R-02-10-10-13E2 - 10/10/2002RESOLUTION NO. R- 02- 10- 10 -13E2
WHEREAS,the City of Round Rock is currently purchasing stop loss
reinsurance from Excess, Inc., acting as the Managing General
Underwriter, with ACE American Insurance Company providing the
underwriting; and
WHEREAS, the City wishes to renew its agreement with Excess, Inc.
to continue to provide stop loss reinsurance for the period of December
1, 2002 to November 30, 2003; 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 the
necessary documents to renew the City's stop loss reinsurance with
Excess, Inc., acting as the Managing General Underwriter, with AIG Life
Insurance Company providing the underwriting.
The City Council hereby finds and declares that written notice of
the date, hour, place and subject of the meeting at which this
Resolution was adopted was posted and that such meeting was open to the
public as required by law at all times during which this Resolution and
the subject matter hereof were discussed, considered and formally acted
upon, all as required by the Open Meetings Act, Chapter 551, Texas
Government Code, as amended.
RESOLVED this 10th day of October, 2002.
T ST_
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CHRISTINE R. MARTINEZ, City Secret
WELL, Mayor
City of Round Rock, Texas
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AIGLIFE
AIG LIFE INSURANCE COMPANY
One Alico Plaza
Wilmington, DE 19801
EXCESS LOSS INDEMNITY POLICY
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In consideration of the payment of the premium, the statements in the Master Application, a copy of
which is attached to and made part of this Policy, and subject to the terms, conditions and limitations of
this Policy, the AIG Life Insurance Company, herein called the Company, does hereby issue this
Policy to
Policyholder
Policy Number: 316 -
Address:
The first payment of premium is due and payable on or before the Effective Date of this Policy shown in
the Schedule and all other premiums are due and payable as set forth in the Payment of Premiums
provision as long as the Policy is in force.
The Policy Year shall begin and end at 12:01 a.m. Standard Time at the address of the Policyholder
shown in this Policy.
The Policyholder understands the liability assumed under the portion of the employee benefit plan which
he is self - insuring and further understands that he is exempted from Article 1.14 -1 of the Texas
Insurance Code only if a qualified employee benefits plan has been filed and meets the requirements of
ERISA.
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE
EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION
SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON -
SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE
ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST
COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON -
SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND
POSTED.
IN WITNESS WHEREOF, the Company has caused this Policy to be signed by its President and
Secretary.
55350TX
President Secretary
Excess Loss Indemnity Policy
SCHEDULE - Excess Loss Indemnity Policy
Policyholder POLICY #:
Address EFFECTIVE DATE: January 1, 2000
EXPIRATION DATE: January 1, 2001
NOTE: 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 $ 10,000
(2) Limit of Liability $ 990,000
(3) Reimbursement Factor 100%
(4) Premium Rates Payable per Covered Unit for the Policy Year:
( ) Composite Basis S - $
(x) Single/Family Basis F - $
(5) Organ Transplant Endorsement Rate Payable per Covered Unit for the Included in
Policy Year Specific Rates
(B) AGGREGATE EXCESS INSURANCE
(1) Monthly Aggregate Retention Amount Factor for Medical S - $
F - $
(2) Anticipated Annual Aggregate Retention Amount $
(3) Minimum Aggregate Retention Amount $
(4) Limit of Liability $ 1,000,000
(5) Reimbursement Factor 100%
(6) Monthly Premium Rate Payable per Covered Unit for the Policy Year $
(C) MINIMUM PREMIUM $
(D) COVERED BENEFITS
(x) Medical (x) Prescription Drug ( ) Dental ( ) Vision ( ) Other
(E) PAYMENT BASIS
(x) Incurred in 12 Months and Paid in 12 Months
(F) ENDORSEMENTS
(x) Organ Transplant; (x) Paid Claims; (x) Waiver of Actively at Work;
(x) Prescription Drug; (x)Specific Advance Funding;
(x) Monthly Aggregate Accommodation;
(G) ADMINISTRATOR OF BENEFIT PLAN
55350TX
PAGE
I - Definitions 2
II - Specific Excess Insurance 3
III - Aggregate Excess Insurance 4
IV - Limitations of Coverage 4
V - Exclusions 4
VI - General Conditions 6
VII - Administration of Claims under the Plan 7
VIII - Uniform Provisions 8
55350TX
Table of Contents
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 on 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 canceled during the Policy Year, means that portion of the Eligible Expenses that is wholly
retained by the Policyholder calculated 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 Policyholder has agreed to provide under
a plan of benefits for the Covered Units, as defined in a written form of such Plan, which is in effect on the
Effective Date of this Policy, and 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 the Policy, and which are paid during the Policy Year. Such amount of benefits shall only
include the Eligible Expenses incurred on or after the Effective Date of this Policy. Such amount of benefits
shall not include deductibles, coinsurance amounts, or any 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 Policyholder.
DATE OF ISSUE means the date printed on the draft or check. It may be 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.
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 Policyholder for the Policy Year.
55350TX 2
MINIMUM AGGREGATE RETENTION AMOUNT means the amount shown in the Schedule
which is wholly retained by the Policyholder 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.
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 requirements 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 Sections of this Policy. Unless otherwise stated and endorsed,
the Policy Year will be assumed to be twelve (12) months.
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 Policyholder. Separate Reimbursement
Factors may apply each to the Aggregate Excess Insurance and to the Specific Excess Insurance.
SPECIFIC RETENTION AMOUNT means the amount specified in the Schedule which is wholly
retained by the Policyholder 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 the 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
Policyholder for the amount, if any, of the Specific Excess Benefit, within sixty (60) days after
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 the Plan Benefit 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 on 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.
55350TX 3
III - AGGREGATE EXCESS INSURANCE
A. After the end of the Policy Year (whether by normal expiration, termination, or cancellation), the
Company will, subject to the terms, conditions and limitations of this Policy, reimburse the
Policyholder for the Amount of the Aggregate Excess Benefit, if any, within sixty (60) days after
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 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 directly reimburse any
Covered Person or provider of professional or medical services for any benefits which the
Policyholder has agreed to provide under the terms of the Plan. The Company's sole liability
hereunder is to the Policyholder, 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
coverage under this Policy, Eligible Expenses shall include only those expenses incurred on or
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 Policyholder who has retained the services of a
Preferred Provider Organization or any other organization providing discounted provider services
or supplies to the Policyholder will be the actual amount paid by the Policyholder after the
application of all discounts.
V - EXCLUSIONS
This Policy will not reimburse the Policyholder 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 Policyholder under any contract or service agreement other than
the Plan.
55350TX 4
4. Expenses resulting from services which: are not medically necessary; are in excess of the
usual and customary charge for the locality where administered; or are in excess of Plan
Benefits.
5. Expenses for 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 fees.
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 were 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 suicide or any intentionally self - inflicted injury or
illness, whether the Covered Person was 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 expenses of the
organ recipient, unless the donor is without insurance, in which case, a maximum or
$10,000 shall be considered as Eligible Expenses of the recipient.
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 - GENERAL CONDITIONS
PREMIUM: The premium basis and rates for this Policy will be as shown in the Schedule. Upon
termination of this 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
55350TX 5
Policyholder shall pay the excess to the Company; if less, the Company shall return the unearned portion
of the premium paid to the Policyholder 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: Premiums are due in advance on the first day of each month. A period
of thirty-one (31) days will be granted for payment of each premium, during which period the Policy will
continue in force, but the Policyholder shall remain liable to the Company for the unpaid premium.
Should a premium otherwise due not be paid during such period, this Policy will terminate without
further notice on the date the unpaid premium was due.
DATA REQUIRED: The Policyholder will maintain adequate records acceptable to the Company and
provide any information required by the Company in its sole judgment, to administer this Policy. The
Company may periodically examine any of the Policyholder's records including those of the
Policyholder's Administrator, relating to the insurance under the Policy and any claims filed under the
Plan.
CLERICAL ERROR: Clerical error, whether by the Policyholder or by the Company, in keeping any
records pertaining to the coverage, will not invalidate coverage otherwise validly in force or continue
coverage otherwise terminated.
AMENDMENTS TO THE POLICY: This Policy may be amended at any time with the mutual
consent of the Company and the Policyholder, however, no such amendment shall be effective unless
confirmed by an endorsement issued to form part of this Policy.
AMENDMENTS TO THE PLAN AND /OR ADMINISTRATIVE AGREEMENT: The
Policyholder 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 Policyholder shall
also provide the Company with prompt written notice of any changes 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 part of this Policy. At the
time that the Policyholder provides the Company with the Benefit Plan documents, the Policyholder will
provide the Company with a copy of the written agreement between the Policyholder and the
Administrator. The Policyholder 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 provision shall be sent directly to the
Company at One Alico Plaza, P.O. Box 667, Wilmington, DE 19899.
NOTICE: For the purposes of any notice required from the Company under the provisions of this
Policy, notice to the Administrator shall be considered notice the Policyholder.
VII - ADMINISTRATION OF CLAIMS UNDER THE PLAN:
1. The Policyholder shall undertake at all times to employ the services of an Administrator,
who shall be deemed the agent of the Policyholder.
55350TX 6
2. The Administrator, acting on behalf of the Policyholder, under the Plan, shall:
a, supervise the administration and adjustments of all claims and verify the
accuracy and computation of all claims;
b. maintain accurate records of all claims payments;
c. provide 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 as
respects the immediately preceding policy month:
1. Number of Covered Units
2, Premium paid
d. supervise funding of the Plan by the Policyholder.
55350TX 7
3. Amount of paid claims
4. Amount of unpaid processed
claims on hand
AUDIT: The Company shall have the right to inspect and audit all records and procedures of: (1) the
Policyholder; (2) its Administrator; and (3) any other organization involved in the administration or
adjudication of claims. The Company may 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 Policyholder 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 Policyholder 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 5. Acquired Immune Deficiency
injuries Syndrome
2. Severe Bum cases 6. Cancer
3. Severe Trauma 7. Severe Strokes
4. Premature Birth 8. Organ Transplants
In addition to the above notice requirements, the Policyholder 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 notice within the time required shall neither
invalidate nor reduce any claim if it was not reasonably possible to give such written notification within
such time; provided that such written 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 two (2) years after the date of receipt of the first
written notification to the Company of the payment by the Policyholder under the Plan.
NOTICE OF APPEAL: Any objection, notice of legal action, or complaint received on a claim
processed by the Policyholder 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 Policyholder or Plan Administrator shall pursue all actions that the
Policyholder may have against a third party because of any claim resulting in a Plan payment by the
Policyholder. The Policyholder or Plan Administrator shall account to the Company for all amounts
recovered. If the Policyholder or Plan Administrator fails to pursue any action against a third party and
the Company has made excess benefit payments to the Policyholder under this Policy, the Company
shall be subrogated to all rights of the Policyholder. The Policyholder 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 Policyholder, 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 Policyholder.
VIII - UNIFORM PROVISIONS
ENTIRE CONTRACT: The entire contract is made up of this Policy, the application, and any
attached riders and endorsements.
TIME LIMIT ON CERTAIN DEFENSES: In the absence of fraud, all statements made by
the Policyholder shall be deemed representations and not warranties.
55350TX 8
If these statements appear as part of the written Master Application or other written instrument
signed by the Policyholder, we may use them to contest the Policy. If we do, we will furnish the
Policyholder with a copy of the document in question.
After two (2) years, only fraudulent misstatements may be used to contest the Policy coverage
under the Policy.
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 canceled by the Policyholder by surrendering the
Policy to the Company or by mailing to the Company at its Administrative Offices in
Wilmington, Delaware, written notice stating when thereafter such cancellation shall be
effective.
This Policy may be canceled by the Company by mailing to the Policyholder 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 by the Policyholder or by the Company shall be equivalent to mailing.
If the Policyholder cancels coverage, earned premium shall be computed in accordance with the
customary short rate table and procedure. If the Company cancels coverage, earned premium
shall be computed pro rata. Premium adjustment may be made either at the time cancellation is
effected or as soon as practicable after cancellation becomes effective. Payment or tender of
unearned premium is not a condition of cancellation.
This Policy will be considered cancelled upon termination of the underlying Benefit Plan.
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 three
(3) years after the time written proof of loss is required to be furnished.
CONFORMITY WITH STATE STATUTES: If any time limitation of this Policy with
respect to giving notice of claim or furnishing proof of loss or bringing action is less than that
permitted by the law of the state in which the Policyholder resides, such limitation is hereby
extended to agree with the minimum period permitted by such law.
55350TX 9
AIGLIFE AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
ENDORSEMENT 1
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1, 2000 and expires at the
same time as the Policy.
