R-93-11-23-9I - 11/23/1993 r {
t • A
RESOLUTION NO.
WHEREAS, the Council of the City of Round Rock has previously
determined that it is in its best interest to self-fund its employees'
health care benefits, and
WHEREAS, it is necessary to provide for stop loss insurance for
the City's health benefit plan, Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK,
TEXAS,
That the Mayor is hereby authorized and directed to execute on
behalf of the City an agreement with Ii-_)P_\RV3we- AM&Y�NC.,(�r'l L,1 �C,
for stop loss insurance for the City's health benefit plan, a copy of
which is attached hereto and incorporated herein.
RESOLVED this 23rd day of November, 1993 .
d1_14/2r:=42
CHARLES CULP P , Mayor
City of Round ock, Texas
ATTEST:
(O�"E LAND, City Secretary
M"BOLMON
RSI 1233K
t R i
DATE: November 22, 1993
SUBJECT: City Council Meeting, November 23, 1993
ITEM: 9.1. Consider a resolution authorizing the Mayor to enter into an agreement for
City health plan stop—loss insurance.
STAFF RESOURCE PERSON: David Kautz
NARRATIVE AND STAFF RECOMMENDATION:
The City will implement a self—funded health plan beginning December 1, 1993. To protect
the City's financial exposure under self—funding, a"safety net" is purchased in the form of
stop—loss insurance. The stop—loss insurance covers all health claim expenses in excess of
contractual limits agreed to by the City and the stop—loss carrier.
The stop—loss insurance was bid along with the third party administrator and staff
recommends entering into an agreement with Delaware American Life as the stop—loss
carrier.
The cost of the insurance is dependent upon the number of employees/families covered by the
plan:
Individual (*1) Approximate Approximate
Stop Monthly Employee Annual
Loss Cost Units Cost
Employee Only Unit $22.17 200 $53,208
Employee & Dependent Unit $59.85 100 $71,820
Aggregate (*2)
Stop
Loss
Employee Only Unit $2.37 300 $8,532
Employee & Dependent Unit n/a n/a $0
Total Approximate Annual Cost $133,560
(*1) The Individual Stop Loss provides coverage for individual claims which exceed
$30,000
(*2) The Aggregate Stop Loss provides coverage for claims which exceed a
contractually established annual aggregate. The annual aggregate is referred
to as the Attachment Point.
EXECUTED
DOCUMENT
FOLLOWS
K. f J3
DELAWARE AMERICAN LIFE INSURANCE COMPANY
200 State Street
Boston, Massachusetts 02109
EXCESS LOSS INDEMNITY POLICY
In consideration of the payment of premium, the statements in the
application, a copy of which is attached to and made a part of
the Policy, and subject to the terms, conditions and limitations
of this Policy, Delaware American Life Insurance Company, herein
called the Company, does insure:
Insured: City of Round Rock Policy: 864-6783
Address: 221 E. Main Street,
Round Rock, TX 78664
The first payment of premium is due and payable on or before the
Effective Date shown in the Schedule and all other premiums are
due and payable as set forth in the Payment of Premiums provision
while the Policy is in force.
The Policy Year shall begin and end at 12 :01 a.m. Standard Time
at the address of the principal office of the Named Insured.
� Y:
Countersigned at Boston Mass B
g
_ +
Authorized Representative
Date: 1/21/94
c l �
I - DEFINITIONS
ACTIVELY AT WORK means that the Covered Person is performing on a full
time basis all regular duties of his or her normal occupation on the
Effective Date of this Policy, or on his or her last regularly
scheduled work day prior to that Effective Date, or the date a Covered
Person becomes eligible if after the Effective Date of this Policy.
ANNUAL AGGREGATE RETENTION AMOUNT for the Policy Year or 'any fraction _
thereof if this Policy terminates or is cancelled during the Policy
Year, means that portion of the Eligible Expenses that is wholly
retained by the Named Insured calculated by multiplying the number of
Covered Units by the Covered Units' corresponding Monthly Aggregate
Retention Amount Factor applied for each policy month, or the Minimum
Aggregate Retention Amount shown in the Schedule, whichever is
greater.
BENEFIT PLAN (also called the Plan) means the welfare benefits the
Named Insured has agreed to provide under a plan of benefits for the
Covered Units, as defined in the written form of such Plan which is in
effect on the Effective Date of this Policy, including any amendments
to such Plan to which this Policy applies.
