Guaranteed Issue for members and their spouse's ages 18 through 64. Coverage terminates at age 70.
Pays Indemnity Benefits - There are NO Deductibles or Co-pays
Pays Benefits for Doctors Office Visits, Hospitalization, ICU or CCU, Surgery, Anesthesia, Preventive Care, Emergency Room Care, Lab and X-Ray Testing, and Ambulance Services*
Dependent Child Coverage is available to age 21 if the child is dependent on the parent member; or to age 23 if attending an accredited school full-time.
Save money through access to Beech Street PPO Network
Or you can use your own Doctor, Hospital or Licensed Provider
Pays Benefits in Addition to any Other Insurance Coverage
Pre-existing Conditions Incurred within the 12 Month Period Preceding the Effective Date are not covered. The Pre-existing Conditions Limitation is waived under the Outpatient Doctors Office Visits Indemnity Benefit**
* This plan is not available in all states and benefit options vary by state.
Select your state for availability, benefits and pricing:
These options are approved for the states of: AL, AK, AZ, AR, CO, DC, DE, FL, GA, IL, IN, IA, KY, LA, ME, MA, MI, MS, MO, NE, NM, NC, OH, OK, PA, RI, SC, TN, TX, VA, WI, WV, WY
VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS
Option 1
Option 2
Option 3
Option 4
Waiting Period after Coverage Effective date:
Injury
0 Days
0 Days
0 Days
0 Days
Illness
30 Days
30 Days
30 Days
30 Days
Doctors Office Visit Indemnity Benefit (Paid per Visit):
$50
$50
$75
$75
Maximum Visits per Calendar Year per Individual
5
5
5
5
Maximum Visits per Calendar Year per Family (This benefit is not subject to the Preexisting Conditions Limitation)
10
10
10
10
Preventive Care Indemnity Benefit:
Maximum 1 Visit per Calendar Year per Individual
$50
$50
$75
$75
Daily In-Hospital Indemnity Benefit:
Paid for each day of hospital confinement
$500
$1,000
$1,250
$1,500
Maximum number of days per confinement
30 days
30 days
30 days
30 days
Daily Hospital Intensive Care Unit Confinement Indemnity
Benefit: Not paid in addition to the Daily In-Hospital Indemnity
$900
$1,200
$1,500
$1,500
Maximum number of days per confinement per Individual
30 days
30 days
30 days
30 days
Surgery Indemnity Benefit:
The surgery benefit is based on multiplying the Payment Factor for the procedure listed in the Surgical Schedule, by the Surgical Procedure Unit.
Up to $2,400
Up to $5,000
Up to $7,500
Up to $7,500
Surgical Procedure Units:
16
33
50
50
Maximum Surgical Sessions per Calendar Year per Individual
2
2
2
2
Anesthesia Indemnity Benefit:
Payment is based on a Percentage of the Surgical Indemnity Benefit
20%
20%
20%
20%
Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit for each day of testing:
$50
$100
$150
$150
Maximum number of Testing Days per Calendar Year per Individual
5
5
5
5
Emergency Room Indemnity Benefit:
Maximum 1 Visit per Calendar Year per Individual
$50
$100
$150
$150
Ambulance Benefit Indemnity Benefit:
Maximum 1 Visit per Calendar Year per Individual
$50
$50
$50
$100
Monthly Cost†
Option 1
Option 2
Option 3
Option 4
Single:
$130.32
$199.34
$278.82
$288.10
Family:
$318.62
$498.06
$704.72
$728.88
† There is a $20 enrollment fee. The Single rate includes a $15 monthly administration fee and the Family rate includes a $30 monthly administration fee.
These options are approved for the states of: KS, NV, ND, UT, VT
VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS
Option 5
Option 6
Option 7
Option 8
Waiting Period after Coverage Effective date:
Injury
0 Days
0 Days
0 Days
0 Days
Illness
30 Days
30 Days
30 Days
30 Days
Doctors Office Visit Indemnity Benefit (Paid per Visit):
$50
$50
$75
$75
Maximum Visits per Calendar Year per Individual
5
5
5
5
Maximum Visits per Calendar Year per Family (This benefit is not subject to the Preexisting Conditions Limitation)
10
10
10
10
Daily In-Hospital Indemnity Benefit:
Paid for each day of hospital confinement
$500
$1,000
$1,250
$1,500
Maximum number of days per confinement
30 days
30 days
30 days
30 days
Surgery Indemnity Benefit:
The surgery benefit is based on multiplying the Payment Factor for the procedure listed in the Surgical Schedule, by the Surgical Procedure Unit.
