501WestMichigan
Milwaukee,WI53203
OutlineofCoverage
for
AccidentMedicalExpenseInsurancePolicyForm8227.POLLA
WithTermAccidentalDeathandDismembermentBenefitsandOptionalRiders
Notice:ThecoverageappliedforisanAccidentonlyPolicyanditdoesnotpaybenefitsforloss
fromSickness[,exceptasprovidedforunderoptionalRider[s]].ThePolicy[andoptional
Rider[s]]provide[s]limitedbenefits.Benefitsprovidedaresupplementalandarenotintended
tocoverallmedicalexpenses.
TobeeligibleforanybenefitsunderthisPolicy,anAccidentmustoccuronoraftertheCovered
PersonsEffectiveDateandwhilethisPolicyisineffect.Tobeeligibleforanybenefitsunder
theSicknessIndemnityRider,theConfinementPeriodforHospitalizationduetoSicknessmust
occuronoraftertheCoveredPersonsEffectiveDateandwhiletheRiderisineffect.Tobe
eligibleforanybenefitsundertheCancerandHeartStrokeRiderthefirsteverDiagnosisofa
SpecifiedDiseasemustoccuronoraftertheCoveredPersonsEffectiveDateandwhilethe
Riderisineffect.
AccidentmedicalexpensesareeligibleforbenefitsonlyuptotheamountofCoveredTreatment
ofanAccidentforwhichnoOtherBenefitsarereceivedunderanyothercoverage,suchas
benefitsunderanothermedicalplan,hospitalindemnitypolicy,medicalpaymentsunderan
motorvehicle,orotherliabilitypolicy.
THISISNOTMEDICARESUPPLEMENTINSURANCECOVERAGE.
THEPLANHASLIMITEDBENEFITSANDANNUALMAXIMUMS.PLEASEREADYOUR
POLICYCAREFULLYTOUNDERSTANDPLANLIMITATIONS.
ConditionallyRenewablePlan:ReadtheTerminationDateprovisionofYourPolicycarefully.We
reservetherighttochangepremiumsbyclassuponanyrenewaldateaftertheinitial12months
coverageisinforce.
ThisoutlineofcoverageprovidesabriefdescriptionoftheimportantfeaturesofYourPolicy.This
isnottheinsurancecontract.ThePolicyitselfsetsforthindetailthelimitsandconditionsof
coverageaswellastherightsandobligationsofbothYouandtheinsurancecompany.ThePolicy
provideslimitedbenefitsonlyandcontainsMaximumBenefitLimitations.Itisimportantthat
YouREADYOURPOLICYANDBENEFITSCHEDULECAREFULLY.
8227.OOCR.LA Page1OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
SECTION1:SCHEDULEDBENEFITS
AccidentBenefits
WewillpaythebenefitsshownbelowonlyasdescribedintheAccidentBenefitssectionofthe
Policy.AllbenefitsandlimitationsstatedbelowarestatedperCoveredPerson.
AccidentMedicalExpenseBenefits
AccidentMedicalExpense AMEMaximumBenefitLimitation:$__________per
Benefit: Accident
DeductibleperAccident:$250
BenefitPercentage:100%
BenefitPeriod:thefirst365daysafterthedatetheAccident
occurs.
InitialTreatmentPeriod:Initialtreatmentorevaluationof
theAccidentalInjurymustbereceivedwithinthefirst7
daysafterthedatetheAccidentoccurs.
TreatmentSpecificLimitations:
Benefitsforgroundambulanceservicesarelimitedto
$300perAccident.
PhysicalMedicineislimitedtoamaximumbenefitof
$25pervisitdayupto$250perAccident.
DurableMedicalEquipmentandPersonalMedical
Equipmentbenefitsarelimitedtoamaximumbenefitof
$100perAccident.
AccidentalDeathandDismembermentBenefits
AccidentalDeathand AllAccidentalDismembermentBenefitsandtheAccidentalDeath
DismembermentMaximum Benefitscombinedarelimitedto$__________perAccident.
BenefitLimitation:
AccidentalDismemberment InitialTreatmentPeriod:Initialtreatmentorevaluationofthe
Benefit: AccidentalDismembermentmustbereceivedwithinthefirst7days
afterthedatetheAccidentoccurs.
Accidental BenefitAmount
Dismemberment
Lossofonehand. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit
Limitation
Lossofonefoot. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit
Limitation
LossofSightofone 25%oftheAccidentalDeathand
eye. DismembermentMaximumBenefit
Limitation
8227.OOCR.LA Page2OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
LossofHearinginone 25%oftheAccidentalDeathand
ear. DismembermentMaximumBenefit
Limitation
LossofSpeech. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit
Limitation
AccidentalDeathBenefit: CoveredPerson BenefitAmount
Policyholder: $__________
CoveredDependentSpouse/Domestic $__________
Partner:
CoveredDependentChild(ren): $__________
CANCERANDHEARTSTROKERIDER
LimitedSpecifiedDiseaseRiderBenefits
BenefitswillbepaidforSpecifiedDiseasesfirsteverDiagnosedwhilethisRiderisinforce.
Paymentofbenefitsissubjecttoalltheterms,limitsandconditionsintheRider.
WewillpaytheScheduledBenefitshownbelowonlyfortheSpecifiedDiseaseslistedbelow.
AllbenefitsandlimitationsarestatedperCoveredPerson.
CancerBenefit BenefitWaitingPeriodforCancer:Canceriseligibleforbenefits
underthisplanonlyifDiagnosedafterthefirst90calendardays
fromtheEffectiveDate.
AllCancerBenefitsarelimitedtoaMaximumLifetimeBenefitof
$__________.