It is hereby understood and agreed that in consideration of the premium paid, the policy is amended to
include the following additional coverage excluded in Section V - Exclusions, item 13:
SPECIFIED ORGAN TRANSPLANT COVERAGE
Subject to all conditions and limitations of the policy, the Company agrees to reimburse the Policyholder
for Eligible Expenses in excess of the Specified Retention Amount resulting from or directly related to
the completion of a kidney, cornea, heart, lung, bone marrow, heart -lung, liver, or pancreas human organ
transplant and/or tissue transplant. This Endorsement provides coverage only for Eligible Expenses
incurred while this Endorsement is in effect and paid during the Benefit Period.
The Company also agrees to reimburse the Policyholder for surgical, storage, and transportation costs
directly related to the donation of a human organ used in an organ transplant procedure covered under
this rider, subject to a maximum of $10,000 for each organ transplant procedure completed.
All benefits provided as stated in this Endorsement are subject to a lifetime maximum of $1,000,000.
While this Endorsement is in effect, the coverage provided shall apply to all current and new Covered
Units.
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
53704
President Secretary
AIGLIFE AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
It is hereby understood and agreed that:
ENDORSEMENT 2
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1, 2000 and expires at the
same time as the Policy.
1. A Claim is deemed to be paid on the date the Policyholder's payment check or draft is issued,
provided sufficient funds are then available to cover such payments, and it is:
a. placed in the United States mail or other means of delivery to the payee, and
b. paid upon presentation.
2. The provisions of Section IV- LIMITATIONS OF COVERAGE Part B "Actively at Work" and
"Totally Disabled" are hereby waived for those individuals as reasonably disclosed on the
Addendum to Excess Loss Indemnity Application.
3. Prescription Drug Programs, from Section V- Exclusions, Item 2, is included as Eligible Expenses
under the Aggregate Excess Insurance.
4. The term "incurred and paid" wherever used in the policy is hereby amended to read "Paid."
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
President Secretary
53705
Page 1 of 2
53705
AIGLIFE AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
ENDORSEMENT 3
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1 2000 and expires at the same
time as the Policy.
It is hereby understood and agreed that this group is eligible for Specific Advance Funding under the
following guidelines:
The administrator may request, on behalf of the Insured, Advance Funding of eligible processed claims
when these conditions have been satisfied.
1. Eligible claims paid by the Employer have exceeded an amount equal to or greater than the
applicable Specific Retention amount shown in this policy.
2. The Company has received the premium for the month for which the Advance is requested.
3. The Advance requested must be for a minimum of $1,000.00 and must be requested during the
policy year or no later than 21 days following the end of the policy period as defined in this
contract.
4. Funds advanced under this benefit must be used to pay the providers within 5 working days
after receiving the advance. Payment within this time period will be deemed to constitute
payment within the Policy Period, even if the actual payment occurs after the end of the Policy
Period. If the funds are not used as required within this time frame, the Company reserves the
right to require repayment of the advance.
Advance funding requests will be processed according to the Company's normal published claim
turnaround time.
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
Page 2 of 2
53705
5. Any portion of the advance not used to pay eligible expenses (due to additional discounts or
any other reason) must be returned to the Company within 5 days.
6. The Company reserves the right to withhold a portion of The Advance due to discounts,
hospital bill audits or Pre- Screen audits.
President Secretary
AIGLIFE AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1, 2000 and expires at the same
time as the Policy.
It is hereby understood and agreed that:
ENDORSEMENT 4
MONTHLY AGGREGATE BENEFIT
Benefit
In any month in which the total Claims paid to date exceeds items 1 and 2 below by at least $5,000 the
Policyholder may request reimbursement under the Aggregate Excess Benefit.
1. The greater of the year to date cumulative total of the Monthly Aggregate Retention Amount for the
Coverage Period, or the year to date prorated Minimum Aggregate Retention Amount, and
2. Any previous reimbursement(s).
Conditions
The initial request for reimbursement cannot be made prior to the end of the 90 day period following the
first day of the Coverage Period. The request for reimbursement must:
1. Be made in writing; and
2. Be made on or before the 21st of the month following the month for which the reimbursement is
requested.
The Company must have received a report showing the monthly census, the total of the monthly claims
paid and the total of the claims paid in excess of the Specific Deductible.
Additionally, the Company reserves the right to perform an audit in connection with any request for a
reimbursement prior to disbursement.
Page 1 of 2
53705
Reconciliation
At the end of the Coverage Period, the Aggregate Excess Benefit will be calculated on a year -to-
date basis and will be equal to the year -to -date aggregate claims less the greater of (a) the year -to -date
Aggregate Retention Amount or (b) the Minimum Aggregate Retention Amount indicated on the
Schedule page. If, as a result of the calculation, it is determined that prior reimbursements exceed the
amount that would have been payable under the Aggregate Benefit had the reimbursement(s) not been
made, the Company, at its option may require repayment of the overpayment or may reduce subsequent
reimbursements under the Aggregate or Specific Excess Benefits by the amount of the overpayment.
The Policyholder agrees to repay the amount of any overpayment within 60 days of written notice from
the Company of the amount due. If repayment is not made within such period, interest at the rate of 10%
per annum will be added to the amount due and must be remitted to the Company.
Termination
If the Policyholder's insurance under the Aggregate Excess Benefit terminates before the end of the
Coverage Period, this benefit will automatically terminate. In such a case, the date of termination will be
considered the end of the Coverage Period and a determination of any Aggregate Excess Benefit will be
made at that time, subject to the Minimum Aggregate Retention Amount shown on the Schedule page.
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
Page 2 of 2
53705
President Secretary
AIGLIFE AIG LIFE INSURANCE COMPANY
SPECIFIC "Run -Out"
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
ENDORSEMENT 5
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1. 2000 and expires at the same
time as the Policy.
It is hereby understood and agreed that:
The total amount of "Run -Out" benefits to which Covered Units or Covered Persons become entitled
under this Policy shall only include the Eligible Expenses incurred in the Policy Year of 11/01/2000 to
11/01/2001 as defined in Section I Definitions of the Policy, and paid during the period of 11/01/2000 to
02/01/2001,
The run -out provision stated above will not be applicable in the event of the termination of this Policy by
the Insured prior to the Expiration Date as shown on the Schedule page.
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
53705
President
U// Secretary
AIGLIFE AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
(hereinafter called the Company)
This endorsement is attached to and made part of Policy No. 316 -0000, written on Form 55350TX, and
is subject to all the terms and conditions of the Policy. It takes effect on 1. 2000 and expires at the same
time as the Policy.
It is hereby understood and agreed that:
SPECIFIC and AGGREGATE "RUN -IN"
ENDORSEMENT 6
The total amount of "Run -in" benefits to which Covered Persons become entitled under this Policy shall
only include the Eligible Expenses incurred on or after 12/01/1999 and received by the Administrator of
the Plan for payment. These Eligible Expenses must be picl during the Policy Period of 12/01/2000 to
12/01/2001 as defined in Section I DEFINITIONS of this Policy.
In witness whereof, this Endorsement has been signed by the President and Secretary of the Company.
53705
eitatclk
President !/fJ Secretary
DATE: October 7, 2002
SUBJECT: City Council Meeting — October 10, 2002
ITEM: 13.E.2. Consider a resolution renewing the City's existing excess loss
indemnity policy (stop loss reinsurance).
Resource: Teresa Bledsoe, Human Resources Director
History: The City's self - insured medical plan has three principal components: a health care
provider, claims administration, and stop loss reinsurance. The City has selected
AIG Life Insurance Company for the stop loss reinsurance.
Funding: General Fund, Water/Waster Utility Fund
Cost: The cost of this insurance is a function of the number of employees and dependent
units covered.
Source of funds: City contribution and Employee paid premiums for dependent health
care.
Impact: The stop loss reinsurance provides coverage for the City's health benefit plan
claim payments, which exceed limits the City has chosen to self - insure.
Benefit: This coverage protects the City's self - funded plan from catastrophic financial
losses.
Public Comment: N/A
Sponsor: N/A
AIG LIFE
AIG LIFE INSURANCE COMPANY
Incorporated as A CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
Medical Excess, LLC One Macarthur Place Suite 620 South Coast Metro, California 92707 (800) 634 -7462
Mail All Payments To Lock Box Address Of: Medical Excess, LLC Dept. 2173 Los Angeles, CA 90084 -2173
POLICYHOLDER: City of Round Rock
POLICYHOLDER ADDRESS: 221 E. Main St., Round Rock, TX 78664
POLICY NUMBER: 467 -4113
POLICY EFFECTIVE DATE: December 1, 2003
POLICY ANNIVERSARY DATE: December 1 of each succeeding year
PREMIUM DUE DATE: Premium is due on the Policy Effective Date and the first of each calendar
month thereafter.
AIG Life Insurance Company (herein called the Company), in consideration of the application made by the Policyholder,
attached to and made a part of this Policy, payment of the initial premium on the Effective Date of this Policy, the payment of
all subsequent premiums when due, and the continual compliance by the Policyholder with all the terms and conditions of this
Policy, agrees to reimburse the Policyholder for certain Plan Benefits the Policyholder has provided under a self- funded benefit
plan (Plan). Such reimbursement will be subject to all the terms and conditions of this Policy.
All periods of time under this Policy will begin and end at 12:01 A.M. local time at the Policyholder's address.
By acceptance of this Policy, the Policyholder (Employer) understands the liability assumed under the portion of the
Policyholder's employee benefit plan which is self - insured and further understands that the Policyholder is exempt from Article
1.14 -1 of the Texas Insurance Code (Unauthorized Insurance) only if a qualified employee benefit plan has been filed and
meets the requirements of ERISA.
IN WITNESS WHEREOF, AIG Life Insurance Company has caused the Policy to be executed as of the Effective Date.
M20005 -TX
Secretary
EXCESS LOSS POLICY
President
TABLE OF CONTENTS
SCHEDULE OF COVERAGES
DEFINITIONS
SPECIFIC EXCESS LOSS BENEFIT
AGGREGATE EXCESS LOSS BENEFIT
CLAIMS PROVISIONS
EXCLUSIONS AND LIMITATIONS
PREMIUMS
TERMINATION OF COVERAGE
GENERAL PROVISIONS
3
6
9
9
9
11
12
13
14
M20005 -TX 2 of 16
SCHEDULE OF COVERAGES
POLICYHOLDER: City of Round Rock
POLICYHOLDER ADDRESS: 221 E. Main St., Round Rock, TX 78664
POLICY NUMBER: 467 -4! 13
COVERAGE PERIOD: From December 1, 2003 Through November 30, 2004
Classes of Covered Participants Number of Covered
Enrollment at the beginning of the Coverage Period Included Participants Not Included
Active Employees and their Eligible Dependents ® 612 ❑
Retired Employees and their Eligible Dependents ® ❑
Disabled Employees and their Eligible Dependents ® ❑
COBRA Employees and their Eligible Dependents ® ❑
Enrollment By Coverage Categories
Single Employee 344 Family 268
Benefit Options (Describe all medical plan choices available to all employees during Open Enrollment whether they are
included or not included under Stop Loss.)
Plan Description Included Not Included
Designated Third Party Administrators (TPA(s)):
TPA Name
TPA Address
Great West Life & Annuity PBM #204, 1150 N. Loop 1604 West # 108, San Antonio, TX 78248
Designated Preferred Provider Network(s):
PPO Name PPO Address Covered Zips /States
Great West Healthcare 13045 Tesson Ferry Rd., St. Louis, MO 63128 TX
M20005 -TX 3 of 16
SCHEDULE OF COVERAGES CONTINUED
SPECIFIC EXCESS LOSS
SPECIFIC COVERAGE: Included
Specific Deductible Amount per Covered Participant per Coverage Period: $50,000
Lifetime Limit of Liability per Covered Participant: $950,000
Lifetime Limit of Liability for Mental, Nervous, Drug and Alcohol Abuse: As Stated in the Plan Document.
Specific Percentage Reimbursable per Covered Participant: 100%
Monthly Premium Rate(s) Payable Per Covered Participant Unit for the Coverage Period:
Single Employee S42.59 Family $106.73
MINIMUM PREMIUM:
® Is the greater of 1) the sum of the first four months Premiums and 2) the first month's Premium Multiplied by four.
❑ Not Applicable
Specific Benefit Period: Eligible Expenses Incurred from December 1, 2002 through November 30, 2004 and Paid from
December 1, 2003 through November 30, 2004.