Up to $2,400
Up to $5,000
Up to $7,500
Up to $7,500
Surgical Procedure Units:
16
33
50
50
Maximum Surgical Sessions per Calendar Year per Individual
2
2
2
2
Anesthesia Indemnity Benefit:
Payment is based on a Percentage of the Surgical Indemnity Benefit
20%
20%
20%
20%
Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit for each day of testing:
$50
$100
$150
$150
Maximum number of Testing Days per Calendar Year per Individual
5
5
5
5
Monthly Cost†
Option 5
Option 6
Option 7
Option 8
Single:
$118.48
$184.28
$257.08
$264.66
Family:
$287.86
$458.92
$648.24
$667.92
†There is a $20 enrollment fee. The Single rate includes a $15 monthly administration fee and the Family rate includes a $30 monthly administration fee.
These options are approved for Florida
VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS
Option 5
Option 9
Waiting Period after Coverage Effective date:
Injury
0 Days
0 Days
Illness
30 Days
30 Days
Doctors Office Visit Indemnity Benefit (Paid per Visit):
$50
$75
Maximum Visits per Calendar Year per Individual
5
5
Maximum Visits per Calendar Year per Family (This benefit is not subject to the Preexisting Conditions Limitation)
10
10
Daily In-Hospital Indemnity Benefit:
Paid for each day of hospital confinement
$500
$1,000
Maximum number of days per confinement
30 days
30 days
Surgery Indemnity Benefit:
The surgery benefit is based on multiplying the Payment Factor for the procedure listed in the Surgical Schedule, by the Surgical Procedure Unit.
Up to $2,400
Up to $2,400
Surgical Procedure Units:
16
16
Maximum Surgical Sessions per Calendar Year per Individual
2
2
Anesthesia Indemnity Benefit:
Payment is based on a Percentage of the Surgical Indemnity Benefit
20%
20%
Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit for each day of testing:
$50
$100
Maximum number of Testing Days per Calendar Year per Individual
5
5
Monthly Cost†
Option 5
Option 9
Single:
$118.48
$170.10
Family:
$287.86
$419.48
†There is a $20 enrollment fee. The Single rate includes a $15 monthly administration fee and the Family rate includes a $30 monthly administration fee.
* This plan is not available in all states and benefit options vary by state.
** Pre-Existing Conditions:
No benefits will be payable for expenses incurred as a result of a Pre-Existing Condition until coverage has been in effect under the Policy for 12 consecutive months. This Pre-Existing Conditions Limitation is waived under the Outpatient Physician Office visit Indemnity Benefit.
About Companion Life:
Companion Life Insurance Company has specialized in group benefits for more than 35 years. They have earned an A.M. Best rating of A+ (Superior) due to their fiscal strength, investment practices and sound management. Now, Companion Life wants to earn your trust by giving you the highest level of service and responsiveness possible.
10 Day Right To Return:
If not completely satisfied with the coverage provided, simply return the certificate within 10 days after it is received, and all moneys' received will be refunded.
Important Notice:
The policy terms and conditions are briefly outlined in this marketing overview. Complete provisions pertaining to this insurance are contained in the Master Policy on file with Value Benefits of America (VBA). If you would like to see the policy in its entirety, please contact your agent or VBA at 800-366-2467. In the event of any conflict between this information contained herein and the Master Policy, the Policy will govern.
Value Access Guarantee members also have access to one of the nationals largest Preferred Provider Organizations.
Beechstreet PPO Network Providers:
Beech Street Corporation has over 50 years of reliable service in the healthcare industry and has a network of over 400,000 respected doctors, 3,800 hospitals and over 52,000 ancillary network providers. Beech Street provides cost containment Network Services, URAC accredited and NCQA certified Clinical Services, and healthcare financial Specialty Services. More information about Beech Street can be found at www.beechstreet.com.
VALUE BENEFITS OF AMERICA MEMBERSHIP BENEFITS *
CallMD:
Members have access to a nationwide network of medical doctors available 24 hours per day / 7 days per week for consultation or routine medical needs through the convenience of a toll free phone number, without having to take time to make an appointment or wait in line at a doctor's office. CallMD maintains members' electronic medical records (EMR) in a highly secured, Internet accessible environment and makes this information available to our network doctors prior to a doctor consultation. Furthermore, a CallMD Doctor can write a prescription where allowed by law when sufficient medical history is available.
