SUMMARY OF BENEFITS

Note: The coverage provided by this Policy is individual coverage only. A separate Policy will be issued to each person eligible for and accepted for coverage.

Note: Many covered services require pre-certification or the benefit level is reduced to 50% of covered charges. Please review the Policy carefully to determine which covered services require pre-certification.

Major Medical Expense Benefits For All Plans For Each Covered Person

The Plans are defined by the Deductible amount and Stop Loss Limit (Maximum Out-Of-Pocket Expense). Deductible means the amount of Eligible Expenses that a Covered Person must pay before the Policy starts to pay. Stop Loss Limit means the amount of Eligible Expenses that must be incurred by each Covered Person after the applicable Deductible is met.

Maximum Benefits Payable per Lifetime $ 500,000

Maximum Benefits Payable per Calendar Year $ 100,000

Maximum Benefits Payable for Prescription Drugs

Per Calendar Year $ 15,000*

Maximum Benefits Payable for Eligible Transplants

Per Lifetime (including work ups, and other

procedures to determine the suitability of a

patient for transplant) $ 100,000**

Note Regarding to All Deductibles Under All Plans:

Beginning January 1, 2004, a Policyholder renewing coverage may not select a lower deductible than the deductible selected when the original application was completed. A Policyholder on renewal may only select a higher deductible, or keep the current deductible.

Deductible- Individual

NO BENEFITS WILL BE PROVIDED UNTIL THE DEDUCTIBLE HAS BEEN MET.

All Eligible Expenses incurred are subject to the

following deductible per Calendar Year for individuals

Plan J $ 1,000

Plan K $ 2,000

Plan L $ 3,500

Plan M $ 5,000

Benefit Period

Calendar Year(Jan. 1 - Dec. 31)

Benefit/Coinsurance Percentages

Benefit Coinsurance

Percentage Percentage

(LHP Pays) (You Pay)

Eligible Expenses (in general) 75% 25%

Eligible Inpatient Hospital Expenses

**without Pre-Certification 50% 50%\

with Pre-Certification 75% 25%

Eligible Outpatient Surgery

**without Pre-Certification 50% 50%

with Pre-Certification 85% 15%

Pre-Admission Testing 85% 15%

*Second Surgical Opinion Benefit 100% 0%

Second Surgical Opinion is mandatory for the following procedures only:

1. All surgery of the nose or jaw (except after trauma)

2. All surgery of the breast (except biopsies or cancer)

3. Podiatric Surgery

4. Any plastic or reconstructive surgery, when cosmetic versus medical necessity is in question.

Stop Loss Limits (Out-Of-Pocket Expenses)

Maximum Out-Of-Pocket Expense

(for each Covered Person after deductible met)

Plan J $3,500

Plan K $4,500

Plan L $4,500

Plan M $4,500

After the Stop Loss Limit (Maximum Out-Of-Pocket Expense) is reached, LHP will pay 100% of covered reasonable and customary charges up to the applicable maximum benefits limit.

Daily Hospital Room & Board

Maximum Room & Board Limit Semi-Private Room Rate

Skilled Nursing Facility*** Limited to 120 Days per Calendar Year

Home Health*** Limited to 270 Days per Calendar Year

Mammography Examination & Pap

Testing Benefit One Visit per Calendar Year

Prescription Drugs Benefit Coinsurance

Percentage Percentage

(LHP Pays) (You Pay)

Brand Name Drugs 70% 30%

Generic Drugs 80% 20%

Mail Order Drugs 90% 10%

Medical Necessity Review Organization

(Calais Health)

This Plan uses the services of Calais Health for the following:

The Benefit Percentage for inpatient Hospital charges and outpatient surgery is 50%. However, if Calais Health is used to obtain Pre-Certification, the Benefit Percentage will be 75% for Hospital admissions and 85% for outpatient surgery, and co-insurance (unreimbursed) amounts will be applied to the Stop Loss Limit.

MAJOR MEDICAL EXPENSES NOT COVERED

Benefits are NOT provided for and this Policy does not cover care or services for:

    A. Any Injury or Illness covered by any Workers’ Compensation Act, Occupational Disease Law or similar law.

    B. Any Injury or Illness arising out of the commission of or attempt to commit an assault, battery, felony or act of aggression, insurrection, rebellion, participation in a riot, or self-inflicted.