HeartStrokeBenefit BenefitWaitingPeriodforHeartStroke:HeartStrokeiseligible
forbenefitsunderthisplanonlyifDiagnosedafterthefirst30
calendardaysfromtheEffectiveDate.
AllHeart/StrokeBenefitsarelimitedtoaMaximumLifetime
Benefitof$__________.
SpecifiedDisease ScheduledBenefit
Cancer $__________
CoronaryArteryDiseaseorCardiacArrhythmiaresultinginHeartAttack $__________
CoronaryArteryDiseaseorCardiacArrhythmiaresultinginCoronary 25%ofHeartAttack
ArteryBypass Benefit
CoronaryArteryDiseaseresultinginCoronaryAngioplasty 10%ofHeartAttack
Benefit
CerebrovascularDiseaseresultinginStroke $__________
8227.OOCR.LA Page3OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
SICKNESSINDEMNITYRIDER
HospitalConfinementFixedIndemnityBenefit
WewillpaytheScheduledBenefitshownbelowonlyforHospitalizationsduetoSicknessasdefined
intheRider.Paymentofbenefitsissubjecttoallterms,limitsandconditionsintheRider.
BenefitsstatedbelowareperCoveredPersonexceptfortheMaximumHospitalizationBenefit.
InpatientHospitalizationfor BenefitWaitingPeriodforInpatientHospitalizationfor
SicknessBenefit: Sickness:HospitalizationiseligibleforbenefitsunderthisRider
onlyifitoccursafterthefirst30calendardaysfromthe
EffectiveDate.
InpatientHospitalizationScheduledBenefit:$__________per
ConfinementPeriod
MaximumCalendarYearBenefitPerCoveredPerson:
$__________
MaximumCalendarYearBenefitCombined:2Inpatient
HospitalizationforSicknessBenefits
SECTION2:BENEFITDESCRIPTIONS:
AccidentMedicalExpenseBenefitDescription:
AfterYouhavesatisfiedpaymentoftheDeductibleamount,WewillpaytheBenefitPercentage
shownaboveforchargesforCoveredTreatmentIncurredbyaCoveredPersonforthetreatmentof
AccidentalInjuriesifallofthefollowingaremet:
1. ThechargesforCoveredTreatmentsofanAccidentalInjuryareIncurredwithintheBenefit
PeriodshownontheBenefitSchedule.
2. ThefirsttreatmentormedicalevaluationfortheAccidentalInjuryisIncurredwithinthe
InitialTreatmentPeriodshownabove;ifnotreatmentfortheAccidentalInjuryisrendered
withintheInitialTreatmentPeriod,anysubsequentchargesfortreatmentoftheAccidental
InjuryarenoteligibleforbenefitsunderthisPolicy.
3. YoudonotreceivebenefitsequaltosuchchargesunderanyOtherBenefits.
4. Thetotalchargesforthemedicaleventortreatmentrenderedarenotinexcessofthe
MaximumAllowableAmountshownabove.Anyportionofsuchchargesinexcessofthe
MaximumAllowableAmountwillnotbeconsideredwhendeterminingbenefitsunderthis
Policy.
AccidentalDismembermentBenefitDescription:
WewillpayanAccidentalDismembermentBenefitifallofthefollowingrequirementsaremet:
1. TheAccidentandAccidentalDismembermentoccurwhiletheAccidentalDismemberment
Benefitprovisionisinforce.
8227.OOCR.LA Page4OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
2. ThefirsttreatmentormedicalevaluationfortheAccidentalDismembermentorAccidental
InjuryresultinginsuchdismembermentisIncurredwithintheInitialTreatmentPeriod.If
notreatmentormedicalevaluationfortheAccidentalDismemberment,orcausalAccidental
Injury,isrenderedwithintheInitialTreatmentPeriod,noAccidentalDismemberment
BenefitwillbepaidunderthePolicy.
3. TheAccidentalDismembermentoccurswithin90daysofthedatetheAccidentoccurred.
TheAccidentalDismembermentBenefitwillnotbepaidiftheseveredbodypartissubsequently
reattached.TheAccidentalDismembermentBenefitpayableforeachtypeofdismembermentis
shownontheBenefitSchedule.OnlyAccidentalDismembermentsshownontheBenefitSchedule
areeligibleforbenefitsunderthisprovision.AccidentalDismembermentBenefitsaresubjecttothe
AccidentalDeathandDismembermentMaximumBenefitLimitation.
AccidentalDeathBenefitDescription:
IftheCoveredPersondiesasadirectresultoftheAccident,Wewillpaythecorresponding
AccidentalDeathBenefittotheBeneficiaryifallofthefollowingrequirementsaremet:
1. WereceivelegalproofoftheCoveredPersonsdeath;and
2. TheproofshowsthatdeathresulteddirectlyfrombodilyAccidentalInjurycausedsolelyas
aresultofanAccidentandindependentofdisease,physicalcondition,bodilyinfirmityor
anyothercause;
3. AccidentalDeathoccurredwithinthefirst90daysaftertheAccident,exceptthat,incases
whenattheendofthe90dayperiodaCoveredPersoniscomatoseorisbeingkept
clinicallyalivebyanartificiallifesupportsystem,the90daylimitwillbeextendedto365
days;and
4. AccidentalDeathoccurredpriortothedatetheCoveredPersonattainsage75.
WereservetherighttohaveanautopsyperformedatOurexpensewhereitisnotprohibitedby
lawbeforebenefitsareconsidered.
WewillnotpayanyAccidentalDeathBenefitsfordeathoccurringbetweenthedatethecoverage
lapsesandthedatecoverageisreinstated.