BENEFIT PLAN PAYMENTS ON AN INCURRED AND PAID BASIS means, for a
Policy Year, the total dollar amount of benefits to which Covered
Units or Covered Persons become entitled under the Plan subject to any
limitations of this Policy. Such amount of benefits shall only
include the Eligible Expenses incurred on or after the Effective Date
of this Policy and paid by the Named Insured during the Policy Year.
Such amount of benefits shall not include deductibles, coinsurance
amounts, or any other expenses or claims which are not payable or
reimbursable under the terms of the Plan, nor shall it include
expenses which are payable or reimbursable from any other source. No
cost of claim payment or expense of litigation shall be included. An
Eligible Expense will be considered to be incurred at the time the
service or the supply to which it relates is provided. Drafts or
checks issued shall be counted as amounts paid provided sufficient
funds are then available to cover such payments.
COVERED PERSON means each person, individually, who is a Covered Unit,
or, in the case of a dependent, a member of a Covered Unit.
COVERED UNIT means an employee, an employee and his or her dependents,
or such other defined unit as agreed upon in writing between the
Company and the Named Insured.
DATE OF ISSUE means the date printed on the draft or check, but no
later than the last day of the Policy Year.
ELIGIBLE EXPENSES means the charges which are covered and paid under
the Plan subject to any limitations of this Policy.
ELIP 1 of 10
c
EXPERIMENTAL PROCEDURE means any medical procedure, equipment,
treatment or course of treatment, or drugs or medicines that are: (a)
limited to research; (b) not proven in an objective manner to have
therapeutic value or benefit; (c) restricted to use by medical
facilities capable of carrying out scientific studies; (d) of
questionable medical effectiveness; or (e) would be considered
inappropriate medical treatment. To determine whether a procedure is
experimental, the Company will consider, among other things,
commissioned studies, opinions and references to or by the American
Medical Association, the federal Food and Drug Administration, the
Department of Health and Human Services, the National Institutes of
Health, the Council of Medical Specialty Societies and any other
association or program or agency that has the authority to review or
regulate medical testing or treatment.
LIMIT OF LIABILITY means the amount shown in the Schedule which is the
maximum payable under this Policy to the Named Insured for the Policy
Year.
MINIMUM AGGREGATE RETENTION AMOUNT means the amount shown in the
Schedule which is wholly retained by the Named Insured regardless of
how long this Policy remains in force.
MONTHLY AGGREGATE RETENTION AMOUNT FACTOR means the factor which is
multiplied by the number of Covered Units each policy month of the
Policy Year to determine the Annual Aggregate Retention Amount.
NAMED INSURED means the Insured named in this Policy.
NUMBER OF COVERED UNITS means the total number of Covered Units
existing in any one policy month. The Number of Covered Units
anticipated for the first policy month of the Policy Year is shown as
Initial Enrollment in the Schedule. The Number of Covered Units for
subsequent policy months will be determined on a monthly basis in
accordance with the definition of Covered Units and with the
eligibility requirement of the Plan.
ORGAN TRANSPLANT PROCEDURES means kidney, cornea, heart, lung, heart-
lung, liver, pancreas and bone marrow (including autologous bone
marrow) transplants
POLICY YEAR means the period from 12:01 a.m. Standard Time on the
Effective Date to 12 :01 a.m. Standard Time on the Expiration Date, as
shown on the Schedule of this Policy except as provided in the
Cancellation and Payment of Premiums Conditions of this Policy. Unless
otherwise stated and endorsed, the Policy Year will be assumed to be
twelve (12) months.
ELIP 2 of 10
REIMBURSEMENT FACTOR means the percentage shown in the Schedule which
will determine the dollar amount of the Limit of Liability which will
be paid to the Named Insured. Separate Reimbursement Factors may
apply each to the Aggregate Excess Insurance and to the
Specific Excess Insurance.
SPECIFIC RETENTION AMOUNT means the amount shown in the Schedule which
is wholly retained by the Named Insured per Covered Person for the
Policy Year.
TOTALLY DISABLED means that the Covered Person is hospital confined or
is unable to engage in the normal activities of a person in good
health of like age and sex on the Effective Date of this Policy or on
the date a Covered Person becomes eligible under the Plan if other
than the Effective Date of this policy.