SPECIFIC BENEFITS COVERED NOT COVERED
Medical ® ❑
Prescription Drug Plan (Card) ❑ El
ENDORSEMENTS INCLUDED NOT INCLUDED
Specific Terminal Liability Endorsement ❑
Adjusted Specific Deductible Endorsement ❑ El
Experimental/Investigational & Medical Necessity Endorsement ® ❑
Specific Cash Flow Assistance Benefit ® ❑
Aggregating Specific Corridor Endorsement ❑ El
❑ Flat Corridor Amount
❑ Factor
❑ Minimum Corridor Amount
ADDITIONS INCLUDED NOT INCLUDED
Quota Share ❑ El
Hospital Reimbursement Limitation ❑ El
EXCLUSIONS INCLUDED NOT INCLUDED
Organ and Tissue Transplant Exclusion Endorsement ❑ El
M20005 -TX 4 of 16
SCHEDULE OF COVERAGES CONTINUED
AGGREGATE EXCESS LOSS
AGGREGATE COVERAGE: Included
Monthly Aggregate Factors:
Single Employee $324.18 Family $849.07
Estimated Annual Aggregate Attachment Point: $4,068,824.00
Minimum Aggregate Attachment Point: $4,068,824.00
Lifetime Limit of Liability for the Coverage Period $1,000,000
Maximum Eligible Expenses per Covered Participant accumulating toward the Aggregate Excess Loss Benefit $50,000.00
Aggregate Percentage Reimbursable: l00%
AGGREGATE PREMIUM PAYABLE:
Per Employee Per Month of: $3.58
MINIMUM PREMIUM:
Is the greater of 1) the sum of the first four months Premiums and 2) the first month's Premium Multiplied by four.
❑ Not Applicable
Aggregate Benefit Period: Eligible Expenses Incurred from December 1, 2002 through November 30, 2004 and Paid from
December 1, 2003 through November 30, 2004.
Aggregate Benefits
Medical
Prescription Drug
Dental
Vision
Weekly Income
OPTIONAL AGGREGATE ENDORSEMENTS:
❑ Monthly Aggregate Protection Endorsement Premium:
❑ Premium Rate Per Employee Per Month:
❑ Included In Above Aggregate Premium
❑ Annual Premium:
❑ Aggregate Terminal Liability Endorsement Premium:
❑ Premium Rate Per Employee Per Month:
❑ Included In Above Aggregate Premium
❑ Annual Premium:
M20005 -TX 5 of 16
Covered Not Covered
0
® ❑
® ❑
O El
O El
DEFINITIONS
ACTIVELY AT WORK means:
1. With respect to an Eligible Employee -- the employee is present on a full -time basis (as defined in the Policyholder's
Plan) and is capable of performing his/her normal job duties. Persons absent from work due to regularly scheduled
vacation or maternity leave will be considered Actively at Work.
2. with respect to an Eligible Dependent — the Dependent is able to perform all the normal activities of a person in good
health of the same age and sex and is not being confined in a provider facility because of injury or sickness.
Persons not Actively At Work on the date of the Excess Loss Disclosure Statement is executed who are required to be disclosed
but have not been disclosed on the Excess Loss Disclosure Statement will not be considered a Covered Participant under the
Policyholder's Plan for the purposes of this Policy.
ADJUSTED SPECIFIC DEDUCTIBLE means the amount shown on the Adjusted Specific Deductible Endorsement and is the
amount of expense that the Policyholder is responsible to pay before Excess Loss benefits are reimbursable under the Policy. The
Adjusted Specific Deductible applies separately to each Covered Participant shown in the Adjusted Specific Deductible
Endorsement.
ANNUAL AGGREGATE ATTACHMENT POINT means for the Coverage Period, or any portion of the Coverage Period, the
amount of the Eligible Expenses that the Policyholder is responsible to pay. The Annual Aggregate Attachment Point must be
met in each Coverage Period and will be determined at the end of each Coverage Period. It is equal to the greater of the
cumulative total of the Monthly Aggregate Attachment Points for the Coverage Period and the Minimum Aggregate Attachment
Point. If this Policy is terminated before the end of the Coverage Period the Company will not pro -rate the Annual Aggregate
Attachment Point.
BENEFIT OPTIONS are shown on the Schedule of Coverages and include all medical plan choices available to the participants
in the Plan during an Open Enrollment period.
BENEFIT PERIOD is shown on the Schedule of Coverages and means the period of time in which an Eligible Expense must be
incurred by the Covered Participant and Paid by the Plan to be eligible for reimbursement under this Policy. This period does not
alter the Policy Effective Date and Coverage Period, nor does it waive the eligibility requirements of this Policy. If the Policy is
terminated prior to the end of the Coverage Period the Benefit Period ends on the termination date.
CLAIMS means requests for reimbursement made by the Policyholder for Eligible Expenses incurred by a Covered Participant,
which are processed by the Third Party Administrator, paid by the Policyholder according to the terms of the Plan Document and
eligible for reimbursement under this Policy. Claims will only include payments for Covered Benefits that are covered in the Plan
Document and are included in the Schedule of Coverages. Claims will not include any amounts paid for expenses or charges
listed in the Exclusions and Limitations sections of the Policy.
CLAIM INCURRED DATE means the date a service or supply is provided to the Covered Participant, or the dates of a rental
period but excluding dates beyond the end of the Coverage Period. With respect to disability income benefits (if disability income
benefits are included as Covered Benefits) Claim Incurred Date means the date each periodic benefit payment is payable to the
Covered Participant but excluding dates beyond the end of the Coverage Period.
CLAIM PAID DATE means the date which is printed on the Policyholder's payment check or draft, provided:
• sufficient funds are then available to cover such payments, and
• both occur within the Benefit Period, and
• the check or draft is placed in the United States mail, or is electronically deposited directly to the payee, within the
Benefit Period, and
• is payable upon presentation.
If the above conditions are not satisfied the Claim Paid Date will be the first date that all of the above conditions have been
satisfied.
COVERAGE PERIOD means the period shown in Schedule of Coverages during which the Company will be liable for Claims.
A Coverage Period begins at 12:01 A.M., on the Policy Anniversary Date. In no event will a Coverage Period extend beyond the
date Excess Loss Insurance under this Policy terminates.
M20005 -TX 6 of 16
COVERED PARTICIPANT means an individual covered under the Plan who is covered under one of the Benefit Options
included under this Policy as shown in the Schedule of Coverages. Covered Participants may include a covered employee; a
covered dependent of a covered employee; a participating COBRA continuee and his or her dependents; and a covered retiree and
his or her dependents. All classes of Covered Participants will be indicated on the Application form included as part of this Policy
and will be included on the Schedule of Coverages. Any person the Company could reasonably have expected to be disclosed but
who was not disclosed by the Policyholder and the TPA (or Broker) in the Excess Loss Disclosure Statement will not be a
Covered Participant under the Plan for the purposes of this Policy.
The Claims of a Covered Participant who becomes covered under the Policyholder's Plan after the Policy Effective Date will be
Covered under this Policy on the date the Covered Participant is covered under the Plan provided the Covered Participant is
eligible for benefits by the terms of the Plan and is Actively At Work on such date. If a Covered Participant is not Actively At
Work on such date, coverage under this Policy will not be effective until the Covered Participant is again Actively At Work. It is
further understood that an individual who becomes a Covered Participant by changing benefit options to a Benefit Option
included under this Policy from a Benefit Option not included through an open enrollment process during the Coverage Period
will not be considered eligible for coverage under this Policy until the Company has received notification of the change and has
approved the Covered Participant for coverage under this Policy.
Coverage for expenses incurred by a Covered Participant, other than a COBRA continuee, who is not Actively At Work on the
date the Excess Loss Disclosure Statement is executed shall be limited to the length of time specified in the Policyholder's Plan
Document on file with the Company. In no event, however, shall coverage extend beyond the end of the Benefit Period. These
individuals must be disclosed prior to the Policy Effective Date in order to be considered eligible for coverage under this Policy.
Failure to disclose will result in the denial of all such coverage provided by this Policy for those individuals meeting the above
definition.
COVERED PARTICIPANT UNIT means one employee if the employee has no dependents. If the employee has dependents,
Covered Participant Unit means the employee together with the dependents. The Company and the Policyholder may agree to
another definition of a Covered Participant Unit. Covered Participant Units are used to calculate the Annual Aggregate
Attachment Point. Coverage for a single day will be considered covered for the entire month for the purposes of calculating the
aggregate attachment.
DISCLOSURE means the disclosure forms completed and signed by the Policyholder and the TPA (or Broker) and attached to
and made a part of this Policy. For a renewed Policy, claim information (including paid claims, known illnesses, case
management records and other requested information) provided in lieu of the completed Disclosure form will constitute
Disclosure for purposes of renewal. Disclosure information must be provided in a timely manner. Non - Disclosure will result in
the need to re- underwrite and/or deny coverage.
ELIGIBLE EXPENSES means those expenses which the Policyholder is required to pay in accordance with the Plan Document
to a Covered Participant or to another person for providing a service or tangible product to a Covered Participant in treatment of
an illness or injury; or, for a period of total disability because of illness or injury, if disability income benefits are provided by the
Plan Document and are covered by this Policy, as shown in the Schedule of Coverages.
Eligible Expenses do not include expenses that are in excess of, or not covered by, the Plan; or, are specifically excluded or
limited by this Policy, the Schedule of Coverages, any Endorsements, or any Amendments. Eligible Expenses do not include any
payment for the cost,of administering the Plan.
EXPERIMENTAL/INVESTIGATIONAL has the meaning as defined in the Plan. If there is no definition in the Plan, then, for
the purposes of this Policy, the meaning shall be as given in the Experimental/Investigational & Medical Necessity Endorsement
attached to and made a part of this Policy.
While the determination of benefits under the Plan is the sole responsibility of the Policyholder, the Company reserves the right to
interpret the terms and conditions of the Plan as it applies to this Policy. The Company will make a final determination as to
whether a service or supply is Experimental/Investigational under this Policy.
LARGE CLAIM means paid and/or pending Eligible Expenses equal to or greater than 50% of the Specific Deductible.
MAXIMUM REIMBURSEMENT means the Specific Lifetime Limit of Liability per Covered Participant for the Specific
Excess Loss benefit and the Aggregate Limit of Liability for the Coverage Period for the Aggregate Excess Loss benefit as shown
in the Schedule of Coverages.
M20005 -TX 7 of 16
MEDICALLY NECESSARY or MEDICAL NECESSITY has the meaning as defined in the Plan. If there is no definition in
the Plan, then, for the purposes of this Policy, the meaning shall be as given in the ExperimentaUInvestigational & Medical
Necessity Endorsement attached to and made a part of this Policy.
While the determination of benefits under the Plan is the sole responsibility of the Policyholder, the Company reserves the right to
interpret the terms and conditions of the Plan as it applies to this Policy. The Company will make a final determination as to
whether a service or supply is Medically Necessary under this Policy.
MINIMUM AGGREGATE ATTACHMENT POINT means the amount shown in Schedule of Coverages. This amount is the
lowest possible Attachment Point for the applicable Coverage Period. If coverage under this Policy terminates before the end of
the Coverage Period, the Company will not prorate the Minimum Aggregate Attachment Point.
MINIMUM PREMIUM is defined on the Schedule of Coverages. The Minimum Premium must be paid prior to the termination
date if this Policy is terminated prior to the end of the Coverage Period. If the Policy terminates prior to the end of the Coverage
Period and the Minimum Premium has not been paid by the termination date the Company may, at its option, either offset the
shortfall in the actual premiums paid against any claims submitted for reimbursement, or rescind the Policy, or seek the required
Minimum Premium through a collection agency. If the Policy is rescinded the Company will refund the excess of the actual
premiums paid over actual claim reimbursements within thirty (30) days of the termination date. If actual claim reimbursements
exceed the actual premium paid the Policyholder will pay to the Company the excess of claims reimbursed over premiums paid
within thirty (30) days of notice by the Company. If repayment in full is not made within this thirty day period, the Company will
be entitled to assess monthly a late payment fee equal to 0.5% per month (6% per annum) of the outstanding balance.
MONTHLY AGGREGATE ATTACHMENT POINT means the amount calculated monthly by multiplying the appropriate
Monthly Aggregate Factors by the corresponding Covered Participant Units for the month.
PAID CLAIM means an Eligible Expense paid by the Claim Paid Date.
PLAN means the Policyholder's self- funded benefit plan as described in its Plan Document, to or on behalf of Covered
Participants, and approved for attachment herein, by the Company. A copy of the plan document is attached to this Policy for the
purpose of determining the Company's liability under this Policy. The Plan must be in effect on the Policy Effective Date. No
changes to the Policyholder's Plan, including the Designated Third Party Administrator(s) or the Preferred Provider
Organization(s), will be recognized by this Policy without prior notification to, and written approval by, the Company. A change
in the Plan may result in a change in premium, factors, percentages, limits or maximum amounts as set forth in the Schedule of
Coverages or termination of this Policy.
PLAN BENEFITS means eligible amounts properly Incurred and Paid under the Plan to a Covered Participant or to a provider of
services to a Covered Participant,
PLAN DOCUMENT means the Summary Plan Description and other information as required by ERISA.