    C. Any Injury or Illness due to war or act of war, declared or undeclared.

    D. Charges that in the absence of coverage would not be made; or, charges for which there is no legal obligation to pay.

    E. Any and all charges incurred after termination of coverage.

    F. Charges for care or services furnished by any federal agency.

    G. Any Injury or Illness while serving as a member of the Armed Forces.

    H. Charges that are not Medically Necessary (as defined) for treatment of Illness or Injury.

    I. Charges in excess of the Maximum Allowable Charge (as defined) for care or services provided under this Policy.

    J. Care or treatment given by a member of the Covered Person’s immediate family. (Parents, spouse, children or siblings).

    K. Any charges for services that are not related to and consistent with the treatment of any Injury or Illness of the Covered Person.

    L. Charges for routine physicals or general health exams other than those specifically listed as covered.

    M. Charges for medical care, services, or supplies that are not furnished or prescribed by a Physician (as defined).

    N. Charges for experimental or investigational treatment or procedures, or for research purposes, or when not a generally recognized accepted medical practice.O. Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an Injury or Illness by any of the following:

        1. The American Medical Association; or

        2. The U.S. Surgeon General; or

        3. The U.S. Department of Public Health; or

        4. The National Institute of Health; or

        5. The Medical Necessity Review Organization(ies) which administer(s) the Utilization Review Program.

Contact the Medical Necessity Review Organization for information concerning whether particular goods, services, treatments or procedures are approved under the Policy.

    P. Charges related to Cosmetic Surgery and Treatment, as defined.

    Q. Charges not specifically listed as covered under "Major Medical Charges" for:

        1. Dental treatment;

        2. Oral Surgery.

    R. Charges for diagnosis and treatment of Mental and Nervous Disorders or Substance Abuse Disorders, including charges for prescription drugs prescribed, used or intended for use in treating such disorders.

    S. Charges incurred by a Special Enrollee that relate to a Pre-Existing Condition, as defined in this Policy, until the Special Enrollee has been covered under this Policy for twelve (12) consecutive months. The Special Enrollee shall be given credit against the twelve (12) month Pre-Existing Condition Exclusion period for the aggregate of any prior Creditable Coverage that the Special Enrollee may have.

No Pre-Existing Condition Exclusion shall apply to any Eligible Enrollee as defined in this Policy.

    T. Charges for eye refractions, eyeglasses or hearing aids or their fitting.

    U. Charges in connection with obesity, weight reduction, or dietetic control, including, but not limited to, any surgical procedures related thereto.

    V. Charges for treatment or services for temporomandibular joint dysfunction or TMJ pain syndrome, orofacial, or myofascial syndrome whether medical or dental in scope.

    W. Charges for procedures in connection with male or female sterilization, or procedures to reverse same.

    X. Charges for routine immunizations and vaccinations, including but not limited to polio, mumps, measles, small pox, DPT, or tuberculosis tine tests.

    Y. Charges for services in the nature of educational or vocational testing or training.

    Z. Any charges for elective abortions.

Any charges for outpatient food, food supplements or vitamins.

BB. Any charges for radial keratotomy, photo refractive keratotomy, or other surgery to correct myopia (nearsightedness) or hyperopia (farsightedness).

CC. Any charges for human heart, human lung, human heart-lung, human bone marrow, human liver, human kidney, human pancreas, or human kidney-pancreas transplants not performed at approved hospital centers in the United States, as designated by the Health Care Financing Administration of the Department of Health and Human Services of the United States or the United Network for Organ Sharing. A list of approved hospital centers is available from the Medical Necessity Review Organization, and that list is incorporated by reference as a part of this Policy.

DD. Any charges for treatment of male or female infertility; in vitro and in vivo fertilization of an ovum; or artificial insemination including but not limited to:

1. Drugs and medicines;

2. Diagnostic and surgical procedures including but not limited to:

a. Aspiration of ovarian cysts; or

b. Harvesting or obtaining eggs; or

c. Other surgical treatment of infertility; or

d. Diagnostic laboratory and pathology procedures; or

e. Diagnostic radiology, nuclear medicine and ultra sound procedures.

EE. Any charges for stand-by surgeons, pediatricians, anesthesiologists, anesthetists, or other Physicians as defined by this Policy; or stand-by supplies, equipment, rooms, or any other service, supply or treatment not actually used in the care or treatment of an Illness or Injury.

FF. Charges made by; durable medical equipment recommended by, or drugs dispensed by, a physician, surgeon, nurse or other Physician (as defined) who:

1. Normally lives with the Covered Person; or

2. Is a member of the Covered Person’s family; or

3. Is the Covered Person’s employer.

                                        GG. Any charges for Custodial Care.

                                         HH. Any charges related to smoking cessation.

II. Any charges not included in "Major Medical Charges", except those alternate forms of treatment or facilities suggested for use by the Medical Necessity Review Organization which have been approved by the Plan.