II - SPECIFIC EXCESS INSURANCE
A. The Company will, subject to the terms, conditions and
limitations of this Policy, reimburse the Named Insured for the
amount, if any, of the Specific Excess Benefit, within sixty (60)
after the receipt by the Company of documentation acceptable to
the Company of both proof of loss and verification of Payment of
Benefits under the Plan.
B. The Specific Excess Benefit for the Policy Year is the total
amount of Benefit Plan Payments On An Incurred And Paid Basis for
a Covered Person less the Specific Retention Amount, multiplied
by the Reimbursement Factor. The amount of this benefit shall
not exceed the Limit of Liability shown in the Schedule for
. Specific Excess Insurance.
C. If a Covered Person incurs Eligible Expenses, a single Specific
Retention Amount shall apply for such Covered Person to those
Eligible Expenses which are incurred and paid during the Policy
Year.
III - AGGREGATE EXCESS INSURANCE
A. After the end of the Policy Year, (whether by normal expiration,
termination, or cancellation) , the Company will reimburse the
Named Insured for the amount of the Aggregate Excess Benefit, if
any, within sixty (60) days after the receipt by the Company of
documentation acceptable to the Company of both proof of loss and
verification of Payment of Benefits under the Plan.
B. The Aggregate Excess Benefit for the Policy Year is the total
amount of Benefit Plan Payments On An Incurred And Paid Basis,
less: (1) the Annual Aggregate Retention Amount, and (2) the
Specific Excess Benefit which has been or will be reimbursed by
ELIP 3 of 10
the Company under the Specific Excess Insurance, multiplied by
the Reimbursement Factor. The amount of this Benefit shall not
exceed the Limit of Liability shown in the Schedule for Aggregate
Excess Insurance.
IV - LIMITATIONS OF COVERAGE
A. The Company has no responsibility or obligation under this Policy
to reimburse directly any Covered Person or provider of
professional or medical service for any benefits which the Named
Insured has agreed to provide under the terms of the Plan. The
Company's sole liability hereunder is to the Named Insured,
subject to the terms, conditions, and limitations of the Policy.
B. If a Covered Person is not Actively At Work or is Totally
Disabled on the Effective Date of this Policy, Eligible Expenses
shall include only those expenses incurred on and after the date
the Covered Person returns to work full-time or the Total
Disability ends and the Covered Person meets the eligibility
requirements of the Plan.
C. Coverage of expenses for the treatment of Mental and Nervous
Conditions is limited to $25, 000.00 in excess of the Specific
Retention Amount.
D. Any reimbursement amount payable to a Named Insured who has
retained the services of a Preferred Provider Organization or any
other organization providing discounted provider services or
supplies to the Named Insured will be the actual amount paid by
the Named Insured after the application of all discounts.
V - EXCLUSIONS
This Policy will not reimburse the Named Insured for any loss or
expense caused by or resulting from any of the following:
1. Expenses incurred while the Plan is not in force.
2 . Expenses resulting from the provision of weekly income benefits
or any dental, vision, hearing, or prescription drug program,
unless specifically endorsed hereon.
3 . Liability assumed by the Named Insured under any contract or
service agreement other than the Plan.
ELIP 4 of 10
a
4. Expenses resulting from services or supplies which are not
medically necessary, are in excess of the usual and customary
charge for the locality where supplied or administered, or are in
excess of the Plan benefits.
5. Expenses for any accidental bodily injury or sickness for which
the Covered Person would be entitled to benefits under any
Worker's Compensation or occupational Disease policy whether or
not such policy is actually in force.
6. Expenses for the administration of claims or other service(s)
provided by the Administrator.
7. Any consulting fee(s) .
8. Expenses of litigation.
9. With respect to each Covered Person who is eligible for benefits
under Medicare, a benefit otherwise payable under this Policy
shall be reduced by the amount of any similar Medicare benefit so
that the total reimbursements hereunder on behalf of a Covered
Person shall not exceed one hundred percent (100%) of the Covered
Person's actual expenses. It will be conclusively presumed that
each Covered Person eligible for benefits under Medicare became
covered for all parts of Medicare to which he or she is entitled
on the earliest possible date and thereafter maintained such
coverage in force.
10. Expenses for any bodily injury or sickness incurred by a Covered
Person that was the result of a Covered Person committing or
attempting to commit an assault or a felony or from a Covered
Person engaging in an illegal occupation.
11. Expenses incurred in connection with a suicide or any
intentionally self-inflicted injury or illness, whether the
Covered Person were sane or insane when he or she committed the
act.