POTENTIAL LARGE CLAIM means any Eligible Expense resulting from a condition, or event, included in the list of Potential
Large Claims shown in the Claims Provision section of this Policy whether or not any Eligible Expenses have actually been paid.
REIMBURSEMENT PERCENTAGE means the percentage of paid claims which the Company will reimburse the Policyholder
as shown in the Schedule of Coverages. Separate reimbursement percentages may apply to the Aggregate Excess Loss benefit
and to the Specific Excess Loss benefit.
SPECIFIC DEDUCTIBLE means the amount of expense that must be wholly paid by the Policyholder with respect to each
Covered Participant, (or Covered Family, if the Family deductible option is shown on the Schedule of Coverages) for each
Coverage Period before Excess Loss benefits are reimbursable under the Policy. It is shown in the Schedule of Coverages. This
amount applies separately for each Coverage Period.
FAMILY SPECIFIC DEDUCTIBLE means the amount of Eligible Expenses which must be paid by the Plan for any Covered
Family member or combination of Covered Family members for each Coverage Period before Specific Excess Loss benefits are
reimbursable under the Policy. It is shown in the Schedule of Coverages.
THIRD PARTY ADMINSTRATOR means a firm or person which has been retained by the Policyholder to be the
Policyholder's agent and attomey -in -fact to pay claims in accordance with the Plan Document and/or provide other administrative
services on behalf of the Policyholder's Man.
M20005 -TX 8 of 16
SPECIFIC EXCESS LOSS BENEFIT
The Schedule of Coverages indicates whether Specific Excess Loss insurance is provided under this Policy. If, while this Policy
is in effect, the Eligible Expenses for a Covered Participant for the applicable Benefit Period exceed the Specific Deductible, the
Company will reimburse the Policyholder, subject to the terms and conditions of this Policy including the limits set forth in the
Schedule of Coverages, within sixty (60) days after:
• the Company's acceptance of the proof of loss as a satisfactory proof;
the Company's receipt of proof of payment of the benefits by the Policyholder under the Plan to, or on behalf of, the
Covered Participant, which payment by the Policyholder is expressly agreed to be a condition precedent to
reimbursement; and
the completion of an audit of the claim, if requested by either the Policyholder or the Company.
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount by which Claims
exceed the Specific Deductible amount, but will not exceed the Lifetime Limit of Liability. The Company will not reimburse any
expenses that are in excess of the Plan's lifetime maximum, if any. For purposes of determining whether such Lifetime Limit of
Liability or the Plan's lifetime maximum have been exceeded, Eligible Expenses incurred or paid in all prior periods are included.
Claims for any Covered Participant during the Coverage Period will be determined according to the terms of the Benefit Period as
listed in the Schedule of Coverages. The Specific Deductible applies separately to each Covered Participant (or Covered Family,
if the Family deductible is shown on the Schedule of Coverages) during a Benefit Period.
AGGREGATE EXCESS LOSS BENEFIT
The Schedule of Coverages indicates whether Aggregate Excess Loss insurance is provided under this Policy. If the Eligible
Expenses for the applicable Benefit Period (subject to the Maximum Eligible Expenses per Covered Participant accumulating
toward the Aggregate Excess Loss benefit) exceed the Annual Aggregate Attachment Point for the Coverage Period, the Company
will reimburse the Policyholder (subject to the terms and conditions of this Policy including the limits set forth in the Schedule of
Coverages) within sixty (60) days after:
• The Company's acceptance of proof of loss as satisfactory proof; and
• The Company's receipt of proof of payment of Eligible Expenses under the Plan; and
• Completion by the Company, or its designee, of a satisfactory on -site audit of the Claims, eligibility and all records
relevant to a claim under the Aggregate Excess Loss benefit, if the Company elects to do so.
The amount of the reimbursement will be equal to the Aggregate Percentage Reimbursable times the amount by which Claims
exceed the Annual Aggregate Attachment Point, but will not exceed the Limit of Liability for the Coverage Period.
CLAIMS PROVISIONS
Claims Administration
The TPA will be the Policyholder's agent in performing duties under this Policy and will not be the agent of the Company. The
Company will not be held liable for any act or omission of the TPA. The Company will only reimburse the Policyholder for
claims paid by the TPA that are paid in accordance with the Plan.
The TPA, acting on behalf of the Policyholder, under the Policyholder's Plan, shall:
• Audit, calculate and pay all Eligible Expenses in accordance with the Policyholder's Plan.
• Provide the Company with periodic reports, including monthly reports of Eligible Expenses paid. The monthly report
shall provide the following information:
• Eligible Expenses paid;
• Eligible Expenses pending; and
Number of Covered Participants or Covered Participant Units in each category shown on the Schedule of
Coverages.
• Report the following events within 10 days of their occurrence:
• Notice of Eligible Expenses that reach 50% of the Specific Deductible; and
• Potential Large Claims
M20005 -TX 9 of 16
Maintain a monthly record of expenses not covered by the Plan and expenses paid for by the Plan but excluded from
Eligible Expenses under this Policy.
Management of Large Claims
The Policyholder or the TPA must notify the Company in writing within ten (10) business days of receiving information
indicating that Eligible Expenses qualify as a Large Claim or Potential Large Claim. If the Policyholder receives information that
any Claim may be or become a Large Claim, the Policyholder will immediately notify the TPA.
Medical Management
The Policyholder agrees to famish clinical information about Covered Participants who could incur or have incurred actual claims
under this Policy when requested by the Company. The Company will make available to the Policyholder and the TPA, without
obligation, preferred services to benefit the Plan and its Covered Participants. The Policyholder agrees to allow the Company to
identify and offer services that would benefit the Policyholder's Covered Participants. If the Company recommends alternative
care and treatment that is not provided for in the Plan and the Policyholder allows charges for such recommended care and
treatment to be considered eligible under the Plan, then charges will be considered Eligible Expenses under this policy.
Notice of Excess Loss Claims
• Aggregate Excess Loss Claim. The Policyholder will give written notice to the Company within thirty-one (3I) days of
the date Eligible Expenses have reached the Annual Aggregate Attachment Point.
Specific Excess Loss Claim. The Policyholder will give written notice of individual Specific Excess Loss claims to the
Company within thirty -one (31) days of the date the Eligible Expenses, with respect to a Covered Participant (or Covered
Family), have reached the Specific Deductible for the Benefit Period.
Notwithstanding the above, failure to furnish written notice within the time required shall neither invalidate, nor reduce, any
Claim if it was not reasonably possible to give such written notification within such time. In such case written notification must
be 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 (the `Final Notification Date ").
No request for reimbursement under this Policy shall be considered unless the Policyholder has notified the Company as required
above. The reimbursement request must be received by the Company in writing no later than the later of the Final Notification
Date, referenced above, and six months after the last day of the Benefit Period.
Notice of Appeal by Covered Participant
If a Covered Participant appeals a denial, or limitation, of benefits under the Plan and such benefits, had they been considered
covered by the Plan, would result in a Claim under this Policy then the Policyholder must give immediate notice of the appeal to
the claims department of the Company.
Determination of Benefits
While the determination of benefits under the Plan is the sole responsibility of the Policyholder, the Company reserves the right to
interpret the terms and conditions of the Plan as it applies to this Policy. The Company has the sole authority to approve or deny
reimbursements under this Policy.
Potential Large Claims
The Company will not reimburse the Policyholder for Eligible Expenses incurred by Covered Participants that qualify as
Potential Large Claims, unless disclosed and accepted by the Company.
In the event of non - disclosure by the Policyholder, the Company reserves the right to change or modify the premium rates,
Monthly Aggregate Attachment Factors, or Specific Deductible amount(s) or adjust the teens of the Aggregate and Specific
Excess Loss benefits.
List of Potential Large Claims:
Eligible Expenses for conditions which qualify as Potential Large Claims are listed below. The Company retains the right to add
or delete from the list of Potential Large Claims with thirty (30) days advance written notice to the Policyholder:
• Transplants, whether completed or anticipated
• Dialysis, home infusion or injection therapy other than insulin or vitamins
• Cancer, Brain Tumor
• Multiple Trauma or Severe Burns
• High Risk Maternity/ Premature Birth
• Brain or spinal cord injury
M20005 -TX 10 of 16
• Severe Stroke
• Morbid obesity/ Gastric Bypass
• Acquired Immune Deficiency Syndrome
Cardiac/ Circulatory/ Pulmonary Disorders
Degenerative Muscular/ Neurological Disorders
Diabetic Complications
Hemophilia/ Bleeding Disorders
Acute/ Chronic Renal
Ventilator Assisted Individuals
Any inpatient confinement greater than seven (7) days including acute rehabilitation or skilled nursing care
Audit
The Company shall have the right to inspect and audit all records and procedures of the Policyholder, the TPA, and any other
organization involved in the administration or processing of claims. The Company may require, upon request, proof of records
satisfactory to it that payment has been made to the provider of such services or supplies which are the basis for any claim
reimbursable under this Policy.
Subrogation
If the Policyholder is entitled to recover from third parties for benefits paid under the Plan, such amounts cannot be used to satisfy
either the Specific Deductible or Annual Aggregate Attachment Point. The Company will not reimburse the Policyholder for any
Eligible Expense recovered from a third party. If the Company has reimbursed the Policyholder for all or part of an Eligible
Expense and the Policyholder later recovers any part of the Eligible Expense from a third party, the Policyholder must repay the
Company to the extent of the Company's reimbursement regardless of whether the Policy is still in force on the date of recovery.
The Policyholder's repayment may be reduced by reasonable and necessary expenses incurred in recovering from the third party.
If the Policyholder fails to pursue a valid claim for an Eligible Expense against a third party and the Company is required to
reimburse the Policyholder for such Eligible Expense, the Company shall be subrogated to the Policyholder's rights to pursue the
Claim.
Any amount the Company recovers shall first be used to pay the Company's expenses of collection and then applied toward any
amount the Company paid or is required to pay to the Policyholder under the Policy. Any remaining amount will be paid to the
Policyholder.
EXCLUSIONS AND LIMITATIONS
The Company will not reimburse the Policyholder for expenses that:
1. have been reimbursed by another company or reinsurance company or are reimbursable under a government or privately
supported medical research program;
2. are not incurred and paid during the Benefit Period;
3. exceed the Lifetime Limit of Liability (for Specific Excess Loss) or the Limit of Liability (for Aggregate Excess Loss);
4. have been excluded, or adjusted, under the terms of the Adjusted Specific Deductible Endorsement or the Aggregating
Specific Corridor Agreement;
5. are for any injury or illness arising out of, or m the course of, any employment for wage or profit for which the Covered
Participant is entitled to benefits under any Workers Compensation or occupational disease policy whether or not such
policy is actually in force;
6. are for the cost of administration of claims, investigation expenses, payments or other services provided by the TPA,
consulting fees, or any other fees or expenses incurred by the Plan that are not defined as Plan Benefits:
7. are recoverable from any person responsible for causing the injury or sickness which gave rise to the benefit provided
under the Plan or from any other company or other organization providing benefits or services for the injury or sickness
which gave rise to the benefits under the Plan. If a Covered Participant is eligible for Medicare, as their primary payor,
benefits under this Policy will be reduced by the amount of any Medicare benefits received by the Covered Participant so
that total reimbursement will not exceed I00% of the Covered Participant's actual Eligible Expenses;
8. are payments for treatment or services which are considered Experimental or Investigational as defined in the Plan or as
defined in the ExperimentaV Investigational & Medical Necessity Endorsement if not defined in the Plan;
9. are any amount in excess of the amount payable under the Plan;
10. are caused by or result from war, declared or undeclared, invasion, acts of foreign enemies, hostilities, civil war,
rebellion, insurrection, military or usurped power, or martial law or confiscation by order of any government or public
authority;
M20005 -TX l l of 16
11. are for legal fees or expenses related to litigation with claimants under the Policyholder's Plan including but not limited
to compensatory, punitive, exemplary or extra contractual damages, fines or statutory penalties;
12. are payments for treatment or services which are not Medically Necessary as defined in the Plan or as defined in the
Experimental/ Investigational & Medical Necessity Endorsement if not defined in the Plan;
13. result from dental, vision, prescription drugs, hearing care or weekly income unless specifically included in the Schedule
of Coverages;
14. are incurred by any affiliate or subsidiary company of the Policyholder not included in the Policy at issue, unless
specifically added by Rider, Letter of Agreement, or Endorsement;
15. are paid in accordance with amendments, endorsements, letters of agreement to the Plan prior to the date such documents
are approved by the Company in writing;
16. are incurred by the Policyholder for non - compliance with any legal statute or regulation;
17. are incurred for the treatment of any illness or injury resulting from mental and nervous disorders, alcohol or drug abuse
when such expenses exceed the Lifetime Maximum or Policy limitations for such disorders as shown in the Schedule of
Coverages; or
18. are in excess of the usual and customary charges, as referenced in the Plan, for the service or supply in the locality where
such service or supply is received regardless of any preferred provider contract that exists with the provider of such
service or supply.