                                        KK. Any charges incurred for Private Duty Nursing.

LL. Any charges incurred for Maternity Care, as defined, except that charges for Maternity

Care will be covered, as a limited portability benefit only, and only under the following circumstances:

 

1. The applicant is an Eligible Enrollee (i.e., not a Special Enrollee); and

2. The applicant had maternity benefits under her last group coverage; and

3. The applicant was terminated involuntarily from her last group coverage; and

4. The applicant was neither eligible for nor offered any other health coverage providing maternity benefits; and

5. The applicant was pregnant at the time application was made for coverage under this Policy; and

6. The applicant requested maternity coverage at the time application was made for coverage under this Policy

 

In the event that all of the foregoing requirements are met, the applicant shall have coverage for Maternity Care under this Policy, but only for the pregnancy which existed at the time application was made for coverage under this Policy. Coverage for Maternity Care shall be subject to all the other terms, conditions, and limitations of this Policy, including all deductibles, co-payment requirements, and policy limits.

 

Complications of Pregnancy, as defined, are covered.

 

MM. Any charges for sex transformations or treatment of sexual dysfunctions, including, but not limited to, prescription medications and surgical procedures.

 

NN. Sales tax or interest.

 

OO. Penile prostheses implantation.

 

PP. Electrical power, water supply and sanitary waste disposal systems, or the installation and operation of any equipment.

 

QQ. Any charges for air conditioners, dehumidifiers, air purifiers, arch supports, corrective or orthopedic shoes, heating pads, hot water bottles, home enema equipment, rubber gloves and deluxe equipment.

 

RR. Charges made by a Hospital owned or operated by the U.S. Government, where the individual is not required to pay by law, or charges for a hospital confinement in any other Hospital for which the Covered Person is not required to pay if no insurance coverage exists.

 

SS. Charges incurred as a result of a sports-related injury in which the participant is engaged in the sport for profit.

 

TT. Charges incurred for instruction in alternate life patterns for conditions previously diagnosed.

 

UU. Any charge for services or articles the provision of which is not within the scope of the authorized practice of the institution or individual providing the services or articles.

 

VV. Any charge for confinement in a private room to the extent such charge is in excess of the institution's charge for its most common semi-private room, unless a private room is prescribed as medically necessary by a Physician.

 

WW. Services of blood donors and any fee for failure to replace the first three (3) pints of blood provided to an eligible person each Calendar Year.

 

XX. Personal supplies or personal services provided by a hospital or nursing home or any other non-medical or non-prescribed supply or service.

 

YY. Any expense incurred prior to the effective date of coverage by the Plan, or during the pre-existing condition period.

 

ZZ. In the event the amounts charged for services and articles provided by

or at the direction of a (Non-Preferred) health care Provider exceed the

Maximum Allowable Charge for covered expenses as provided herein, the

health care provider may seek payment of the balance owed from the

Policyholder. Reimbursement by Preferred Providers, however, may not

exceed the contracted amount for covered expenses. Preferred Providers

may not collect from the policyholder or plan any reimbursement

exceeding contracted amounts. Preferred Providers may collect any

applicable deductible, co-payment, co-insurance or ineligible charges.

As to the deductible, co-payment or co-insurance, Preferred Providers

agree not to collect more than the contracted rate.

 

AAA. Any charges relating to organ transplants, except for the following human organ transplants only:

 

1. Cornea transplants

2. Artery or vein transplants

3. Kidney transplants

4. Joint replacements

5. Heart valve replacements

6. Implantable prosthetic lenses in connection with cataracts

7. Prosthetic by-pass or replacement vessels

8. Bone marrow transplants

9. Heart transplants

10. Liver transplants

11. Lung transplants

12. Pancreas transplants

 

No charges incurred by organ donors are covered.

 

No charges for organ procurement, organ harvesting or organ acquisition are covered, even if incurred in connection with a covered procedure.

.

 

No experimental replacement of tissue or organs is covered by this Policy.

 

Charges for workups, or other procedures to determine a patient’s need for or suitability for an organ transplant are excluded unless such charges relate to a covered organ transplant. Even if such charges relate to a covered organ transplant, such charges shall be included in the Lifetime Maximum benefit for organ transplants.

 

The Lifetime Maximum for transplants shall not apply separately to multiple organ transplants. When the Lifetime Maximum Benefit has been reached, no further benefits will be paid under the Policy for any charges relating to organ transplants, including workups.

 

BBB. Diagnosis, treatment of or counseling for sleep disorders.