12. Expenses for experimental procedures, drugs, or research studies,
or for any services or supplies not considered legal in the
United States.
13. Expenses incurred by a live organ donor unless the donor is a
Covered Person under this Policy. Expenses of a live organ donor
shall not be considered as eligible expense of the organ
recipient unless the donor is without insurance, in which case a
maximum of $10,000 shall be considered as Eligible Expenses of
the recipient.
ELIP 5 of 10
14. Expenses resulting from war, whether declared or undeclared,
hostilities, invasion, or civil war.
15. Expenses resulting from injury or illness that is the result of a
nuclear or radioactive accident.
VI CONDITIONS
PREMIUM: The premium basis and rates for this Policy will be as shown
in the Schedule. Upon termination of the Policy, the earned premium
shall be computed in accordance with the premium and exposure basis
shown in the Schedule. If the earned premium exceeds the premium
paid, the Named Insured shall pay the excess to the Company; if less,
the Company shall return the unearned portion the premium paid to the
Named Insured subject to the minimum premium, if any, shown in the
Schedule.
MINIMUM PREMIUM: The Minimum Premium payable will be the amount shown
in the Schedule or, in the event of termination or cancellation, the
sum of all monthly premium rates payable, multiplied by the Minimum
Enrollment shown in the Schedule multiplied by the number of policy
months.
PAYMENT OF PREMIUMS: Premium payments are due in advance on the first
day of each month. A period of fifteen (15) days from the first day
will be granted for payment of each premium, during which period this
Policy will continue in force, except that should a premium otherwise
due not be paid during such period, this Policy will terminate without
notice on the. first day of the month in which the unpaid premium was
due.
DATA REQUIRED: The Named Insured will maintain adequate records
acceptable to the Company and provide any information required by the
Company in its sole judgement, to administer this Policy. The Company
may periodically examine any of the Named Insured's records including
those of the Named Insured's Administrator, relating to the insurance
under this Policy and any claims filed under this Policy.
CLERICAL ERROR: Clerical error, whether by the Named Insured or by
the Company in keeping any records pertaining to this insurance, will
not invalidate coverage otherwise validly in force or continue
coverage cancelled or otherwise terminated.
AMENDMENTS TO THE POLICY: This Policy may be amended at any time with
the mutual consent of the Company and the Named Insured, however, no
such amendment shall be effective unless confirmed by an endorsement
issued to form a part of this Policy.
ELIP 6 of 10
AMENDMENTS TO THE PLAN OR AGREEMENT WITH ADMINISTRATOR: The Named
Insured will provide the Company with a copy of all Benefit Plan
documents (i.e. booklets, brochures, sub-group variations, etc. ) prior
to the Effective Date of this Policy. The Named Insured shall also
provide the Company with prompt written notice of any change in the
Benefit Plan. The Company reserves the right to
refuse to apply- this Policy to any change in the Benefit Plan unless
and until and only to the extent provided in an endorsement issued by
the Company to form a part of this Policy. At the time it provides
the Company with the Benefit Plan documents, the Named Insured shall
also provide the Company with a copy of the Agreement between the
Named Insured and the Administrator. The Named Insured shall provide
the Company with a copy of any and all changes to such Agreement prior
to their effective date. The notices required by this Condition shall
be sent directly to the Company at 200 State Street, Boston,
Massachusetts 02109 to the attention of the Special Accident
Department.
NOTICE: For the purpose of any notice required from the Company under
the provisions of this Policy, notice to the Administrator shall be
considered notice to the Named Insured.
TAXES: The Named Insured shall reimburse and hold the Company
harmless from any premium tax liability, including interest,
penalties, or costs assessed against the Company by law,
administrative ruling, or judicial decision because of Benefit Plan
Payments paid under the Named Insured's Benefit Plan. The Named
Insured shall pay such amounts upon receipt of notification of the
assessment.
ADMINISTRATION OF CLAIMS UNDER THE PLAN:
1. The Named Insured shall undertake at all times to employ the
services of an Administrator, who shall be deemed the agent of
the Named Insured.
2. The Administrator, acting- on behalf of the Named Insured, shall:
a. supervise the administration and adjustment of all claims and
verify the accuracy and computation of all claims;
-b. maintain accurate records of all claims payments;
C. provide the underwriting department of the Company on or
before the 15th day of each and every policy month, on a
reporting form supplied by the Company, the following data
for the immediately preceding policy month:
ELIP 7 of 10
1. Number of Covered Units 3. Amount of paid claims
2 . Premium paid 4. Amount of unpaid
processed claims on hand
d. supervise funding of the Benefit Plan by the Name Insured.