AccidentalDeathBenefitsaresubjecttotheAccidentalDeathandDismembermentMaximum
BenefitLimitationshownontheBenefitSchedule.
CancerandHeartStrokeRider
SpecifiedDiseaseBenefitDescription:
IfthisRiderispurchasedandifaCoveredPersonhasafirsteverDiagnosisofaSpecified
DiseasewhileinsuredunderthisRider,WewillpaythecorrespondingScheduledBenefitshown
intheBenefitSchedule.
8227.OOCR.LA Page5OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
WewillnotpaybenefitsforanySpecifiedDiseaseiftheCoveredPersonhasreceivedthat
DiagnosisatanytimepriortotheCoveredPersonsEffectiveDateofcoverageunderthisRider.
SicknessIndemnityRider
InpatientCoveredHospitalizationforSicknessBenefitDescription:
IfthisRiderispurchasedand,WewillpaytheScheduledBenefitamountperConfinementPeriod
foraCoveredHospitalizationasaresultofSickness.
BenefitsarelimitedtotheMaximumCalendarYearBenefitsshownontheBenefitSchedule.]
SECTION3:DEFINITIONS:
AsusedinthisOutlineofCoverage,capitalizedterms(otherthanheadingsandtitles)aredefined
asfollows.ConsultthePolicyforafulllistofalldefinedtermsusedinthePolicydocuments.
Accident
Anyeventthatmeetsallofthefollowingrequirements:
1. Itcausesharmtothephysicalstructureofthebody.
2. Itisthedirectcauseofaloss,independentofdisease,bodilyinfirmityoranyothercause.
3. Itisdefiniteastoasingletimeandplace.
4. Ithappensinvoluntarily.
AnAccidentdoesnotincludeharmresulting,whetherdirectlyorindirectly,fromsickness,cerebral
vascularaccident(stroke),orexposuretosickness,toxin,aninfectiousagent,orcommunicable
disease.Accidentdoesnotincludeanyoverdoseofcontrolledsubstance,drug,ornarcotic.
Accidentdoesnotincludebug/insectbitesorstings.
AccidentalDeath
DeathcausedbyanAccidentandindependentandexclusiveofallothercauses.Tobeeligiblefor
benefitsunderthePolicy,suchdeathmustoccurwithin90daysaftertheAccidentinitially
occurred,exceptthat,incaseswhenattheendofthe90dayperiodaCoveredPersoniscomatose
orisbeingkeptclinicallyalivebyanartificiallifesupportsystem,the90daylimitwillbeextended
to365days.
AccidentalDismemberment
Completeseveranceofabodypartfromtherestofthebody,includingamputation,asaresult,
whetherdirectorindirect,ofanAccidentandindependentofallothercauses.Partial
dismembermentwherethebodypartisrippedortornbutnotcompletelyseveredisnotconsidered
AccidentalDismembermentforpurposesofthePolicy.Forpurposesofthisplan,uncorrectable
LossofSpeech,LossofHearing,orLossofSight,duetoanAccidentiseligibleforAccidental
DismembermentBenefitsasshownontheBenefitSchedule.
AccidentalDismembermentseligibleforbenefitsunderthisplanandthecorrespondingbenefit
percentageamounttobepaidforeachtypeofAccidentalDismembermentareshownonthe
BenefitSchedule.AnyotherdismembermentsnotlistedontheBenefitSchedulearenoteligiblefor
AccidentalDismembermentBenefitsunderthisPolicy.
8227.OOCR.LA Page6OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
AccidentalInjury
BodilydamageoccurringunexpectedlyandunintentionallyastheresultofanAccident,
independentofallothercauses.
BenefitPercentage
ThepercentageofchargesforCoveredTreatmentsWewillpayforAccidentMedicalExpense
BenefitsaftersatisfactionoftheDeductibleuptotheAMEMaximumBenefitLimitation.
BenefitWaitingPeriod
TheperiodofconsecutivedaysthatmustpassaftertheEffectiveDatebeforeaCoveredPersonis
eligibleforScheduledBenefitsunderthetermsofthisplan.
Cancer
1. Amalignanttumor,includinganinsitu,andhematopoieticmalignancyforwhichanyof
thefollowingisrecommendedbyYourHealthCarePractitioner:
a.Radiation;
b.Chemotherapy;or
c.Immunotherapy;or
d.Completeexcisionofaninternalorganwithoutneedforfurthertreatment
2. Anymetastaticcancerforwhichnotherapyisrecommended.
ForpurposesofthisPolicy,Cancerdoesnotinclude:
1. Noninvasivedermatologiccarcinomas(basalcellcarcinoma(BCC),squamouscell
carcinomas(SCC),melanomainsitu),cervicalcarcinomainsituorotherpremalignant
conditionssuchasmyelodysplasticandmyeloproliferativedisorders,leukoplakia,
hyperplasia;or
2. Anincidentalpathologicaldiagnosisfoundfollowingsurgicalexcisionofanorganunless
additionalchemotherapy,radiationtherapyand/orimmunotherapyisrecommended.
CardiacArrhythmia
Cardiacdysrhythmias,paroxysmalsupraventriculartachycardia,paroxysmalventricular
tachycardia,atrialfibrillationandflutter,andventricularfibrillationandflutter.
CerebrovascularDisease
Subarachnoidhemorrhage,intracerebralhemorrhage,occlusionandstenosisofprecerebral
arteries,andocclusionofcerebralarteries.
ConfinementPeriod
Acontinuousanduninterruptedperiodofatleast24hoursduringwhichaCoveredPersonisadmittedtoa
HospitaltoobtainMedicallyNecessaryInpatienttreatmentofaSicknesswhileundertheregularcareand
attendanceofaHealthCarePractitioner.