(CallMD cannot write prescriptions for narcotics or DEA controlled substances.)
The Dividend Club:
Members will earn Dividends (paid quarterly to you) on Merchandise, Services, Travel & Entertainment when you shop from our On-line Mall and make a purchase. Choose from retailers like these, just to name a few, and get the dividends: Walmart.com, Target.com, BestBuy.com, CircuitCity.com, CompUSA.com, DisneyStore.com, OfficeMax.com, Brooks- Brothers.com, Brookstone.com, Buy.com, EddieBauer.com, LizClairborne.com, FOA.com, FOSSIL.com, HotelDiscounts. com, Jcrew.com, etc.
Enhanced Benefit Card:Dental Savings up to 40% off or more with almost 100,00 Dentists, Vision & LASIK Savings of 10%-50%, Lab Tests Savings of 10%-70%, RX Savings up to 20%, Hearing Savings up to 65%, Diabetic Supplies Savings of 15%-48% , X-Rays & Imaging Savings of 10%-80%, Chiropractic Savings of 10%-60%
Rewards Network:
America's Premier Dining Rewards Program and Hotel Discounts. Save up to 20% off every meal plus up to 15% off your hotel room rate
Refund Sweepers:
Free Merchandise, Bargains, On-line Coupons, Rebates, Sweepstakes & more
Car Rental Services:
Provides discounts at Alamo, National, Hertz and Avis
DISCOUNTS AND DIVIDENDS ARE NOT INSURANCE BENEFITS*
Benefits Details
BENEFITS DETAILS
HEALTH INDEMNITY BENEFITS. Subject to the provisions of this Policy, the Company will pay Covered Benefits for one or more of the following:
Daily In-Hospital Indemnity Benefit
If a Covered Person, while insured, is Confined in a Hospital as a result of Accident or Sickness, the Company will pay the Daily In-Hospital Indemnity Benefit amount, as shown in the Schedule, for each day of Confinement, for up to the Maximum Number of Days of Confinement, as shown in the Schedule. No benefit will be paid during any period the Covered Person is not under the regular care and attendance of a Physician.
Hospital Intensive Care Unit Confinement
(Applicable only if this benefit is not excluded on the Schedule) If a Covered Person, while insured, is confined in a Hospital Intensive Care Unit, the Company will pay the Intensive Care benefit amount, as shown in the Schedule of Hospital Intensive Care Unit Confinement Benefit. If the covered person is confined in a Hospital Intensive Care Unit and is confined to a hospital intensive care unit again within 90 days for the same or related condition, it will be treated as a continuation of the prior confinement. If more than 90 days have passed between the periods of confinement in a Hospital Intensive Care Unit, it will be treated as a new confinement. The Hospital Intensive Care Unit Confinement and Hospital Confinement benefit will not be paid concurrently.
Surgical Indemnity Benefit
If a Covered Person has a covered surgery performed, the Company will pay the Surgical Indemnity Benefit amount. This amount is based on the Payment Factor amount, as shown in the Schedule of Surgical Indemnity Benefits, times the number of Surgical Procedure Units, as shown in the Schedule.
If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed.
Unlisted Procedures: In addition to the procedures listed in the Schedule of Surgical Indemnity Benefits, amounts shall be payable for any other covered operations. The amounts for such procedures shall be determined by the Company in amounts consistent with those listed in the Schedule of Surgical Indemnity Benefits.
Anesthesia Indemnity Benefit
If the Surgical Indemnity Benefit is payable, the Company will pay the Anesthesia Indemnity Benefit amount, as shown in the Schedule, for the administration of anesthesia.
The Company will pay the Outpatient Physician Office Visit Indemnity Benefit, as shown in the Schedule, for a Physician office visit as a result of Sickness or Accident, not to exceed the Maximum Number of Office Visits per Calendar Year, as shown in the Schedule.
Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit
The Company will pay the Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit, as shown in the Schedule, when a Covered Person has diagnostic x-ray and laboratory tests performed. This benefit is limited to once per day of testing, not to exceed the Maximum Number of Testing Days per Calendar Year, as shown in the Schedule. These include tests that show a need for treatment or that are made because of definite symptoms of Accident or Sickness.