AUDIT: The Company shall have the right to inspect and audit all
records and procedures of the (1) Named Insured, (2) its
Administrator, or (3) any other organization involved in the
administration or adjudication of claims, and to require, upon
request, proof of records satisfactory to the Company that payment has
been made to the provider of such services or benefits which are the
basis for any claim hereunder.
NOTICE OF CLAIM: The Name Insured shall provide immediate written
notification to the Company when it becomes evident that benefits have
been or will be incurred which will exceed the Specific Retention
Amount of this Policy.
The Named Insured shall provide immediate written notification to the
Company when a Covered Person incurs Eligible Expenses for any of the
following diagnoses:
1. Head or Spinal Cord Injuries 5. Acquired Immune
Deficiency Syndrome
2 . Severe Burn Cases 6. Cancer
3. Severe Trauma 7 . Severe Strokes
4 . Premature Birth 8. Organ Transplants
In addition to the above notice requirements, the Named Insured shall
provide written notification to the Company within thirty (30) days
after Plan benefit payments for any Covered Person exceeding fifty
(50%) percent of the Specific Retention Amount have been made.
Notwithstanding the above, failure to furnish written notification
within the time required shall not invalidate nor reduce any claim if
it was not reasonably possible to furnish written notification within
such time, provided that such notification is furnished as soon as
reasonably possible but in no event later than six (6) months after
the date that written notification of Plan benefit payment is
otherwise required. No claim for reimbursement shall be considered
under this Policy unless it is received by the Company in writing no
later than (2) years after the date of receipt of the first written
notification to the Company of the payment by the Named Insured under
the Plan.
ELIP 8 of 10
NOTICE OF APPEAL: Any objection, notice of legal action, or complaint
received on a claim processed by the Named Insured or its
Administrator and on which it reasonably appears benefits will be
payable under this Policy shall be brought to the immediate attention
of the Claims Department of the Company.
SUBROGATION: The Named Insured or Administrator shall pursue all
actions that the Named Insured may have against a third party because
of any claim resulting in a Plan benefit payment by the Named Insured.
The Named Insured or Administrator shall account to the Company for
all amounts recovered. If the Named Insured or Administrator fails to
pursue any action against a third party and the Company has made
excess benefit payments to the Named Insured under this Policy, the
Company shall be subrogated to all rights of the Named Insured. The
Named Insured shall cooperate fully and do all things necessary and
required for the Company to pursue any action to recover against the
third party.
Any amounts recovered by the Named Insured, Administrator, or the
Company in such action shall be used first to reimburse the expenses
of recovery and then to reimburse the Company for any payments made to
the Named Insured. Any remaining amount shall be paid to the Named
Insured.
CHANGES: Notice to any broker or agent or knowledge possessed by any
broker or agent or by any other person shall not effect a waiver of a
change in any part of this Policy or stop the Company from asserting
any right under the terms of this Policy; nor shall the terms of this
Policy be waived or changed, except by endorsement issued to form a
part of this Policy.
ASSIGNMENT: Assignment of interest under this Policy shall not bind
the Company until its consent is endorsed hereon.
CANCELLATION: This Policy may be cancelled by the Named Insured by
surrender thereof to the Company or by mailing to the Company written
notice stating when thereafter such cancellation shall be effective.
This Policy may be cancelled by the Company by mailing to the Named
Insured at the address shown in this Policy written notice stating
when, not less than thirty (30) days thereafter such cancellation
shall be effective. The mailing of notice shall be sufficient proof
of notice. The time of surrender or the effective date and hour of
cancellation stated in the notice shall become the end of the Policy
Year. Delivery of such written notice either by the Named Insured or
by the Company shall be equivalent to mailing.
If the Named Insured cancels, earned premium shall be computed in
accordance with the customary short rate table and procedure. If the
company cancels, earned premium shall be computed pro rata.
ELIP 9 of 10
Premium adjustments may be made either at the time cancellation is
effected or as soon as practicable after cancellation becomes
effective, but payment or tender of unearned premium is not a
condition of cancellation.
LEGAL ACTION: No action at law or in equity shall be brought to
recover on this Policy prior to the expiration of sixty (60) days
after written proof of loss has been furnished in accordance with the
requirements of this Policy. No such action shall be brought after
the expiration of two (2) years after the time written proof of loss
is required to be furnished.