CoronaryAngioplasty
8227.OOCR.LA Page7OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
Aninterventionalproceduretowidenorunblocktherightcoronaryartery;leftmainstem;left
anteriordescending;orcircumflexartery.
CoronaryArteryBypass
Aprocedurewhichusesasaphenousveinorinternalmammaryarterygrafttosurgicallybypass
obstructionsinanativecoronaryarteryorarteriestotreatcoronaryarteryatherosclerosis.
CoronaryArteryBypassdoesnotinclude:balloonangioplasty,laserreliefofobstructionorany
otherintraarterialprocedures.
CoronaryArteryDisease
Acutecoronaryocclusion,coronaryatherosclerosis,aneurysmanddissectionoftheheart,and
coronaryatherosclerosisduetolipidrichplaque.
CoveredHospitalization
AHospitalizationforwhichthisplanprovidesaScheduledBenefitandthatmeetsallofthe
followingrequirements:
1. TheHospitalizationmeetstheConfinementPeriod.
2. ItisincurredbyaCoveredPersonwhilecoverageisinforceunderthisplanastheresultof
aSickness.
3. ItdoesnotoccurduringaBenefitWaitingPeriod.
4. ItisMedicallyNecessary.
CoveredPerson
Apersonwhoisenrolledandeligibletoreceivebenefitsunderthisplan,asshownontheBenefit
Schedule.
CoveredTreatment
ThatportionofmedicaltreatmentorevaluationofAccidentalInjuryforwhichaCoveredPerson
doesnotreceiveanyOtherBenefits,andthatmeetsallofthefollowingrequirements:
1. ItisIncurredformedicaltreatment,services,supplies,casts,bloodplasma,oxygen,
anesthesia,durablemedicalequipment,personalmedicalequipment,diagnosticimaging
andtesting,ordentalinjuryprovidedbyoratanappropriatelylicensed:Healthcare
practitioner,hospital,outpatientorsurgicalfacilityincludingafreestandingfacilityor
urgentcareclinic,retailhealthclinic,supplier,andairorgroundambulanceservices.
2. ItisIncurredbyaCoveredPersonwhilecoverageisinforceunderthisplanastheresultof
anAccidentthatisfirstsustainedonoraftertheCoveredPersonsEffectiveDate.
3. ItiseligibleforbenefitslistedintheAccidentBenefitssectionandnotexcludedunderthis
Policy.
Deductible
ThetotaldollaramountofchargesperAccidentthatmustbepaidbytheCoveredPersonbefore
AccidentMedicalExpenseBenefitsarepaidbyUs.IftheCoveredPersonreceivesanyOther
8227.OOCR.LA Page8OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
BenefitsduetoAccidentalInjury,orrelatedsickness,sustainedduetotheAccident,suchamounts
arenotconsideredforpurposesofsatisfactionoftheDeductibleunderthePolicy.TheDeductibleis
shownontheBenefitSchedule.
Diagnosis/Diagnosed
IdentificationofaSpecifiedDiseasemadeduringtheCoveredPersonslifebyaHealthCare
Practitionerthatissupportedbyevaluations,clinicalorlaboratorytests,andobservations
documentedintheCoveredPersonsmedicalrecords.
HeartAttack
Amyocardialinfarctionresultinginthedeathofanareaoftheheartmuscleduetoinsufficient
bloodsupplytothatarea.ThebasisoftheDiagnosismustinclude:
1. serialmeasurementsofcardiacbiomarkersshowingapatternandlevelconsistentwithan
acutemyocardialinfarction;and
2. newelectrocardiographicchangesconsistentwithacutemyocardialinfarction.
ForthepurposesofthisPolicy,HeartAttackdoesnotinclude:
1. Anyotherdiseaseorinjuryinvolvingthecardiovascularsystem;
2. Acardiacarrestthatisnotcausedbymyocardialinfarction.
Hospitalization
AMedicallyNecessaryInpatientstayinaHospitalofatleast24hoursastheresultofaSickness.
InitialTreatmentPeriod
TheperiodimmediatelyfollowingthedateofanAccidentduringwhichaCoveredPersonmust
receivetreatmentorclinicalevaluationfromahealthcarepractitioneroftheAccidentalInjuryor
AccidentalDismembermentforAccidentMedicalExpenseBenefitsandAccidental
DismembermentBenefitstobeconsideredunderthisPolicy.TheInitialTreatmentPeriodduration
isshownontheBenefitSchedule.
MaximumAllowableAmount
ThemaximumamountofabilledchargeWewillconsiderwhendeterminingchargesforCovered
Treatments.AmountsbilledinexcessoftheMaximumAllowableAmountbyoronbehalfofa
healthcarepractitioner,facilityorsupplierarenotpayablebyUs.
Forgoodsandservicesprovidedbyahealthcarepractitioner,facilityorsupplierincluding,butnot
limitedto,professional,inpatientandoutpatientclaims,theMaximumAllowableAmountisthe
lesserof:
1. Billedcharges;or
2. TheamountnegotiatedbetweenUs,oronbehalfofUs,andthehealthcarepractitioner,
facilityorsupplierastotalpaymentfortheservicesorsuppliesprovided;or
3. InaccordancewithOurcurrentmethodologiesfordeterminingthereasonableand
customarychargeforservicesandsuppliesinaspecificregionandbyaparticulartypeof
provider.
8227.OOCR.LA Page9OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
MaximumBenefitLimitation
ThisPolicycontainsvariousMaximumBenefitLimitations,asdescribedbelow.Theapplicable
MaximumBenefitLimitationsareshownontheBenefitSchedule.
