duly executed on a form acceptable to the Insurer; and
2. A copy is on file with the Insurer.

1. During the time the Plan is in force; or
2. Until the Insurer pay the last claim.

UniCare Life & Health Insurance Company
233 S. Wacker Drive, Suite 3900
Chicago, Illinois 60606

Dispute Resolution
All complaints or disputes relating to coverage under this Plan must be resolved in accordance with the Insurer's grievance procedures. Grievances may be reported by telephone or in writing. All grievances received by the Insurer that cannot be resolved by telephone conversation (when appropriate) to the mutual satisfaction of both the Insured Person and the Insurer will be acknowledged in writing, along with a description of how the Insurer propose to resolve the grievance.

The Insurer shall not take any retaliatory action, such as refusing to renew or canceling coverage, against the Insured Participant and his/her Insured Dependents or the Group because the Insured Participant's, the Group's, or any person's action on the Insured Person's or the Group's behalf, has filed a complaint against the Insurer or has appealed a decision made by the Insurer.

BCR 174 04/03