REPRESENTATIONS: By acceptance of this Policy, the Named Insured
agrees that the statements in the application, the Schedule, and any
information supplied by or on behalf of the Named Insured are its
agreements and representations; that this Policy is issued and
continued in reliance upon the truth of such representations; and that
this Policy embodies all agreements existing between the Named Insured
and the Company. Any misrepresentations or omissions, shall make the
coverage null and void.
SERVICE OF SUIT: In the event of failure of the Company to pay any
amount claimed to be due hereunder, the Company, at the request of the
Named Insured, will submit to the jurisdiction of a court of competent
jurisdiction within the United States. Nothing in this condition
constitutes or should be understood to constitute a waiver of the
Company's rights to commence an action in any court of competent
jurisdiction in the United States, to remove an action to a United
States District Court or to seek a transfer of a case to another court
as permitted by the laws of the United States or of any state in the
United States. It is further agreed that service of process in such
suit may be made upon Counsel, Legal Department, Delaware American
Life Insurance Company, 200 State Street, Boston, Massachusetts,
02109, or his or her representative, and that in any suit instituted
against the Company upon this policy, the company will abide by the
final decision of such court or of any appellate court in the event of
an appeal.
Further, pursuant to any statute of any state, territory, or district
of the United Sates which makes provision therefor, the Company hereby
designates the Superintendent, Commissioner or Director of Insurance,
other officer specified for that purpose in the statute, or his
successor or successors in office as its true and lawful attorney upon
whom may be served any lawful process in any action, suit, or
proceeding instituted by or on behalf of the Named Insured arising out
of this Policy of insurance and hereby designates the above named
Counsel as the person to whom the said officer is authorized to mail
such process or a true copy thereof
IN WITNESS WHEREOF, the Company has caused this Policy to be signed by
its President and Secretary, but this Policy shall not be valid unless
countersigned by a duly authorized representative of the
Company
August, 1992 ELIP 10 of 10
SCHEDULE - Excess Loss Indemnity Policy
POLICY # 864-6783
EFFECTIVE DATE: 12/1/93 - 12/1/94
Coverage is only applicable to the category for which a retention
amount is shown below. If no retention amount is shown, coverage
is not provided for that category.
(A) SPECIFIC EXCESS INSURANCE
(1) Specific Retention Amount per Covered person
for the Policy Year $ 30,000
(2) Limit of Liability $970,000
(3) Reimbursement Factor 100%
(4) Monthly Premium Rates Payable per
Covered Unit for the Policy Year
( ) Composite (xx) Single/Family Basis $22.17/59.85
(5) Monthly Optional Transplant Endorsement Rate
Payable per Covered Unit for the Policy Year $Included
(B) AGGREGATE EXCESS INSURANCE
(1) Monthly Aggregate Retention Amount Factor $154 . 65
(2) Anticipated Annual Aggregate Retention
Amount $554,884
(3) Minimum Aggregate Retention Amount $499,396
(4) Limit of Liability $1,000,000
(5) Reimbursement Factor $ 100%
(6) Monthly Premium Rate Payable Per Covered
Unit for the Policy Year $ 2.37
(7) Minimum Premium $124 ,008
(C) COVERED BENEFITS
(xx) Medical (xx) Dental ( ) Weekly Indemnity
(xx) Prescription Drug ( ) Other
(D) PAYMENT BASIS
(xx) Incurred & Paid ( ) Paid ( ) other
(E) ENDORSEMENTS
( ) Other
(F) ADMINISTRATOR OF BENEFIT PLAN
Healthcare Benefits, Inc.
12-13-1993 09:46 2146698663 HBI P.05
1200/93 13:50 IM21 14 0093 S.R.S.DAUAS W002/003
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DELAWARE, AMERICAN
LI F2 INSURANCE COMPANY
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P. 0. box �67, Wilmington, Delavare 19899
A capital stock company
(herein called the Company)
EXCESS LOSS INDEMNITY COVERAGE
APPLICATION
The Applicant is applying for the insurance specified below.
1. Name at Applicant City of laaund Rn&k
Address 321 B. Hien Street, Round Rocks= Zip Code 78664
Type of Business m uniglaiity
Other Locations YES ( NO (E)
If so, Where
2. Platt Administrator Eealtbearl DgMefits, Inc.
Address 1201 S. Sherman. Suits 2001 R chardson, Zip Code
3 . Broker Southern Risk Soecialiats, Inc.