1. AccidentalDeathandDismembermentMaximumBenefitLimitation
Themaximumamount,asshownintheBenefitSchedule,thatWewillpayfortheAccidental
DismembermentBenefitsandtheAccidentalDeathBenefitscombinedresultingfromthe
sameAccident.
2. AccidentMedicalExpense(AME)MaximumBenefitLimitation
Themaximumamount,asshownintheBenefitSchedule,thatWewillpayfortheAccident
MedicalExpenseBenefitperAccident.TreatmentSpecificLimitationsmayalsobeapplicable
asshownontheBenefitScheduleforspecifictypesoftreatment,suppliesorcharges.Benefits
withinthesetreatmentcategoriesarestillsubjecttotheoverallAMEMaximumBenefit
Limitation.
3. MaximumBenefitforCancerandHeartStrokeRider
AMaximumBenefitistheamountofbenefits,asshownintheBenefitsSchedule,thatWe
willpayforeachCoveredPersonunderthisplan.ThisplanhasvaryingtypesofMaximum
Benefitlimitations.EachMaximumBenefitlimitationisstatedontheBenefitSchedule
correspondingtotheapplicablebenefitprovision.AparticularMaximumBenefitonly
appliesifitisshownontheBenefitSchedule.
1. MaximumLifetimeBenefitforCancer:ThemaximumamountofbenefitsthatWewill
payforeachCoveredPersonforCanceroverthelifetimeofthatCoveredPerson.
2. MaximumLifetimeBenefitforHeartStroke:ThemaximumamountofbenefitsthatWe
willpaycombinedforallHeartStrokeSpecifiedDiseasesforthatCoveredPerson.]
4. MaximumCalendarYearBenefitforSicknessIndemnityRider
MaximumCalendarYearBenefitistheamountofbenefits,asshownintheBenefits
Schedule,thatWewillpayperCalendarYearunderthisRider.Therearetwotypesof
MaximumCalendarYearBenefits:
1. PerCoveredPerson:ThemaximumamountofInpatientHospitalConfinement
BenefitsthatWewillpayperCalendarYearforeachCoveredPersonunderthisRider.
2. Combined:ThemaximumamountofInpatientHospitalConfinementBenefitsthatwe
willpayperCalendarYearforallCoveredPersonscombined.WhentheMaximum
CalendarYearBenefitCombinedhasbeenpaidbyUs,nofurtherbenefitsarepayable
foranyCoveredPersonfortheremainderoftheCalendarYear.
OtherBenefits
8227.OOCR.LA Page10OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
BenefitsYoureceiveforamedicaleventortreatmentduetoanAccidentunderanyofthe
following:
1. Aselffundedorselfinsuredemployeewelfarebenefitplanthatprovideshealthbenefits
andisestablishedinaccordancewiththeEmployeeRetirementIncomeSecurityActof1974
(ERISA);
2. Individualorgroupdisabilityorhealthinsurancecoverage,includingshorttermlimited
durationhealthcoverageorlimitedmedicalexpenseplans;
3. Individualorgrouphealthplancoverage,includingHMO,capitationarrangement,pre
paid,orservicebasisplans;
4. Workerscompensationprotectionbywhatevernamecalled;
5. Hospitalorotherfixedindemnity,oranyothersupplementalcoverage;
6. Medicalcoverageunderamotorvehicleinsurancecontract;
7. MedicarePartAorPartB(TitleXVIIIoftheSocialSecurityAct);
8. MedicaidpursuanttoTitleXIXoftheSocialSecurityAct,otherthancoverageconsisting
solelyofbenefitsundersection1928;
9. Militarysponsoredhealthcare(Chapter55oftitle10,UnitedStatesCode);
10. AmedicalcareprogramofIndianHealthServiceorofatribalorganization;
11. Astatehealthbenefitriskpool;
12. FederalEmployeeHealthBenefitPlan(FEHBP)(healthplanunderchapter89oftitle5,
UnitedStatesCode);
13. Anypublichealthplan;
14. Achurchplanorbenefitsreceivedfromaserviceorganization;
15. AhealthplanunderthePeaceCorpsAct(22U.S.C.Section2504(e)).
PreExistingConditionforCancerandHeartStrokeRider
ASpecifiedDisease:
1. Forwhichmedicaladvice,consultation,careortreatmentwassought,receivedor
recommendedfromaproviderorPrescriptionDrugswereprescribedduringthe24month
periodimmediatelypriortotheCoveredPersonsEffectiveDate,regardlessofwhetherthe
conditionwasdiagnosed,misdiagnosedornotdiagnosed;or
2. Thatproducedsignsorsymptomsduringthe24monthperiodimmediatelypriortothe
CoveredPersonsEffectiveDate.
Thesignsorsymptomsweresignificantenoughtoestablishmanifestationoronsetbyoneof
thefollowingtests:
a. Thesignsorsymptomsreasonablyshouldhaveallowedorwouldhaveallowedone
learnedinmedicinetodiagnosethecondition;or
b. Thesignsorsymptomsreasonablyshouldhavecausedorwouldhavecausedan
ordinarilyprudentpersontoseekdiagnosisortreatment.
PreExistingConditionforSicknessIndemnityRider
ASicknessandrelatedcomplications:
8227.OOCR.LA Page11OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
1. Forwhichmedicaladvice,consultation,diagnosis,careortreatmentwassought,receivedor
recommendedfromaproviderorPrescriptionDrugswereprescribedduringthe12month
periodimmediatelypriortotheCoveredPersonsEffectiveDate,regardlessofwhetherthe
conditionwasdiagnosed,misdiagnosedornotdiagnosed;or
2. Thatproducedsignsorsymptomsduringthe12monthperiodimmediatelypriortothe
CoveredPersonsEffectiveDate.