Emergency Room Visit Indemnity Benefit
(Applicable only if this benefit is not excluded on the Schedule) The Company will pay an Emergency Room Visit Indemnity Benefit for services that result from a Sickness or Injury that are Medically Necessary and are provided on an Emergency basis that do not result in Hospital Confinement. Emergency Room Visit Indemnity Benefits will be paid for an Insured or a Dependent. The Emergency Room Visit Indemnity Benefit amount is shown on the Schedule of Benefits. Benefits payable will not exceed the Calendar Year maximum benefit amount shown on the Schedule of Benefits. A Covered Person shall have free choice of any Physician and the Physician-patient relationship shall be maintained.
Preventive Care Indemnity Benefit
(Applicable only if this benefit is not excluded on the Schedule)
Preventive Care Indemnity Benefit will be paid for a Covered Person as described below: A. The Company will pay the indemnity benefit shown in the Schedule of Benefits for an annual physical examination for the Insured and his covered Dependents up to the Calendar Year maximum shown on the Schedule of Benefits. These services will only be covered to the extent that the services are provided by, or under the supervision of, a single Physician during the course of one (1) visit. Services include:
A history;
Physical Examination;
X-rays;
Laboratory services including, but not limited to, a Pap test, colorectal screening and prostate cancer screening.
B. The Company will pay the indemnity benefit shown in the Schedule of Benefits for a low-dose screening mammogram for any nonsymptomatic woman covered under the Policy/Certificate with the following frequency.
One (1) baseline mammogram for women aged thirty-five (35) through thirty-nine(39);
One (1) every two (2) years for women aged forty (40) through forty-nine (49); and
One (1) annually for women age fifty (50) AND OVER.
C. The Company will pay the indemnity benefit shown in the Schedule of Benefits for well child care from the moment of birth to Age six (6) years. Benefits will be limited to one (1) Physician's visit at the following specified age intervals: 1 visit at age 30 days to 1 year, and annually thereafter, up to Age 6. Covered well child care is the periodic review of a child's physical and emotional status. This periodic review will only be covered to the extent that the services are provided by, or under the supervision of, a single Physician during the course of one (1) visit. A review shall include:
A history;
Complete physical examination;
Developmental assessment;
Anticipatory guidance;
Appropriate immunizations;
Laboratory tests; and
Hearing and vision screening;
In keeping with prevailing medical standards.
Such services must be provided within one (1) month prior to or after reaching each Age without benefit or carrying over any visitations. In the event an appropriate immunization, lab test or portion of an examination cannot be performed at a particular Age, such service shall be deemed to be covered upon the next scheduled visit.
If a benefit is already shown for one of the above-described benefits, the benefit terms of the Policy/Certificate will control to the extent the terms are not consistent with the above described benefit.
The benefits described above will be paid directly to the provider of services. To authorize the benefit payment to the Covered Person, the Insured must make the proper authorization on the medical claim form.
Ground Ambulance Service Indemnity Benefit
(Applicable only if this benefit is not excluded on the Schedule) If a Covered Person requires the use of Ground Ambulance Service for transportation to or from a Hospital as a result of Accident or Sickness, the Company will pay the Ground Ambulance Service Indemnity Benefit, as shown in the Schedule, up to the maximum number of trips, as shown in the Schedule. Air ambulance transportation will be payable only if medically necessary and to the nearest facility equipped to handle the Covered Person's Accident or Sickness.
Any exclusion or limitation in the policy/certificate relating to ambulance services will be disregarded to the extent that it is inconsistent with this benefit.
ELIGIBILITY AND EFFECTIVE DATES
ELIGIBILITY AND EFFECTIVE DATES
2.01
All persons who:
a)
are members in good standing of the Association to which the Policy is issued; and
b)
are under age 70;
are eligible to be insured under the Policy. Evidence of insurability acceptable to the Company may be required.
2.02
The insurance on eligible persons will take effect at 12:01 A.M., local time at the Insured's address on the Certificate Effective Date shown in the Schedule if:
a)
an application/enrollment form is completed and received by the Company on or before said Certificate Effective Date;
b)
the underwriting rules of the Company are met; and
c)
the first premium is received by the Company on or before said Certificate Effective Date.
2.03
If and where Dependent coverage is available under the Policy, each Insured will be eligible for such coverage on the latest of the following dates:
a)
the day the Insured becomes eligible for insurance; or
b)
the day the Insured acquires his or her first Dependent.