PREMIUMS
Payment of Premiums
The Policyholder, or the TPA (if instructed by the Policyholder), must pay all premiums to the Company lock box at the lock box
address shown on the cover page of this Policy on or before the Premium Due Date. Subject to the Grace Period, coverage will
terminate if a premium is not paid when due. Premiums are shown on the Schedule of Coverages.
Grace Period
The Company will allow a Grace Period of thirty -one (31) days for payment of each premium except the fast. If the Policyholder
does not pay the premium due within the Grace Period, insurance under this Policy will terminate as of the Premium Due Date for
the unpaid premium.
Minimum Premium
The Minimum Premium, as stated in the Schedule of Coverages, must be paid prior to the termination date if this Policy is
terminated prior to the end of the Coverage Period. Reimbursements under this Policy may be limited and coverage under this
Policy may be rescinded entirely if the Minimum Premium is not paid. The Minimum Premium requirement only applies if the
Policy is terminated prior to the end of the Coverage Period. The limitations on reimbursements and coverage are listed in the
Effect of Termination provision in the TERMINATION OF COVERAGE section of this Policy.
Premium Taxes
If by present or future law, administrative ruling or judicial decision, premium taxes are ever assessed against the Policyholder or
the Company with respect to Claims paid under the Policyholder's Plan, the Policyholder will save and hold harmless the
Company from such premium tax liability. The Policyholder will reimburse the Company for the amount of such premium tax
liability plus any other interest penalty or cost incurred by the Company on account of such premium tax assessment. Such
reimbursement will be due and payable by the Policyholder at the end of each Coverage Period for any tax expense determined by
the Company.
Renewal Rating Provision
The Company has the right to establish new Premium Rates and Monthly Aggregate Factors on each Policy Anniversary Date.
The Company will provide the Policyholder advance written notice of any change in Premium Rates or Monthly Aggregate
Factors at renewal no later than thirty -one (31) days prior to the Policy Anniversary Date or within thirty-one (31) days after the
Company receives the required claims and enrollment data needed for the renewal, if later than thirty -one (31) days prior to the
Policy Anniversary Date.
Changes in Premium Rates and Monthly Aggregate Factors
The Company reserves the right to change the Premium Rates and/or the Monthly Aggregate Factors for a Coverage Period
(retroactive to the beginning of the Coverage Period) if the average Paid Claims for the last two Coverage Months of the
immediately preceding Coverage Period exceeds 125% of the average Paid Claims for all other prior Coverage Months in that
preceding Coverage Period.
M20005 -TX 12 of 16
The Company has the right to establish new Premium Rates and/or new Monthly Aggregate Factors at any time during a
Coverage Period if:
the number of enrolled Covered Participant Units changes by more than 25% from the Enrollment shown on the
Schedule of Coverages;
the number of enrolled Covered Participant Units changes by more than 25% in any three consecutive month period;
the number of enrolled Covered Participant Units changes by more than 15% in any one month;
the Company discovers an individual who it could reasonably have expected to be disclosed and who was not disclosed
and whom the Company determines to be an unacceptable risk;
an amendment (change) is made to the Plan, including a change in the Preferred Provider Organization(s) or TPA(s); or
a change in the terms of the Excess Loss coverage occurs.
TERMINATION OF COVERAGE
By the Policyholder
The Policyholder may terminate this Policy on any Premium Due Date by giving the Company at least thirty -one (31) days
written notice. The Minimum Premium must be paid by the Policyholder prior to the termination date. The cancellation will be
effective on the earlier of the end of the period for which the Group has paid premiums or the next Premium Due Date.
By the Company
The Company may terminate this Policy by giving the Policyholder 3l days written notice. The effective date and hour of
cancellation stated in the notice shall become the end of the Coverage Period.
The Company can only terminate this Policy for the following reasons:
I. it is determined that the Policyholder has failed to perform any of its duties or obligations under this Policy; or
2. a petition in bankruptcy is filed with respect to the Plan or the Policyholder, whether voluntary or involuntary, or the
Plan, or the Policyholder, becomes subject to liquidation, receivership or conservatorship;
3. the percentage of employees participating in one or more Health Maintenance Organizations, prepaid plans, or insurance
plans exceeds 40% of employees eligible to participate in the Plan, unless the Company has agreed in writing to continue
coverage; or
4. the Policyholder fails to provide the information required in the Excess Loss Disclosure Statement.
Automatic
This Policy will automatically terminate without notification required upon the earliest of the following dates:
L the date of the Policyholder's Plan terminates; or
2. the date the Policyholder fails to:
(a) provide money when needed for the timely payment of claims under the Plan,
(b) renew insurance under this Policy; or
(c) maintain the agreement with the TPA(s) stated on the application, or with a TPA(s) approved in advance by the
Company; or
5. at the end of any Grace Period when the premium due remains unpaid; or
6. the date the Plan is found to be in violation of Federal law; or
7. the date the Group ceases to meet the underwriting regulations for this coverage in force on the effective date of this
Policy; or
8. sixty (60) days after the Policy Effective Date if the Policyholder has failed to furnish the Company with any information
or materials requested by the Company. Such information or materials must be of reasonable nature to allow the
Company to determine its liability under this Policy. If the Policy is terminated for this cause, the Company's sole
liability will be to return any monies given by the Policyholder as consideration for this Policy less other expenses paid
by the Company under this Policy. If such amounts paid by the Company are greater than the amounts paid by the
Policyholder, the Policyholder shall pay the amount of the deficit to the Company within thirty days of notice from the
Company. If repayment in full is not made within this thirty day period, the Company will be entitled to assess monthly a
late payment fee equal to 0.5% per month (6% per annum) of the outstanding balance.
If a Covered Participant makes a material misrepresentation on a claim for benefits under the Plan, the Company will not
reimburse the Policyholder for payments resulting from such misrepresentation. If a Covered Participant ceases to meet the
Plan's definition of an "eligible person" or a "dependent,' that Covered Participant's expenses are not eligible for reimbursement.
M20005 -TX 13 of 16
Ineligibility of a Covered Participant's coverage ends the Covered Participant's and the Covered Participant's dependents'
coverage under this Policy, effective on the date of ineligibility. Ineligibility of a dependent's coverage ends the dependent's
coverage and rights under the Policy, effective on the date of ineligibility.
Effect of Termination
The Company will not refund any portions of premium paid by the Policyholder whose Policy or Plan terminated during the
Coverage Period, provided the Minimum Premium has been paid to the Company by the termination date, except as described
above. The Company has no obligation to reimburse the Policyholder for any Plan Benefits, which are incurred after the date this
Policy is terminated.
If the Policy terminates prior to the end of the Coverage Period and the Minimum Premium has not been paid by the termination
date the Company may, at its option, either offset the shortfall in the actual premium against any claims submitted for
reimbursement, or rescind the Policy, or seek the required Minimum Premium through a collection agency. If the Policy is
rescinded the Company will refund the excess of the actual premiums paid over the actual claim reimbursements within thirty
(30) days of the termination date. If actual claim reimbursements exceed the actual premiums paid the Policyholder will pay to
the Company the excess of claims reimbursed over premiums paid within thirty (30) days of notice by the Company. If
repayment in full is not made within this thirty day period, the Company will be entitled to assess monthly a late payment fee
equal to 0.5% per month (6% per annum) of the outstanding balance.
Renewal
The Company may choose not to renew the Policyholder's coverage under this Policy by giving the Policyholder thirty-one (31)
days advance written notice. Otherwise, the Company will send a renewal offer to the Policyholder. It will outline the premium
rates, aggregate factors, and policy terms for the next Coverage Period. The renewal will be effective only if the Policyholder
accepts such offer in writing in accordance with the Policy's terms and conditions.
GENERAL PROVISIONS
Assignment
Assignment of interest under this Policy shall not bind the Company until its consent is endorsed hereon.
Amendments to the Policy
This Policy may be amended if requested in writing and the Company approves it, however, no such amendment shall be effective
unless confirmed by an endorsement issued to form a part of this Policy. The endorsement must be signed by the Company's
President or by one of its Vice Presidents. No other person may amend the Policy or waive any provision.
Bankruptcy and Insolvency
In the event of bankruptcy or insolvency of the Policyholder or the Plan, and for purposes of claim payment under this Policy,
such bankruptcy or insolvency shall not relieve the Company of its obligation to pay claims otherwise payable to the Policyholder
in accordance with the terms, conditions, limitations and exclusions of this Policy. Any requirement in the Policy relating to the
actual payment of benefits by the Policyholder under its Plan shall not apply for purposes of this provision. Any such claim
payment under this Policy as a result of this provision will be made to the liquidator, receiver, trustee, successor, or such other
entity as named by federal or state authority governing such transition.
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 or 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.
Changes in Policyholder's Plan or TPA Agreement or Preferred Provider Organization
The Policyholder will provide the Company with a signed copy of all Plan documents (i.e. booklets, brochures, sub -group
variations, etc.) prior to the effective date of insurance under this Policy. The Policyholder must promptly provide the Company
with written notice of any changes in the Policyholder's Plan. The Company reserves the right to refuse to apply this Policy to
any change in the Plan unless and until the Company has approved the change, and only to the extent provided in an endorsement
issued by the Company to become part of this Policy, and the Policyholder has agreed to pay any changes in the premium rate and
has agreed to any changes in the coverage terms required by the Company to accommodate the change in the Plan. If the
Company cannot reach an agreement with the Policyholder with respect to the Plan change, the change will not affect insurance
under this Policy and the Policy will be administered as if the Plan had not changed.
M20005 -TX 14 of 16
At the time that the Policyholder provides the Company with the Plan documents, the Policyholder will provide the Company
with a copy of the written agreement between the Policyholder and the TPA(s) The Policyholder shall provide the Company with
a copy of any and all changes to such agreement(s) prior to their effective date. The TPA(s), and the Preferred Provider
Organization(s), named in the application and/or endorsements to this Policy cannot be changed without the Company's written
consent. A TPA, or a Preferred Provider Organization, not approved by the company, may result in modification or termination
of this Policy.
Clerical Error
Clerical error, whether by the Policyholder or by the Company, in keeping any records pertaining to the coverage, will not
invalidate coverage otherwise validly in force or continue coverage otherwise terminated. Any clerical error in data that the
Policyholder or TPA provides to the Company must be corrected and promptly reported to the Company. The Company will then
make an appropriate adjustment in the premiums due or the claims eligible for reimbursement under this Policy. Any refund in
premiums that may be due from the Company as a result of clerical error by the Policyholder are limited to the twelve month
period prior to the date of request for refund.
Conformity With State Statutes
While the determination of benefits under the Plan is the sole responsibility of the Policyholder, the Company reserves the right to
interpret the terms and conditions of the Plan as it applies to this Policy. This Policy will be interpreted in accordance with the
laws of the state where it is issued. If any provision of this Policy conflicts with that law, it will be amended so as to conform.
Data and Records
The Policyholder and TPA must maintain all records the Company requires and provide the Company monthly with all reasonable
data requirements relating to Covered Participants when requested in writing by the Company. The Company or its duly
authorized representative has the right to inspect and copy these records and data that relate to this Policy at any reasonable time.
Non - disclosed Data
This Policy is issued by the Company in reliance upon the Application for Insurance Coverage and the Excess Loss Disclosure
Statement, both of which have been executed by the Policyholder and are attached and made a part of this Policy. If this Policy is
a renewal, the Company may at its option issue the renewal in reliance upon Claim Information provided by the Policyholder and
the TPA without requiring a signed Disclosure Statement. Failure by the Policyholder to disclose on the Disclosure Statement or,
in the case of a renewal (if waived by the Company), on the Claims Information submitted in lieu of the Disclosure Statement,
individuals for whom disclosure was required will result in the denial of all coverage under this Policy for such individuals.
Entire Contract and Misstated Data
The entire contract consists of this Policy, the Schedule of Coverages, the Plan Document, application(s), endorsements, riders,
letters of agreement issued by the Company, Disclosure Statements and the claim information supplied by the Policyholder, or
TPA, in lieu of Disclosure Statements during the renewal process. The Company has relied on information provided by the
Policyholder directly or through its TPA in the underwriting of the insurance provided by this Policy. The Policyholder agrees
that this information is true and complete. If the Company discovers that this information is not true and complete and if the true
and complete information would have affected the premium rate, or any term or condition of the contract, the Company may
revise the rates, or any term or condition of the contract, or may terminate this contract by notifying the Policyholder.