Thesignsorsymptomsweresignificantenoughtoestablishmanifestationoronsetbyoneof
thefollowingtests:
a. Thesignsorsymptomsreasonablyshouldhaveallowedorwouldhaveallowedone
learnedinmedicinetodiagnosethecondition;or
b. Thesignsorsymptomsreasonablyshouldhavecausedorwouldhavecausedan
ordinarilyprudentpersontoseekdiagnosisortreatment.
ApregnancythatexistsonthedaybeforetheCoveredPersonsEffectiveDatewillbe
consideredaPreExistingCondition.
ScheduledBenefitforCancerandHeartStrokeRider
ThefixedbenefitamountpayableupontheDiagnosisofaSpecifiedDiseaseunderthetermsof
thisplan.TheScheduledBenefitforaSpecifiedDiseaseisshownontheBenefitSchedule.
ScheduledBenefitforSicknessIndemnityRider
The fixed benefit amount payable upon occurrence of a Covered Event under the terms of this
Rider.TheScheduledBenefitforaCoveredHospitalizationisshownontheBenefitSchedule.
SpecifiedDisease
Any disease identified as a Specified Disease on the Benefit Schedule. Diseases first ever
Diagnosed anytime prior to the Covered Persons Effective Date under the Policy are not
consideredSpecifiedDiseasesforthepurposeofthisPolicy.
Sickness
A disease or illness of a Covered Person. Sickness does not include an illness or disease resulting,
whetherdirectlyorindirectly,fromanAccident.
Stroke
Braintissueinfarctionduetoacutecerebrovascularincident,embolism,thrombosisorhemorrhage.
ThebasisoftheDiagnosismustincludeimagingdocumentationofnewbraintissueinfarctionin
associationwithacuteonsetofsymptomsconsistentwithcentralnervoussystemneurological
damage.
ForthepurposesofthisPolicy,Strokedoesnotinclude:
1. TransientIschemicAttacks(TIAs).
2. TransientGlobalAmnesia(TGA).
3. ExternaltraumacausingAccidentalInjurytothebrain.
4. Braindamageduetoinfection,vasculitis,encephalopathyandinflammatorydisease.
8227.OOCR.LA Page12OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
5. Ischemicdisordersofthevestibularsystem.]
SECTION4:EXCLUSIONSANDLIMITATIONS
NoBenefitforAccidentSustainedPriortoEffectiveDate
Wewillnotpaybenefitsforanycharges,dismembermentordeaththatresultfromorarerelatedto
anAccidentsustainedpriortotheEffectiveDateofthecoverageunderthisPolicy.
Exclusions
ThisPolicydoesnotpayanybenefitsforclaimsresultingfromorrelatedtoSickness,exceptwhen
suchSicknessisthedirectresultofanAccidentalInjuryorAccidentalDismembermentcovered
underthisPolicy.
Wewillnotpaybenefitsforchargesresultingfrom,whetherdirectlyorindirectly,anyofthe
following:
1. Medicalevent,treatment,servicesorsuppliesforwhichbenefitsequaltoorinexcessof
suchchargesarereceivedunderanyOtherBenefits.
2. ChargesinexcessoftheMaximumAllowableAmount.
3. Treatment,servicesorsuppliesthat:
a. ArenotincludedintheCoveredTreatmentdefinition.
b. Areduetocomplicationsofanoncoveredservice.
c. AreIncurredbeforetheCoveredPersonsEffectiveDateoraftertheterminationdate
ofcoverage.
4. DentaltreatmentexceptasotherwisecoveredforaDentalInjury.
5. Tendonitis,tenosynovitis,bursitis,overuse,strains,repetitivemotionsorstress,repetitiveor
cumulativetraumasincluding,butnotlimitedto,carpaltunnelsyndrome,tenniselbow,
andthoracicoutletsyndrome.
6. Herniaorheatexhaustion.
7. Treatmentofmentaloremotionaldisorders,alcoholism,substanceabuseanddrug
addiction,whetherorganicornonorganic,chemicalornonchemical,biologicalor
nonbiologicalinoriginandirrespectiveofcause,basisorinducement,including,butnot
limitedto,drugsandmedicinesforinpatientoroutpatienttreatmentofsuchdisordersor
abuse.
8. CosmeticService;treatmentthatisnotMedicallyNecessary;treatment,servicesand
suppliesforExperimentalorInvestigationalServices.
9. Treatment,services,andsuppliesprovidedfororby:
a. amasseur,masseuseormassagetherapist,arolfer;massagetherapy;
8227.OOCR.LA Page13OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
b. Meditationorrelaxationtherapy;aromatherapy;holistictherapies.
c. Acupuncture,biofeedback,neurotherapy,andelectricalstimulation.
10. Servicesordered,directedorperformedbyaHealthCarePractitionerorsuppliespurchased
fromamedicalsupplyproviderwhoisaCoveredPerson,anImmediateFamilyMember,
employerofaCoveredPersonorapersonwhoordinarilyresideswithaCoveredPerson.
11. AnyamountinexcessoftheMaximumLifetimeBenefitoranyotherMaximumBenefit
Limitationforcoveredbenefits.
12. TreatmentincurredoutsideoftheUnitedStates,itspossessions,orCanada.
13. Allprescriptionandoverthecounterproducts,drugsormedicines.
WewillnotpaybenefitsforAccidentalInjury,AccidentalDismembermentorAccidentalDeath
resultingfromorrelatedto,whetherdirectlyorindirectly,anyofthefollowing:
1. AnAccidentthatoccurredbeforetheCoveredPersonsEffectiveDateorafterthe
terminationdateofcoverage.