2.04
Dependent coverage may be elected by:
a)
completing and signing an application/enrollment form within 31 days of the date the Dependent becomes eligible; and
b)
paying any required premium for such Dependents.
2.05
The Effective Date of coverage for each eligible Dependent will be the first of the month following the date of:
a)
the Company's acceptance of the application/enrollment form; and
b)
receipt of the first premium by the Company.
However, if on such date the coverage for the eligible Insured has not yet taken effect, the Effective Date for Dependent
coverage will be the same as the Certificate Effective Date for such Insured.
A newborn child will become insured for Accident or Sickness automatically on the day he or she is born as long as the Insured's
coverage was in force on that date. Accident or Sickness includes prematurity, congenital defects and birth abnormalities.
The newborn child's coverage will not continue past the 31-day period following birth unless:
a)
the Company is notified by the end of that 31-day period of the addition of such newborn child; and
b)
any applicable additional premium is paid.
An adopted child who has not attained 18 years of age, will become insured for Accident and Sickness automatically as of
the date of adoption or placement for adoption. Placement for adoption means the assumption and retention by a person of
legal obligation for total or partial support of a child in anticipation of the child's adoption. Coverage for an adopted child will not continue past the 31-day period following birth unless:
a)
the Company is notified by the end of the 31-day period of the addition of such adopted child; and
b)
any applicable additional premium is paid.
In all other instances if a Dependent is Totally Disabled or otherwise does not meet the Company's underwriting requirements
on the date coverage (with respect to that particular Dependent) would otherwise take effect, the coverage of the
Dependent will be deferred until the date the Company approves coverage under the Policy for such Dependent.
2.06
If a Covered Person is Totally Disabled on the date the Policy replaces another group policy or plan in its entirety,
when his or her coverage would otherwise take effect, coverage will take effect on the earlier of the following dates:
a)
with respect to coverage for the disabling condition:
1) the day following the expiration of any extension of benefits or continuation of coverage provided under the
group policy or plan the Policy replaces; or
2) the day coverage would otherwise take effect if the group policy or plan the Policy replaces does not provide an
extension of benefits or continuation of coverage; and
b)
with respect to coverage for conditions other than the disabling condition:
1) the day following the expiration of any continuation of coverage provided under the group policy or plan the
Policy replaces; or
2) the day coverage would otherwise take effect if the group policy or plan the Policy replaces does not provide for continuation of coverage.
Exclusions and Limitations
Pre-Existing Conditions: No benefits will be payable for expenses incurred as a result of a Pre-Existing Condition until coverage has been in effect under the Policy for 12 consecutive months. This Pre-Existing Conditions Limitation is waived under the Outpatient Physician Office visit Indemnity Benefit.
4.01 With respect to all of the benefits provided under this Policy, no benefits will be payable as the result of:
a.
suicide or any attempt thereat, while sane;
b.
any intentionally self-inflicted injury or Sickness;
c.
rest care or rehabilitative care and treatment;
d.
cosmetic surgery or care or treatment solely for cosmetic purposes, or complications there from. This exclusion does not apply to
cosmetic surgery resulting from a covered Accident if initial treatment of the Covered Person is begun within 12 months of the date
of the Accident;
e.
immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; and routine physicals;
f.
routine newborn care, including routine nursery charges; except as provided under the Outpatient Physician Wellness Benefit
g.
voluntary abortion, except with respect to the Insured or covered Dependent spouse: 1) where such person's life would be endangered
if the fetus were carried to term; or 2) where medical complications have arisen from an abortion;
h.
normal pregnancy, except for Complications of Pregnancy;
i.
the treatment of: 1) mental illness; 2) functional or organic nervous disorder, regardless of cause; 3) alcohol abuse;
4) drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed for more than 10 days in any Calendar
Year, with respect to payment of the Daily In-Hospital Indemnity Benefit;
j.
participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while
acting in a lawful manner within the scope of authority;
k.
committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation;
l.
participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding;
m.
air travel, except:1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or 2) as a passenger for transportation
only and not as a pilot or crew member;
n.
any Accident occurring as a result of the Covered Person being intoxicated (where the blood alcohol content meets the legal presumption
of intoxication under the law of the state where the Accident took place);
o.
sex changes;
p.
experimental treatments or surgery;
q.
the reversal of tubal ligation and vasectomies;
r.
artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or Physician's services,
unless required by law;
s.
treatment of exogenous obesity or weight control;
t.
an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization.