Address 1999 Bryan Street, suite 1820. Dallas, TX Zip Code 7520I
4. Initial Enrollment 299 Minimum Enrollment 169
(5:189, f:110)
(A) SPECIFIC EXCESS INSURANCE
(1) Specific Retention Amount per $ 01000
Covered Person for the Policy Year
(2) Limit of Liability $ 970.000
(3)- Reimbursement Factor ioo
(4) Monthly Premium Rated Payable per Covered
Unit for the policy Year
( ) Composite Basis
[x ] Single/Family Basis $ 22.17/59.85
(S) Monthly Optional Transplant Endorsement Rate
Payable per Covered Unit for the Policy Year
$ Included
462511 1
ENDORSEMENT
This endorsement. effective 12:01 (A' M. 12/1/93 forms a part of
policy No. 864--6783 issued to City of Round Rock
by Delaware American Life Insurance Company
AGGREGATE__,.ONLY
It is hereby understood and agreed that Section V - EXCL-USIONS of
the Policy is hereby amended to read:
This policy will not reimburse the Named Insured for any loss or
expense caused by or resulting from any of the following :
V_-2...._E.x..P_enses resp_2_t i n_qf r_om_-_the._..orov i,s i,on_ of_.....-weekly inco
=.Jsion, hearin.gca,re, or, unless specifically endorsed hereon. .
Authorized Representative
i
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ENDORSEMENT
This endorsement,effective 12:01 A. M 12/1/93 forms a part of
policy No. 86)4-6783 issued to City of Round Rock
by Delaware American Life Insurance Company
It is hereby understood and agreed that the provisions of
Section IV-LIMITATIONS of Coverage Part B "Actively at Work" are
hereby waived.
YW�
Authorized Representative
EXCESS CLAIM SUBMISSION PROCEDURE
Here is a supply of claim forms. They are two different types:
1) NOTIFICATION OF CLAIM 2) REIMBURSEMENT REQUEST FOR HOSPITAL
SPECIFIC EXCESS LOSS.
NOTIFICATION OF CLAIM is to notify Delamlife of any and all
claims that exceed 50% of the Hospital Specific Retention amount.
Also, for early notification of any of the following diagnosis.
1. Head or spinal cord injuries 5. Acquired Immune Deficiency
Syndrome -
2 . Severe Burn cases AIDS
3. Severe Trauma 6. Malignant tumors of the
brain, liver, and pancreas.
4. Premature Birth 7 . Severe Strokes
Reimbursement request for Hospital Specific Excess Loss is to be
used when a potential claim has exceeded the specific retention
amount, and reimbursement is requested. The form should be used
in conjuction with the actual submission of claim documentation.
The Lexington requires the following documentation, prior to
Excess Loss reimbursement:
- Enrollment verification
- Hospital admission and discharge summaries
- Operative reports
- Prognosis statement from attending physicians
- Independent claim audit correspondence
- Accident / police reports if applicable
- Subrogation information
-A
it •=
PLAN DOCUMENT NO.: 1169
PLANHOLDER: City of Round Rock
PLANHOLDER'S PRINCIPAL LOCATION: Round Rock, Texas
PLAN EFFECTIVE DATE: December 1, 1993
PLAN ANNIVERSARIES: December 1, 1994 and each year thereafter
STOP LOSS CARRIER: Delaware American Life Insurance Company
The Planholder has established a self-funded Employee Welfare Benefit Plan, and the Planholder
has adopted this'PLAN DOCUMENT" (hereinafter'PLANJ providing for certain medical benefits
as herein described for certain Employees and certain Dependents of such Employees of the
Planholder and other Participant Employers as herein listed.
The Planholder AGREES to pay, subject to all the provisions of this Plan, including any
amendments to this Plan, the benefits hereinafter described to the person or persons entitled to
such payments while covered hereunder.
The provisions of the following pages are a part of this Plan. Such provisions alone constitute
the agreement under which payments will be made and are a part of this 'Plan' as fully as if
recited over the signatures hereto affixed.
IN WITNESS HEREOF, City of Round Rock has caused this Plan to be executed this 1 st day of
December, 1993.
SIG D WITNESSED BY:
A51-57AWr &TV lWNIAI;6elw
True Title /Ty s6cf 671W y
d&�12 0.4� 111199
Dat Date
2