Legal Action
No action at law or in equity shall be brought by the Policyholder to recover on this Policy within sixty (60) days after written
proof of loss has been furnished. No action at law or in equity may be brought after two years from the time written proof of loss
is required to be furnished.
Notice
For the purposes of any notice required from the Company under the provisions of this Policy, notice to the last known TPA shall
be considered notice to the Policyholder. Notice to the Policyholder will be considered notice to the TPA.
Other Coverage or Benefits Payable
If any other coverage exists protecting the Policyholder in whole or in part against losses covered by this Policy, the insurance
provided by this Policy will apply in excess of such other coverage. Other coverage includes, but is not limited to, group
insurance, excess insurance, reinsurance or plan benefits, including insurance or plan benefits established by any federal, state or
local law.
M20005 -TX 15 of 16
Parties to Policy
Except for the provisions relating to the TPA, this Policy involves only the Policyholder and the Company. The Policy does not
create any legal relationship between the Policyholder and a Covered Participant or beneficiary under the Policyholder's Plan nor
does it create a legal relationship between the Company and a Covered Participant or beneficiary under the Policyholder's Plan.
Recovery of Funds
Should the Company issue any advancement of funds, or reimbursement of funds, in error, under any provision outlined herein,
the Policyholder will refund to the Company such amounts reimbursed, or advanced, in error within thirty (30) calendar days of
receipt of written request for such refund by the Company. Any funds owed the Company that are overdue beyond 90 days will
be referred to the Company's attorney for collection. Failure to comply may result in offsets from future claim reimbursements.
Reporting
The Policyholder will furnish the Company with any information required by the Company pertaining to risks covered under this
Policy. Such information must be received by the Company in a form, and during a time period, satisfactory to the Company,
including the reporting of Covered Participants with certain diagnoses and/or procedures exclusive of Claim Provisions contained
herein. The Company will provide reporting requirements and changes periodically. Notification will be provided 30 days prior
to change.
Time Limit on Certain Defenses
In the absence of fraud, all statements made by the Policyholder shall be deemed representations and not warranties. If these
statements appear as part of the written application or other written instrument signed by the Policyholder, the Company may use
them to contest the Policy. If the Company does contest the Policy, the Company will furnish the Policyholder with a copy of the
document in question. After 2 years from the first day of the Coverage Period, only fraudulent misstatements may be used to
contest the coverage under this Policy.
M20005 -TX 16 of 16
EXPERIMENTAL/INVESTIGATIONAL & MEDICAL NECESSITY ENDORSEMENT
TO BE ATTACHED TO AND MADE A PART OF POLICY NO. 467-4113
ISSUED TO City of Round Rock
BY AIG LIFE INSURANCE COMPANY
It is agreed that the above Policy is endorsed, effective December I. 2003 as follows:
In the absence of a definition of "Experimentalllnvestigational" or "Medical Necessity" in the Policyholder's Plan the
following definitions will apply to this Policy:
Experimentalllnvestigational means any drugs, devices, procedures or treatments such that:
its use requires approval by the appropriate federal or other governmental agency which has not been granted, such as,
but not limited to, the Federal Drug Administration (FDA); or
2 its use is not yet recognized as acceptable medical practice throughout the United States to treat that illness or injury;
or is subject to either:
a. a written investigational or research protocol; or
b. a written informed consent or protocol used by the treating facility in which reference is made to the drug,
device, procedure or treatment as being experimental, investigative, educational, for a research study, or
posing an uncertain outcome, or having an unusual risk; or
c. a written protocol, protocols or informed consent used by any other facility studying substantially the same
drug, device, procedure or treatment which states it is experimental, investigative, educational, for a research
study, or posing an uncertain outcome, or having an unusual risk; or
d. an ongoing review by an Institutional Review Board (IRB); or
3. it does not have either:
a. the positive endorsement of national medical bodies or panels, such as the American Cancer Society, the
Agency for Health Care Policy and Research, or the National Cancer Institute; or
b. multiple published peer review articles, in a recognized professional medical journal, concerning such drug,
device, procedure or treatment and reflecting its reproducibility by non - affiliated sources which the Company
determines to be authoritative; or
c. trial results which indicate the drug, device, procedure or treatment are at least as effective as the current
standard therapy; or
4. it does not meet all applicable state mandated criteria required to not be considered Experimental/Investigational.
Any drug, device, procedure or treatment which is deemed to be experimental or investigational in nature by an appropriate
technological body established by state or federal government is considered an experimental procedure.
Medically Necessary or Medical Necessity means drugs, devices, procedures, treatments, services or supplies provided by a
provider facility or a provider individual which are required for treatment of a Covered Participant's illness, injury, diseased
condition, or impairment, and are:
I. consistent with the diagnosis or symptoms and the Covered Participant is an appropriate candidate for the proposed
treatment;
2. appropriate treatment, according to generally accepted standards of medical practice;
3. not provided only as a convenience to the Covered Participant or for the provider;
4. not Investigational or Experimental;
5. not excessive in scope, duration, or intensity to provide safe, adequate, and appropriate treatment. Any service or
supply provided at a facility will not be considered medically necessary if the symptoms or condition indicate that it
would be safe to provide the service or supply in a less comprehensive setting.
The fact that any particular provider individual may prescribe, order, recommend, or approve a service, supply, or level of care
does not, of itself, make such treatment medically necessary or make the charge a covered charge.
IN WITNESS WHEREOF, AIG Life Insurance Company has caused this Endorsement to be executed as of the effective date
shown above.
M20014
Secretary President
SPECIFIC CASH FLOW ASSISTANCE BENEFIT ENDORSEMENT
TO BE ATTACHED TO AND MADE A PART OF POLICY NO. 467 -4113
ISSUED TO CITY OF ROUND ROCK
BY AIG LIFE INSURANCE COMPANY
It is agreed that the above Policy is endorsed, effective December 1 2003, as follows:
Payment of a Specific Excess Loss claim is available to the Policyholder upon meeting all of the following:
• The Claims submitted for Cash Flow Assistance have been fully processed by the Third Party
Administrator in accordance with the terms of the Plan Document and must be ready for payment
under the Plan within the Benefit Period during which the Claim was incurred; and
• The Policyholder must have paid Claims at least equal to the Specific Deductible; and
• The Claim, and supporting documentation satisfactory to the Company, have been received by the
Company no later than fourteen (14) days after the end of the Benefit Period. Requests received after
that date are not eligible for Cash Flow Assistance. The Cash Flow Assistance request must be a
minimum of $1,000, unless the request is the final claim request for the Specific claimant, in which
case there is no minimum. Normal Specific claim audit procedures will be implemented prior to any
checks being issued by the Company. These procedures may include withholding a portion of the
reimbursement for a Claim based on hospital charges, pending results of hospital pre - screen/audit
and/or re- pricing of non -PPO claims or other standard Specific Claim payment procedures.
If the foregoing requirements are satisfied, the Company will promptly reimburse the Policyholder for the
amount that is eligible for reimbursement under the Specific Excess Loss benefit. The Company's
reimbursement may not be deposited until the Plan's payment has been paid.
If any portion of the Company's reimbursement is not used to pay the applicable benefits under the Plan for
any reason, such portion must be returned to the Company within five working days after it is received by
the Policyholder. If the Policyholder fails to comply with any of the above conditions, the right to receive
Cash Flow Assistance shall be rescinded.
IN WITNESS WHEREOF, AIG Life Insurance Company has caused this Endorsement to be executed as of
the effective date shown above.
M20016
/Lea 04/
Secretary President
AIG LIFE
AIG LIFE INSURANCE COMPANY
Incorporated as a CAPITAL STOCK COMPANY by the State of Delaware
One Alico Plaza, Wilmington, DE 19801
Medical Excess, LLC, One MacArthur Place, Suite 620, South Coast Metro, California 92707 (800) 634 -7462
Applicant (Plan Sponsor): City of Round Rock Proposed Effective Date: December 1, 2003
Name of Employer: City of Round Rock Initial Premium Deposit: 845,445.56
Address: 221 East Main St., Round Rock, TX 78664
Telephone Number:
Type of Business: Municipality
Other Locations: ❑ Yes ® No If yes, where:
If any subsidiary or affiliated companies (under common control through stock ownership, contract etc.) are to be included, list legal
name, address and nature of business.
Name(s): Address: Type Of Business
Broker(s): Address:
Watson Wyatt Worldwide 2001 Ross Ave., Suite 4200, Dallas, TX 75201
Third Party Administrator(s):
Great West Life & Annuity Insurance Company
PPO Name(s): Address Coverage Area
Great -West Healthcare 13045 Tesson Ferry Road, St. Louis, MO 63128 TX
Benefit Options (Describe all medical plan choices available to all employees during Open Enrollment whether they are included or
not included under Stop Loss.)
Plan Description(s): Included Not Included
Coverage Applied For: ® Specific Stop Loss ® Aggregate Stop Loss
❑ Life and AD &D — Complete Life Questionnaire
Classes of Covered Participants
Enrollment at the beeinning of the Coverage Period
Active Employees and their Eligible Dependents
Retired Employees and their Eligible Dependents
Disabled Employees and their Eligible Dependents
COBRA Employees and their Eligible Dependents
Enrollment By Coverage Categories
Single Employee 344 Family 268
M20006 -TX 1 of 4
APPLICATION FOR INSURANCE COVERAGE
Address:
PBM 6204, 1150 North Loop 1604 West, Sutie 108, San Antonio, TX 78248
Number of Covered
Included Participants
612
Not Included
Insurance applied for replaces prior coverage as follows: ❑ Yes ® No If yes, Complete Information Below
Name of Company Type of Coverage Termination Date
SPECIFIC EXCESS LOSS INSURANCE: Included
Specific Deductible Amount per Covered Participant for the Coverage Period: $50,000
Lifetime Limit of Liability per Covered Participant: $950,000
Lifetime Limit of Liability for Mental, Nervous, Drug and Alcohol Abuse: As Stated in Plan Document
Specific Percentage Reimbursable per Covered Participant: 100%
Monthly Premium Rates payable per Covered Participant Unit for the Coverage Period
Single Employee $42.59 Family $106.73
MINIMUM PREMIUM:
Is the greater of 1) the sum of the first four months Premiums and 2) the first month's Premium Multiplied by four.
❑ Not Applicable
Specific Coverage Basis
Incurred and Paid
Incurred and Paid with Run -In Period of 12 Months
Incurred and Paid with Run -Out Period of N/A months
Incurred in N/A months and Paid within N/A months
Specific Benefits
Medical
Prescription Drug Plan (Card)
Optional Specific Benefits
H Specific Terminal Liability
ExperimentaVlnvestigational & Medical Necessity
Specific Cash Flow Assistance Benefit
Aggregating Specific Corridor:
11 Flat Corridor Amount
❑ Factor
❑ Minimum Corridor Amount
❑ Adjusted Specific Deductible:
8 Paid (Renewal Option only)
Include Run -In Limit of
Covered Not Covered
® ❑
Limit Of
Name SIR Liability ID /Comments
ADDITIONS
Quota Share
Hospital Reimbursement Limitation
M20006 -TX 2 of 4
INCLUDED NOT INCLUDED
EXCLUSIONS INCLUDED NOT INCLUDED
Organ and Tissue Transplant Exclusion Endorsement ❑
AGGREGATE EXCESS LOSS INSURANCE: Included
Monthly Aggregate Factors:
Single Employee $324.18 Family $849.07
Estimated Annual Aggregate Attachment Point: $4,068,824
Minimum Aggregate Attachment Point $4,068,824
Limit of Liability for the Coverage period $1,000,000
Aggregate Percentage Reimbursable: 100%
AGGREGATE PREMIUM PAYABLE:
Per Employee Per Month of: $3.58
MINIMUM PREMIUM:
Is the greater of 1) the sum of the first four months Premiums and 2) the first month's Premium Multiplied by four.
❑ Not Applicable
Aggregate Coverage Basis:
Incurred and Paid
Incurred and Paid with Run -In Period of 12 Months
Incurred and Paid with Run -Out Period of N/A months
Paid (Renewal Option only)
Include Run -In Limit of
AGGREGATE BENEFITS COVERED NOT COVERED
Medical ® ❑
Prescription Drug ® ❑
Dental ® ❑
Vision ❑
Weekly Income ❑
Optional Aggregate Benefits
❑ Monthly Aggregate Protection Endorsement Premium:
❑ Premium Rate Per Employee Per Month:
❑ Included In Above Aggregate Premium
❑ Annual Premium:
❑ Aggregate Terminal Liability Endorsement Premium:
❑ Premium Rate Per Employee Per Month:
❑ Included In Above Aggregate Premium
❑ Annual Premium:
M20006 -TX 3 of 4
The Excess Loss Disclosure Statement is to be completed by the Applicant and will be attached to and become a part of this
Application.