This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country
engaged in war. The Company will refund the pro rata unearned premium for any such period the Covered Person is not covered;
u.
accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses which are payable
under Occupational Disease Law or similar law, whether or not application for such benefits have been made;
v.
Pre-Existing Conditions, except as described in the Schedule; or
w.
air or ground ambulance service.
4.02 In addition to the Exclusions and Limitations for all coverages, the following are not covered under the Out-Patient Physician Office Visit
Indemnity Benefit and the Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit:
a.
visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while Confined to a Hospital;
b.
routine eye examinations or fitting of glasses;
c.
fitting of hearing aids;
d.
dental examinations or dental care other than expenses resulting from accidental injury; and
e.
benefits which are provided under any other part of this Policy.
4.03 In addition to the Exclusions and Limitations for all coverages, the following are not covered under the Outpatient Prescription Drug Indemnity Benefit, if applicable:
f.
drugs and medicines which may be lawfully obtained without a Physician's prescription; except insulin;
g.
therapeutic devices or appliances. This includes hypodermic needles, syringes, support garments and
other non-medical items;
h.
drugs labeled "Caution - limited by federal law to investigational use" or experimental drugs;
i.
drugs, medicines or insulin, in whole or in part, used by or administered to a Covered Person while Confined
in a Hospital, rest home, sanatorium, extended care facility, convalescent hospital, nursing home or
similar institution;
j.
immunization agents, biological sera, blood or blood plasma; or
k.
contraceptive materials, devices or medications or infertility medication, except where required by law.
DEFINITIONS
1.01
"Accident" means sudden, unexpected and unintended injury which is independent of any Sickness and which takes place while the
Covered Person's coverage is in force.
1.02
"Calendar Year" means the period from January 1 through December 31 of the same year.
1.03
"Certificate" means the individual Certificate issued to the Insured. It describes the coverage under the Policy.
1.04
"Company" means Companion Life Insurance Company, located in Columbia, South Carolina.
1.05
"Complication of Pregnancy" means:
(a)
conditions requiring Hospital Confinement whose diagnoses are distinct from pregnancy,
but are adversely affected by pregnancy when the pregnancy is not terminated, including but not limited to: acute
nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of
comparable severity; and
(b)
non-elective cesarean section, 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 false labor, occasional spotting, Physician prescribed rest during the period of
pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management
of a difficult pregnancy not constituting a nosologically distinct complication. Deliver by cesarean section is considered
a Complication of Pregnancy if the cesarean section is involuntary.
1.06
"Confinement (or Confined)" means that period of time during any Hospital stay that the Covered Person is actually admitted on an
inpatient basis. Two or more Confinements for the same or related causes that are separated by less than 90 days will be considered
the same Confinement. "Confinement" does not include that period of time during which a Covered Person is in a Hospital
emergency room, an observation room, a free-standing surgical facility, or outpatient facility.
1.07
"Covered Benefits" means those services or supplies that:
a) are for necessary treatment and recommended by a Physician;
b) are received while the Covered Person is insured under this Policy, subject to any Extension of Benefits; and are not excluded under section 4.
1.08
"Covered Person(s)" means the Insured and his or her Dependents insured under this Policy.
1.09
"Dependent" means an Insured's:
a) married spouse who lives with the Insured and is under age 70; or
b) unmarried child (natural, step or adopted) who is not eligible for medical coverage as an Insured under the Policy or any other group policy and who:
1) is less than 25 years old and is dependent on the Insured; or
2) is less than 25 years old and going to an accredited school full-time. Such child must be dependent on the Insured for principal support and maintenance; or
3) becomes incapable of self-support because of mental retardation or physical handicap while insured under the Policy and prior to reaching the limiting age for Dependent children. The child must be dependent on the Insured for support and maintenance.
(4) is not living with the Insured, but the Insured is legally required to support such child, and the child would
otherwise qualify under (1), (2) or (3) above.
The term Dependent does not include:
(a)
a grandchild of the Insured (except where required by law); or
(b)
a child who engages for compensation, profit or gain in any employment or business for 30 or more hours per
week, unless such child is a full-time student a described in (b)(2) above.