2. Participationinthemilitaryserviceofanycountryorinternationalorganization,including
nonmilitaryunitssupportingsuchforces.
3. BenefitsinexcessofanyapplicableMaximumBenefitLimitationandAccidentalDeathand
DismembermentMaximumBenefitLimitation.
4. Waroranyactofwar,whetherdeclaredorundeclared;foreignordomesticactsof
terrorism.
5. Voluntarilytaking,absorbing,orinhalinganynarcotic,exceptwhenadministeredin
accordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.
6. TheCoveredPersonsbeingintoxicatedorundertheinfluenceofanarcotic,exceptwhen
administeredinaccordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.
7. TheCoveredPersonsvoluntaryattempttocommitorparticipationinanassaultor
commissionofafelony,whetherornotcharged,resistingorfleeingfromarrest,orwhicha
contributingcausewastheInsuredsbeingengagedinanillegaloccupation.
8. Anyhazardousactivityincluding,butnotlimitedto:Participating,instructing,
demonstrating,guidingoraccompanyingothersinparachutejumping,hanggliding,bungee
jumping,airorspacetravelinanyvehicleotherthanaregularlyscheduledflightbyan
airline,racinganymotorizedornonmotorizedvehicle,includingapitcrew,rockor
mountainclimbing,mountaineering,spelunkingandcaveexploration,parkour,
intercollegiatesportsandextremesports.Alsoexcludedaretreatmentandservicesrequired
8227.OOCR.LA Page14OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
duetoAccidentalInjuryreceivedwhilepracticing,exercising,undergoingconditioningor
physicalpreparationforanysuchactivity.
9.Anyhazardousoccupationorotheractivityforwhichcompensationisreceivedinanyform,
includingsponsorship,suchas,butnotlimitedto:Operatingataxiordeliveryservice;
participating,instructing,demonstrating,guidingoraccompanyingothersinskiing,horse
riding,rodeoactivities,professionalorsemiprofessionalsports,adultsportingcompetition
atanationalorinternationallevelandextremesports.Alsoexcludedaretreatmentand
servicesrequiredduetoAccidentalInjuryreceivedwhilepracticing,exercising,undergoing
conditioningorphysicalpreparationforanysuchcompensatedactivity.
10. Suicideorattemptedsuicide.
11.Intentionallyselfinflictedinjury.
ExclusionsforCancerandHeartStrokeRider
ThisRiderprovidesbenefitsonlyforSpecifiedDiseasesidentifiedintheBenefitSchedule.
Wewillnotpaybenefitsforclaimsresulting,whetherdirectlyorindirectly,fromSpecified
Diseasesthatarerelatedto,orareresultingfromanyofthefollowing:
1. AnydiseaseiftheCoveredPersonwaspreviouslyDiagnosedanytimepriortohisorher
EffectiveDateunderthisRider.
2. AnydiseasefirstDiagnosedwithintheapplicableBenefitWaitingPeriod,asshowninthe
BenefitSchedule,immediatelyfollowingtheRiderEffectiveDate.
3. AnydiseasefirstDiagnosedwithinthePreExistingConditionsLimitation.
4. ArrhythmiaresultinginHeartAttackthatoccursinassociationwithuseofanynarcotic,
exceptwhenadministeredinaccordancewiththeadviceoftheCoveredPersonsHealth
CarePractitioner.
5. AnyamountinexcessofanyMaximumBenefitforcoveredScheduledBenefits.
6. DiseasesorconditionsthatdonotmeetthedefinitionofaSpecifiedDiseaseinthisRider.
7. Suicideorattemptedsuicide.
8. SelfinflictedSickness.
TheExclusionssectionintheAccidentMedicalExpenseInsurancePolicyisnotapplicabletothis
RidersSpecifiedDiseasebenefits.
8227.OOCR.LA Page15OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
ExclusionsforSicknessIndemnityRider
ThisRiderprovidesbenefitsonlyforHospitalizationsidentifiedintheHospitalConfinementFixed
IndemnityBenefitssection.
Wewillnotpaybenefitsforclaimsresulting,whetherdirectlyorindirectly,fromHospitalizations
orlossesthatarerelatedto,orareresultingfromanyofthefollowing:
1. AnytreatmentorservicesforBehavioralHealthorSubstanceAbuse.
2. Anytreatmentorserviceswhethermedicalorsurgical,forpurposesofcontrollingthe
CoveredPersonsweightorrelatedtoobesityormorbidobesity,whetherornotweight
reductionisMedicallyNecessaryorappropriateorregardlessofpotentialbenefitsforco
morbidconditions;weightreductionorweightcontrolsurgery,treatmentorprograms;any
typeofgastricbypasssurgery;suctionlipectomy.
3. Capsularcontraction,augmentationorreductionmammoplasty,exceptforallstagesand
revisionsofreconstructionofthebreastfollowingaMedicallyNecessarymastectomyfor
treatmentofcancer,includingreconstructionoftheotherbreasttoproduceasymmetrical
appearanceandtreatmentoflymphedemas.
4. OutpatientorInpatientconfinementinanEmergencyRoomorafacilityotherthana
Hospital.
5. OutpatientorInpatientconfinementprimarilyforrehabilitationorCustodialCare.
6. Prophylactictreatment,servicesorsurgeryincluding,butnotlimitedto,prophylactic
mastectomyoranyothertreatment,servicesorsurgeryperformedtopreventadisease
processfrombecomingevidentintheorganortissueatalaterdate.