INSURANCE FRAUD WARNING
Any person who with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement, or conceals information for the purpose of misleading, may be found guilty of
insurance fraud and may be subject to criminal and/or civil penalties.
The Applicant hereby applies for Stop Loss, Life, and/or other Insurance coverage and:
1. Represents that the answers included in this application, the attached questionnaires and the Excess Loss Disclosure Statement
have been reviewed and are true and complete to the best of the Applicant's knowledge and belief;
2. Understands and agrees that insurance applied for shall not become effective until the application for insurance is approved by the
Company.
3. Agrees that if the insurance applied for is approved by the Company, the Applicant will pay all premium due after the effective
date of insurance, including any premium which may accumulate between the effective date of the insurance and the date the
Policy is issued.
This Application, as it may be amended, will become part of the Policy, if issued.
Signed at: (Time of Signature)
This day of: (Day and Month of Signature)
Year:(Year of Signature)
Signed by:
Title
4( ....
/
7 5
T .� �v e,ll � •.D'
e f'
REMARKS:
FOR HOME OFFICE USE ONLY
Approved: ❑ Yes ❑ No
Reviewed /Approved By:
Approved Date
M20006 -TX 4 of 4
AIG
Medical Excess
American
International
Group, Inc.
Medical Excess
CLAIM SERVICES & PROCEDURES
Thank you for placing your Excess of Loss coverage with Medical
Excess. We are proud of the fact that you have chosen to work with us and
look forward to building upon this relationship.
The attached information packet includes outlines of the various Cost
Containment services we offer. Please be sure to read this and take
advantage of our Medical Management programs and pre - payment
Discount Re- pricing services. All of these programs have resulted in
tremendous savings to our clients.
All of the necessary forms and instructions for filing claims and notifications
to Medical Excess are included as well.
If you should ever have any questions about our services or forms, please
feel free to contact us at (800) 634 -7462. We are always more than happy
to answer questions and explain our programs.
Table Of Contents
Description
I. Excess Loss Claim Instructions
II. Notification Of Potential Excess Loss Claim
III. Medical Case Management
IV. Cost Containment
Out of Network Discount Services
Hospital Audits
V. Specific Excess Loss Claim Instructions
VI. Advance Funding For Specific Claim
VII. Variable Corridor
VIII. Aggregate Excess Loss Instructions
IX. Advance Aggregate Excess Loss Instructions
X. Sample Forms - Exhibits 1 Through 3
Exhibit 1
Exhibit 2
Exhibit 3
XI. Bulletins
Medical Excess
Excess Loss Claim Instructions
In order to assure that you and your clients receive prompt reimbursement /advance funding
of claims in excess of the Specific or Aggregate Retention, it is essential that all required
information be included when your claim request is first submitted.
The following instructions will outline all of the necessary forms and documentation you will
need to provide in order for us to properly evaluate and reimburse Excess Loss claims. These
administrative guidelines do not alter or amend any terms or provisions of the Excess Loss
Indemnity Policy.
If you have any questions, please call the Grass Valley Excess Claim Department at (530) 477-
0775 or (888) 539 -2377.
Notification Of Potential Excess Loss Claim
Medical Excess requires written notification when expenses for any individual have or are
expected to reach fifty percent (50 %) of the Specific Retention. The TPA must notify us by
submitting the Large Claim Notification form (Exhibit 1) along with pertinent information
relating to the claim.
It is very important that our Medical Management department receive immediate notification
of the following conditions so that a prompt decision may be made as to the need for medical
case management and other necessary investigation or documentation.
1. Head or Spinal Cord Injuries
2. Severe Burn Cases
3. Severe Trauma
4. Premature Births
5. Acquired Immune Deficiency Syndrome
6. Cancer
7. Severe Strokes
8. Organ and Bone Marrow Transplants
9. Brain Tumor
10. Severe Rheumatoid Arthritis
11. Cardiac Et Circulatory Disorders
12. Comatose Patient
13. Degenerative Muscular /Neurological Disorders
14. Any Amputations
15. Life Support Systems In Place
16. Dialysis
17. Diabetic Complications
Also report to the Medical Excess Medical Management department any other serious
conditions which, in your opinion, may require medical case management or result in a
Specific Excess Loss claim.
Medical Excess
Medical Management
Medical Excess believes that one of the keys to large claim cost containment is medical case
management. However, in order for case management to be truly successful, it has to be
implemented as early as possible in the treatment process of a sickness or injury.
Medical Excess' Medical Management department has formed unique partnerships with
Dimensions In Managed Care (DMC) @ Comprehensive Health Services (CHS), which allows us
to offer you and your clients nationwide, on -site case management services. What
differentiates our services from other case management programs is the fact that our initial
assessments are done on -site. This allows the patient and provider to build a more cohesive
relationship with the nurse case manager. In most cases, our carriers will assume the cost of
these services. It is our desire to assist you in the management of claim costs at the earliest
possible point of service..
Therefore, we ask that you notify our Medical Management Department immediately of any
claimant's illness or injury that has the potential to exceed 50% of the Specific Retention. If
medical case management is warranted, we will obtain the necessary information from you
and coordinate the implementation of case management through one of our contracted
vendors.
Our Medical Case Management Department is available to aid you with your more complex
claims and answer any questions you may have regarding our case management and cost
containment programs.
Please contact John Richert at.(317) 876 -1250 for answers to all of your questions and
concerns regarding these programs.
Medical Excess
Cost Containment
We are all aware that health care can be expensive. There are various ways we can assist you
and your clients in controlling medical costs.
However, success depends upon the combined efforts of all parties.
Medical Excess utilizes nationally recognized cost containment companies to reduce medical
costs through the following services:
• P.P.O. Network Discounts
• Line Item Bill Analysis
• Prospective and Retrospective Discount Negotiations
• Medical Necessity Reviews
• Reasonable and Customary Reviews
• Organ Transplant Networks
• Subrogation Recovery
• Hospital Bill Audits
The above services are available to you as part of our ongoing strategy to contain medical
costs, while maintaining the superior care your clients have come to expect.
PPO /Negotiation discounts
Whenever one of our carrier's has potential exposure on a claim and you have notified us of
the potential exposure, we request you comply with the following procedures if the provider
of service does not currently fall within the group's existing PPO network.
1. Forward all Hospital UB -92 billings over $5,000.00 to our South Coast Metro Claim
department.
2. Forward all other provider bills over $2,000.00 to our South Coast Metro Claim
department.
Upon receipt of these bills, we will search through our database to determine the most
appropriate form of discount available. The signed provider discount agreement will then be
returned to you within three working days for processing of payment. Accounts with our
Advance Funding feature may utilize this product in conjunction with the above, upon
satisfaction of the policy terms.
Our carriers will honor the fees charged for obtaining discounts when the claim has exceeded
the Specific Retention amount. If the total eligible paid claims do not exceed the Specific
Retention amount, the cost of these services are the responsibility of the Insured (Employer).
Claims should be faxed to (714) 436 -3652 with a cover sheet indicating the attached are being
referred for discounting.
Questions regarding this program should be addressed to Gerald Addy or Linda Subbiondo at
(714) 436 -3600.
Medical Excess
Hospital Audits -
In the absence of PPO /Negotiated discounts, we require that you pend 10% of all hospital bills
that are $25,000.00 or greater. If a specific reimbursement claim is filed and an audit has not
been performed, we will arrange for an audit with one of our cost containment services. Upon
receipt of the audit results, pay the amount due based upon the audit and submit the balance
to us for reimbursement. We will include the adjustment payment as part of the specific
claim, even if the audit was not completed until after the specific payment period. However,
any unbilled charges resulting from the audit should not be paid unless the hospital agrees
with the audit results and until the hospital has billed you.
Medical Excess
Specific Excess Loss Claim Instructions
Specific Excess Loss Coverage reimburses the Employer after an individual's, or family's,
eligible paid claims exceeds the amount of the Specific retention selected by the Employer.
Only expenses covered by the Employer's Plan Document, which are then subject to the terms
and conditions of the Excess Loss Indemnity Policy, are eligible for reimbursement.
The Excess Loss Indemnity Policy is subject to an Incurred and Paid basis; that is, the
underlying expenses must be incurred and paid per the Plan and must be incurred and paid
within the time frame set forth in the Payment Basis section of the Policy. According to the
terms of the Excess Loss Indemnity Polity in effect at the printing of this Manual, claims shall
be deemed to be paid on the date that: (1) the Policyholder's payment check or draft is
issued; and (2) provided sufficient funds are then available to cover such payments. Claims
shall not be deemed paid until both of these occur and only if the funds remain in the account
until the checks or drafts are honored.
Once a Specific Claim has exceeded the Specific Retention, the following must be provided.
1) Completed, signed and dated Specific Stop -Loss reimbursement form. (Exhibit 2)
2) Copy of employee's enrollment card with hire date and original effective date of
coverage, including all eligible dependents.
3) COBRA election form with qualifying event date, if applicable.
4) HIPAA Creditable Coverage form, if applicable.
5) Copies of all Explanation of Benefits (EOB) attached to their corresponding itemized bill.
6) Copies of all correspondence regarding Coordination of Benefits (COB).
7) Copy of all physicians /surgeons reports and all pertinent hospital records, when
applicable.
8) Copy of accident information which should include a detailed description, location and
date of accident, if applicable.
9) Copy of investigation reports or documents used to determine any of the following:
a) Pre - existing Conditions
b) Prior plan's extension of benefits
c) Subrogation (Employee's reimbursement agreement)
d) Workers' Compensation
e) Divorce, separation decrees or court orders
f) Full -time student status
g) Third -Party Liability /Recovery details
h) Employee disability status
Following receipt of the above - listed information and any other necessary documentation
required to establish proof of loss, Medical Excess will audit the claim and reimburse /advance
the Employer as appropriate.
Medical Excess
Advance Funding For Specific Claims
This product allows a group to be eligible for advance funding when it has exceeded the
individual or family specific retention.
1. Advances must be requested by completing Medical Excess's regular Specific
Reimbursement Request form, and by checking the "Advance" box.
2. The request must indicate the amount of the advance and date of Last check released.
3. Claims should be handled in the usual fashion. However, the checks should be held
pending completion of the advance funding process.
4. The advance funding must be used to cover the claim checks for which the advance was
requested.
5. Claim checks must be released immediately upon receipt of the advance.
For administrative purposes, the minimum advance that may be requested is $1,000.00.
The request for an advance must be made either within the Policy Term; or no later than 21
days after the expiration of the policy.
The above guidelines are to be used in conjunction with Specific Excess Loss claim
instructions.
Variable Corridor
Employers with stable claims experience may need protection against only the most severe
claims. Variable Corridor covers these severe claims, increasing cash flow and reducing
specific premiums. Medical Excess will reimburse the employer at the end of the policy
period for the sum of the claims in excess of the Specific retention and the Variable Corridor
up to the limit of liability. However, to alleviate cash flow strains, reimbursement prior to
the end of the policy period may be available on a case by case basis. Medical Excess will_
reimburse 80% of reimbursement requests in excess of the Specific retention and the
estimated Variable Corridor prior to the end of the polity year. in these cases, the remainder
is paid at the end of the policy year after the recalculation of the annual Variable Corridor.
The Employers Variable Corridor claims liability is not covered under the Aggregate portion
of the Excess Loss coverage.
Aggregate Excess Loss Instructions
Aggregate Excess Insurance provides for reimbursement to the Employer for eligible paid
claims in excess of the greater of the Annual or the Minimum Annual Aggregate Retention,
less Specific Excess reimbursements and any applicable Variable Corridor Amount. The Annual
Aggregate Retention is calculated in the following manner:
Medical Excess
The Minimum Annual Retention is set by the underwriter and is shown in the schedule page of
the policy. The Annual Aggregate Retention is calculated by multiplying the Monthly
Aggregate Factor times the cumulative enrollment for each month of the Policy Year. The
greater of the Annual or Minimum Annual Retention will be utilized as the Annual Aggregate
Retention.
The eligible paid claims are only those claims covered by the Plan Document that are then
subject to the terms and conditions of the Excess Loss Indemnity Policy. Paid means that
drafts or checks have been issued and cashed (see page 6). Incurred means the date the
service or supply to which it relates, was provided.
In the first "Excess Loss Indemnity Policy" year, all claims must be incurred and paid within
the Policy year, unless the Policy is otherwise endorsed. The renewal year provides for claims
incurred after the initial effective date and paid in the Policy Year for which the claim is
presented, unless the Excess Loss Indemnity Policy is otherwise endorsed.
Once an Aggregate claim is eligible for reimbursement, the following must be provided:
1) Completed, signed and dated Aggregate Stop -Loss Reimbursement form. (Exhibit 3)
2) An employee eligibility listing showing all employees covered under the plan along with
any dependents, the effective date of coverage and termination date where applicable.