1.10
"Effective Date" means the date, starting at 12:01 A.M. at the Insured's residence, that coverage for a Covered
Person takes effect under this Certificate. The "Certificate Effective Date" means the date, starting at 12:01
A.M., that coverage under this Certificate takes effect.
1.11
"Hospital" means a licensed institution that has on its premises:
A.
permanent and full-time facilities for the care of overnight resident bed patients under the
supervision of a licensed Physician;
B.
24-hour-a-day nursing service by graduate registered nurses; and
C.
the patient's written history and medical records.
It shall also have (or have available on a pre-arranged basis) laboratory, x-ray equipment and operating rooms where major
surgical operations may be performed by licensed Physicians, or be accredited by the Joint Commission on Accreditation
of Hospitals.
"Hospital" shall not include any institution or portion thereof used as a place for rehabilitation, rest, the aged, education or training;
or a nursing or convalescent home or an extended care facility for the care of convalescent patients.
1.12
"Immediate Family" means the parents, spouse, children, or siblings of a Covered Person, or any person residing with a Covered
Person.
1.13
"Insured" means the person shown on the Schedule of Benefits as the Certificate holder of the Certificate issued to the Insured under
this Policy.
1.14
"Physician" means a practitioner of the healing arts who:
(a).
is practicing within the scope of his or her license in the state where so licensed; and
(b).
is not a member of the Covered Person's Immediate Family.
1.15
"Policy" means the group Policy issued to the Policyholder.
1.16
"Policyholder" means the Value Benefits of America that holds the Master Policy.
1.17
"Pre-Existing Condition" means a disease, Accident, Sickness or physical condition for which a Covered Person:
(a).
had treatment;
(b).
incurred expense;
(c).
took medication; or
(d).
received a diagnosis or advice from a Physician;
during the 12-month period immediately before the Effective Date of his or her coverage. The term Pre-Existing Condition
will also include conditions which are related to such disease, Accident, Sickness or physical condition.
1.18
"Schedule of Benefits (or Schedule)" means the benefit schedule set forth in the Policy or Certificate.
1.19
"Sickness" means illness or disease which begins while the Covered Person's coverage is in force and is the direct cause of the loss.
1.20
"Total Disability or (Totally Disabled)" means the Insured is disabled and prevented from performing the material
and substantial duties of his or her occupation. For Dependents, "Totally Disabled" means the inability to
perform a majority of the normal activities of a person of like age in good health.
VBA Benefits & Terms
Members Benefits and Services:
CallMD:
Members have access to a nationwide network of medical doctors available 24 hours per day / 7 days per week for consultation or routine medical needs through the convenience of a toll free phone number, without having to take time to make an appointment or wait in line at a doctor's office. CallMD maintains members' electronic medical records (EMR) in a highly secured, Internet accessible environment and makes this information available to our network doctors prior to a doctor consultation. Furthermore, a CallMD Doctor can write a prescription where allowed by law when sufficient medical history is available.
(CallMD cannot write prescriptions for narcotics or DEA controlled substances.)
The Dividend Club:
Members will earn Dividends (paid quarterly to you) on Merchandise, Services, Travel & Entertainment when you shop from our On-line Mall and make a purchase. Choose from retailers like these, just to name a few, and get the dividends: Walmart.com, Target.com, BestBuy.com, CircuitCity.com, CompUSA.com, DisneyStore.com, OfficeMax.com, Brooks- Brothers.com, Brookstone.com, Buy.com, EddieBauer.com, LizClairborne.com, FOA.com, FOSSIL.com, HotelDiscounts. com, Jcrew.com, etc.
Included at no charge:
Discounts at over 55,000 pharmacies for your prescription drugs as well as lab tests and x-ray imaging services.
Rewards Network:
America's Premier Dining Rewards Program and Hotel Discounts. Save up to 20% off every meal plus up to 15% off your hotel room rate.
Refund Sweepers:
Free Merchandise, Bargains, On-line Coupons, Rebates, Sweepstakes & more.
Car Rental Services:
Provides discounts at Alamo, National, Hertz and Avis
DISCOUNTS AND DIVIDENDS ARE NOT INSURANCE BENEFITS*
VBA Terms and Conditions:
1
Member understands that VBA is not an insurance company or program. Insured Benefit Payments are made by the administrator for the insurance company issuing the master policy to Members.