3) A list of claims with an accumulated total, showing incurred dates, payment dates, check
numbers, payment amounts, and employee's claimant's name. Preferably, this list will
group paid claims by individual or family for easier verification of Specific claim amounts.
4) Payment of Dental, Pre -Paid Prescription Drug, Vision, Weekly Income, or any other
coverage not included in the Aggregate Excess Coverage should not be included in the
reimbursement request. Please identify these benefits if they are included in the paid
claims listing.
5) Please identify and deduct any refunds, voids and payments outside of the plan if not
previously adjusted from the paid claims list.
6) if Aggregate coverage includes run -in claims, only include service dates within the run -in
period, and deduct any run -in claims in excess of the indicated maximum. If service dates
overlap the beginning or end of the run -in period, please indicate the payment amounts
applicable to each period.
7) If Aggregate coverage is provided for a Prescription Card Drug Plan, please submit copies
of the drug plan's invoice statements and the employer's reimbursement checks.
Administrative fees billed by the drug plan are not a reimbursable expense.
8) Bank Statements for the last month of the policy and the month following the end of the
policy.
9) Medical Excess Reserves the right to perform an on -site audit of enrollment, premium,
financial and claim records prior to final settlement of any Aggregate claim.
Medical Excess
Advance Aggregate Excess Loss Instructions
Advance Aggregate Excess Insurance provides for reimbursement to the Employer for eligible
paid claims equal to, or exceeding by $5,000.00, the year -to -date accumulated Aggregate
Retention or Pro Rata Minimum Aggregate Retention, whichever is greater, less the Specific
Excess reimbursements, applicable Variable Corridor amount and any previous advances for
the same policy year. The Accumulated /Pro- Rata Minimum Aggregate Retention is calculated
in the following manner:
The Accumulated Aggregate Retention is calculated by multiplying the Monthly Aggregate
Factor times the cumulative enrollment through the months for which the advance is being
requested. The Pro -Rata Minimum Annual Aggregate Retention is calculated by multiplying
the Monthly Aggregate Deductible times the number of months through which the advance is
being requested.
Such advances may be requested only after the first three month's of coverage have passed
when the following conditions are met:
1. Medical Excess has received the premium due for the month for which the advance has
been requested.
2. No more than one advance will be made for any one calendar month. The minimum
advance is $5,000.00. Claims presented to Medical Excess for advance will be deemed
paid in the month for which the advance was made.
3. All Aggregate advance requests must be submitted to Medical Excess within 21 days after
the end of the month for which the advance is requested.
When the conditions listed above for an Advance Aggregate Stop -Loss claims have been met,
the following must be provided:
1. Completed, signed, and dated Aggregate Stop -Loss Reimbursement form with the
"Advance" box checked. (Exhibit 3)
2. A list of paid claims for the Excess Loss Policy year -to -date showing Employee /Claimant's
Name, incurred dates, payment dates, check numbers, payment amounts, and
accumulated total. Preferably, this list will group paid claims by individual or family for
easier verification of Specific claim amounts.
3. Please Identify or provide check copies of any plan benefits not yet paid.
At the end of the Policy Year, the administrator must submit a final Aggregate submission as
outlined in the Aggregate Reimbursement section of this manual to determine if an actual
Aggregate claim exists. If advances are greater than the aggregate claim for the Policy year,
the Employer must reimburse Medical Excess the amounts advanced in excess of the actual
claim. Refunds are due and payable from the Employer within 60 days following the end of
the Policy Year. Medical Excess reserves the right to perform an on -site audit of enrollment
and claims prior to final settlement of any Aggregate claim.
Medical Excess
AIG
American
International
Medical Excess
Large Case Notification
8777 Purdue Road — Suite 330
Indianapolis, IN 46268
Tel: 317/876 -1250
Fax: 317/472 -0298
Complete this form if you have an ongoing claim that has reached 50% of the Specific Deductible or as soon as you realize that
the claim has the possibility of exceeding the Specific Deductible. Also use this form when referring a claimant for Case
Management.
Group Name: Policy #: Contract Type:
Policy Year: Specific Deductible
Ernployee:
Employment Date: Effective Date:
Current Status of EE: Active: Yes ❑ No ❑
If Deceased, Date of Death:
Is COBRA applicable? Yes ❑ No ❑ If yes, effective date:
Claimant: DOB: Sex: Male ❑ Female ❑
Relationship to Employee: Effective Date: Termination Date:
Address:
Telephone: Dependent Child over 18? Is he/she a full time student? Yes ❑ No ❑
Diagnosis: Date of Onset:
ICD9 Codes: Prognosis:
If Accident; Date: Location:
Describe how accident occurred:
Attending Physician: Telephone #:
Address:
Inpatient Stay /Surgery Date & Description:
Hospital: Telephone 9:
Address:
TPA:
Submitted By:
Address:
Phone #:
Medical Excess
Ext:
DOB: SSN:
Termination Date:
Disabled: Yes ❑ No ❑
Yes No Other Coverage
❑ ❑ Claimant is still hospitalized Other Group Insurance: Yes ❑ No ❑
❑ ❑ Claimant is continuing treatment If yes, Carrier's Name:
❑ ❑ ESRD Onset Date: lnsured's Name:
❑ ❑ Large Case Management DOB:
Name of LCM Co.: Medicare: Yes ❑ No ❑
Case Manager's Name: Worker's Comp: Yes ❑ No ❑
Case Manager's Phone #: Auto Insurance: Yes ❑ No ❑
Is PPO in place? Yes ❑ No ❑ Subrogation: Yes ❑ No ❑
If yes, name of vendor: If yes, has a Subrogation agreement been filed:
If no, please refer all out -of- network claims in excess Yes ❑ No ❑
of $2,000 to Medical Excess for re- pricing
Initial amount Paid to Date: $
Pended Claims Amount: $
Reason:
Estimates of future expenses:
❑ Less than $50,000 ❑ $50,000 - $100,000 ❑ $100,000 - $150,000 ❑ $150,000 and above
Title: e-mail:
Fax #: Date:
Send / fax ALL 50% Notices or Case Management Referrals to Medical Excess at the above address /fax number.
E -mail to: gabriele.hunter(?aig.com, and cc to: john.richert(o?ai8.com and denise.kazmierzak(d )aig.com
HEN
AIG
American
t'a" " Medical Excess
SPECIFIC EXCESS LOSS REIMBURSEMENT REQUEST
Initial Claim ❑ Subsequent Claim ❑ Final Claim ❑ Advance ❑
Policyholder
Policy Number Policy Year
Name of Employee Birth Date
Hire Date EE's Effective Date
Name of Claimant Birth Date
Relationship to EE Dep's Effective Date
Present Employee Status: Active❑ Disabled ❑ Retired ❑ Retirement Date
Last Day Worked
Termination Date
Diagnosis & ICD 9
Onset Date
Total Mailed Payments for this submission:
Total Unmailed Payments for this submission (advance)
Total Eligible Expenses for this submission
ttotal of mailed and Unmailed payments
Less Specific Retention:
Less Variable Corridor (if applicable):
Reimbursement Requested:
If advance, date of last check released:
Please include the following documentation with your reimbursement request: (if applicable)
Enrollment form Current COB Information
Full time student status Divorce, separation decrees or court orders
COBRA election form Pre- existing /HIPAA Certificate
EOB/Paid Claims Report Accident details/police report
Itemized bills Physician's statements /operative reports
Hospital audits /reviews /discounts Subrogation/TPURecovery details
Pre -certs DME — MD's prescription and purchase price
Large case management reports Name Case Management Co:
I hey Norse& dxc to the lot tiny krva/aig4 the information pn 1ai s ttrtpleeanicorrec and the daimha lesrpaid v aecatiance vith the aerated''s employee benefit
plan, oh&ha leer nudep ocf,'oralamdralmdoe s Las /Way
Submitted By (Print Name)
TPA Name Date
Address
Telephone Number Fax Number
Email Address:
Medical Excess
Mail To:
333 Crown Point Circle, Grass Valley, CA 95945
530 - 477 -0775 530 - 477 -0696 FAX
Leave of Absence Date
COBRA Effective Date
ESRD Onset Date
AIG
American
Internadonal
Group, Inc.
Policyholder
Policy Number
Submitted by (Print Name)
Medical Excess
AGGREGATE CLAIM REIMBURSEMENT REQUEST
Annual Aggregate Request ❑ Monthly Accommodation Request ❑
1. Total Mailed Claim Payments thru Mo / Day / Yr
2. Less Claims in Excess of Specific Retention
3. Less Extracontractual or Ineligible Payments
4. Less the greater of (a) Min. Annual Agg. Ded., or
(b) Calculated Ann. Agg Ded
5. Less Prior Accommodations / Advance
6. Total Amount Requested or Refund Due
(If Negative, Amount Due Medical Excess)
Please include copies of the following documentation with your submission:
• Eligibility listing and/or current census covering all months of the policy to this point through the
month in which the claim is being requested.
• Paid claims analysis showing incurred date of each loss, payment date, amount paid, and the
payee for the period covered by this request.
• Check registers showing check numbers and amounts.
• Report of all voided checks and refunds or credits through the date signed below.
• Monthly Aggregate Report
Other documentation, which may have had an affect upon the consideration and payment of this claim,
may be requested if necessary in the judgement of the Claim Department
I hereby represent that to the best of my knowledge, the information provided is complete and correct, and the claim has been paid in
accordance with the Policyholders Employee Benefit Plan, which has been made part of, and attached to the Excess Loss Policy. I certify that
all checks were mailed to the payee on or before the last day of the Policy Year for which this claim has been presented.
TPA Date
Address
Telephone Number
Email Address
Mail To:
333 Crown Point Circle, Grass Valley, CA 95945
530 - 477 -0775 530 - 436 -0696 FAX
Policy Year
Agg. Deductible
Fax Number
Medical Excess
Bulletins
THE FOLLOWING BULLETINS ARE NOT ADDRESSED ELSEWHERE IN THE CLAIMS SECTION OF THIS
MANUAL. WE WILL PERIODICALLY SEND SUCH BULLETINS TO OUR ADMINISTRATORS. FOR A QUICK
REFERENCE, PLEASE ADD ANY FUTURE CLAIMS BULLETINS TO THIS SECTION OF THE MANUAL
SUBROGATION RECOVERY SERVICES
Medical Excess currently has an arrangement with The Law Office of Bryan B. Davenport, P.C.
to assist with recovery efforts. Medical and disability plan administrators have the potential
to recover benefits paid under employee health and other benefit plans. However, millions of
dollars are "left on the table" every year because of legal and other complexities associated
with enforcing subrogation and right of recovery benefit plan provisions. Mr. Davenport's
objective is to assist the Administrators, Employers, and Medical Excess in increasing the
amount and frequency of subrogation recoveries to reduce the overall cost of the benefit
plan. If you have paid medical benefits to plan beneficiaries that have been involved in:
• Automobile Accidents
• Defective Product Injuries
• Medical Negligence Action
• Slip -Fall Accidents
• Claims with Third Party Liability
The Law Office of Bryan B. Davenport, P.C. can be of assistance to you, your clients and
Medical Excess. We encourage our Administrators to continue their efforts in pursuing
overpayments and Third Party Liability. However, when attempts are unsuccessful or if you
have not secured a recovery firm or legal counsel, please contact us immediately to utilize
the services Mr. Davenport.
Medical Excess
OUT -OF- NETWORK CLAIM DISCOUNTS
Medical Excess is pleased to offer a claim discounting service to all of our clients. We have
access to several national discount vendors. These vendors have contracts with providers
throughout the nation for the purpose of obtaining discounts on out -of- network claims.
Savings realized from this program has averaged 13.5% and has been as high as 75 %. This can
benefit the bottom line to the plan Et have a dramatic affect on the group's renewal.
Refer all of your group's eligible (as defined in the plan document) out -of- network hospital
claims over $5,000.00 and all other bills over $2,000.00 to the South Coast Metro Medical
Excess claim department prior to issuing payment to the provider. You wilt receive a written
explanation of what message must appear on the Explanation of Benefit statement to the
provider and the amount of discount to apply to the bill. All vendor fees for this service are
fully reimbursable under the specific and aggregate coverages, subject to the normal policy
plan /limits.
Turnaround time and ease of access are extremely important to both you and your client.
Therefore, we strongly recommend that the bills you refer for re- pricing be faxed to our
South Coast Metro claim department at (714) 436 -3652. The normal turnaround is two to
three working days.
This service benefits the T.P.A., Client, Insurer and Employee, providing a total win situation
for all involved parties. Please feel free to contact Gerald Addy or Linda Subbiondo at (714)
436 -3600 with any questions regarding this value added service. Just another one of the
many reasons to do business with Medical Excess!!!
Medical Excess
P c()