2
VBA provides savings to its members on services through a number of sources. The current list of benefits may be modified through additions or deletions. A quarterly newsletter, posted on our web site or sent via e-mail, will keep Members up to date on benefits and other pertinent information.
3
Payments for the VBA Program are due in advance. Payments will be drafted on or about 15 days before the due date. If you choose to cancel your program, it is your responsibility to make sure that your membership card and a written request for cancellation are sent to VBA at least 15 days prior to the anniversary of your effective date in order for your account not to be charged for additional fees.
4
Member hereby appoints, Value Benefits of America Association (VBA) President, or failing this person, a VBA Director, as proxy holder for and on behalf of the member with the power of substitution to attend, act and vote for and on behalf of the member in respect of all matters that may properly come before the meeting of the members of VBA and at every adjournment thereof, to the same extent and with the same powers as if the undersigned member were present at the said meeting, or any adjournment thereof. Annual meetings are to be held in Arizona the second Tuesday of August.
5
VBA reserves the right to terminate any enrollment or deny eligibility in the program for lack of payment to VBA. Returned checks, insufficient notices on bank drafts or denial by the member's credit card company for payment of the membership fee are deemed to be evidence of non-payment by a member. There will be a $10.00 charge to be reinstated in the program after such denial. If reinstatement for non-payment happens more than once, a $20.00 reinstatement will apply.
6
In the event of any dispute, member agrees to resolve said dispute solely by binding arbitration that shall be governed by the laws of the state of Arizona and enforceable at Scottsdale, Maricopa County.
7
Memberships canceled within the first 10 days of the receipt of enrollment materials & Certificate of Coverage may be eligible for refund if the membership card and written cancellation request are sent to VBA. The administrative fee is not refundable. Approved refunds will be processed approximately 30 days after cancellation.
8
Membership is effective on the 1st of the month following enrollment acceptance by VBA.
VBA Member Agreement:
By signing the enrollment form; Member expresses desire to become a member of Value Benefits of America. Member acknowledges that the discount plans are not insurance, but membership does include certain limited benefit or supplemental insured coverage's. Membership benefits are not a replacement for health insurance coverage nor are they intended as a substitute for health insurance coverage. Membership fees may be changed for all members, but not individually, with notification.
Surgical Schedule
Schedule Of Surgical Indemnity Benefits.
To determine the surgery benefit multiply the Payment Factor for the Procedure listed by the Surgical Procedure Unit for the Option you selected:
Option
Units
1, 5 and 9
16
2 and 6
33
3, 4, 7 and 8
50
Procedure
Payment Factor
1. ABDOMINAL SURGERY
Abdomen, paracentesis
$
10.00
Herniotomy, single,ingiunal,femorial or umbilical
$
45.00
Herniotomy, hiatus or diaphragmatic
$
120.00
Herniotomy, ventral or incisional
$
65.00
Esophageal diverticulum
$
90.00
Gastrotomy or gastrostomy
$
100.00
Gastrectomy, total
$
150.00
Gastro-enterostomy
$
135.00
Peptic ulcer, perforated, closure
$
75.00
Peptic ulcer, subtotal gastrectomy
$
125.00
Pyloric stenosis (Ramstedt's in infant)
$
55.00
Intestines anastomosis
$
80.00
Intestines (small) resection
$
95.00
Laparotomy
$
80.00
Colon, resection
$
140.00
Colonoscopy
$
40.00
Colostomy
$
95.00
Appendectomy
$
60.00
Diverticulum intestinal (Meckel's)
$
70.00
Common duct with or without Cholecystectomy
$
105.00
Appendiceal, abcess, drainage
$
60.00
Subdiaphragmatic abcess
$
70.00
Cholecystectomy
$
75.00
Cholecystoduodenostomy
$
110.00
Pancreas Drainage
$
95.00
Splenectomy
$
85.00
2. OPHTHALMOLOGY
Foreign body removal within anterior or posterior chamber
$
90.00
Cornea, paracentesis
$
15.00
Conjunctival suture
$
30.00
Conjunctival flap for corneal ulcer, etc.
$
60.00
Chalazion (excision) Simple
$
10.00
Chalazion (excision) Multiple
$
15.00
Lacrimal sac, plastic
$
50.00
Entropion or ectropion or ectropion, Zeigler's puncture
$
50.00
Entropion or ectropion, plastic operation
$
30.00
Entropion or ectropion, plastic operation graphs of flaps
Value Access Guarantee