7. Treatmentorservicesrelatedtothefollowingconditions,regardlessofunderlyingcauses:
sextransformation;genderdysphoricdisorder;genderreassignment;treatmentofsexual
function,dysfunctionorinadequacy;treatmenttoenhance,restoreorimprovesexualenergy,
performanceordesire.
8. Treatmentorservicesrelatedto:infertility;maternity;pregnancy(includingcomplicationsof
pregnancy);routinewellnewborncareatbirthincludingnurserycare;abortion;surrogate
pregnancy;fetalsurgery,treatmentorservices.
9. HospitalizationsorderedordirectedbyaHealthCarePractitionerorproviderwhoisa
CoveredPerson,anImmediateFamilyMember,employerofaCoveredPersonoraperson
whoordinarilyresideswithaCoveredPerson.
8227.OOCR.LA Page16OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
10. HospitalizationthatdoesnotmeetthedefinitionofaCoveredHospitalizationinthisRider
including,butnotlimitedto,HospitalizationthatisnotMedicallyNecessaryorisfor
ExperimentalorInvestigationalServices.
11. Waroranyactofwar,whetherdeclaredorundeclared;foreignordomesticactsofterrorism
thatresultinanationwideepidemic;participationinthemilitaryserviceofanycountryor
internationalorganization,includingnonmilitaryunitssupportingsuchforces.
12. Cosmeticservices,includingbutnotlimitedto,reconstructiveorplasticsurgerythatdoesnot
alleviateafunctionalimpairment.
13. TheCoveredPersonsbeingintoxicatedorundertheinfluenceofanarcoticexceptwhen
administeredinaccordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner;
voluntarilytaking,absorbing,orinhalinganynarcotic,exceptwhenadministeredin
accordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.
14. AnyamountinexcessoftheMaximumCalendarYearBenefitsshownontheBenefit
Schedule.
15. HospitalizationincurredoutsideoftheUnitedStates,itspossessions,itspossessions,or
Canada.
16. Suicideorattemptedsuicide.
17. SelfinflictedSickness.
18. AHospitalizationwhentheConfinementPeriodbeganbeforetheCoveredPersonsEffective
Date,aftertheterminationdateofcoverage,orduringtheBenefitWaitingPeriod.
19. AHospitalizationwhentheConfinementPeriodbeginsduringthePreExistingCondition
Limitation.
20. AHospitalizationresultingfrom,whetherdirectlyorindirectly,anAccident.
TheExclusionssectionintheAccidentMedicalExpenseInsurancePolicyisnotapplicabletothis
RidersInpatientHospitalizationforSicknessbenefits.]
SECTION5:RENEWABILITYPROVISIONS:
WewillrenewthePolicyissuedexceptthatthisPolicywillterminateat12:01a.m.localtimeatthe
Policyholdersstateofresidenceontheearliestofthefollowingdates:
1. thedateWereceivearequestinwritingorbytelephonetoterminatethisplanoronalater
datethatisrequestedbythePolicyholderfortermination.
8227.OOCR.LA Page17OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
2. thedateWereceivearequestinwritingorbytelephonetoterminatecoveragefora
CoveredDependentoronalaterdatethatisrequestedbythePolicyholderfortermination
ofaCoveredDependent.
3. thedatethisplanlapsesfornonpaymentofpremiumpertheGracePeriodprovisioninthe
PremiumProvisionssection.
4. thedatethereisfraudormaterialmisrepresentationmadebyorwiththeknowledgeof
anyCoveredPersonapplyingforthiscoverageorfilingaclaimforbenefits.
5. thedateallpoliciesofthesameplanasthisPolicyarenonrenewedinthestateinwhich
thisPolicywasissuedorthestateinwhichthePolicyholderpresentlyresides.
6. thedateWeterminateornonrenewinsurancecoverageintheindividualmarketinthe
stateinwhichthisPolicywasissuedorthestateinwhichYoupresentlyreside.Wewill
giveYouadvancenotice,asrequiredbystatelaw,oftheterminationofYourcoverage.
7. thedatethePolicyholdermovestoastatewhereWedonotprovideinsurancecoverage
underthesameplanasthisPolicy,Wereservetherighttoterminatethiscoverage.
8. foraCoveredDependent:onthedateaCoveredDependentnolongermeetsthe
Dependentdefinitioninthisplan.
9. thedatethePolicyholderattainsage75years.
IfWeelecttonotrenewthisPolicyforareasonotherthannonpaymentofpremiumornon
renewalofallpolicieswiththesameformnumber,WewillsendYounoticeofthenonrenewal60
daysinadvanceofthedatethisPolicywillterminate.
IfYouatanytimechangeyouroccupationtooneclassifiedbyUsaslesshazardousthanthatstated
inthepolicy,We,uponyourwrittenrequest,andatyouroption,willeithercancelthepolicyupon
itssurrenderandrefundtheunearnedpremiumorwillreducethepremiumrateaccordinglyand
refundtheexcessprorataunearnedpremiumfromthedateofreceiptofproofofsuchchangeof
occupation.
Delayorfailuretoreportterminationofanyinsurancewillnotcontinuetheinsuranceinforce
beyondthedateitwouldhaveterminatedaccordingtothisPolicy.
CoverageundertheRider[s]terminate[s]withthePolicyorthedatetheCoveredPersonattainsage
65,orthedatebenefitsarenolongeravailableundertheCancerandHeartStrokeRider.
SECTION6:INITIALPREMIUMINFORMATION:
PremiumissubjecttochangeasprovidedinthePolicy.
8227.OOCR.LA Page18OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.
InitialPaymentOptionSelected:
________________
InitialPremium: Annual
AccidentMedicalExpensePlan $________ $________
CancerandHeartStrokeRider $________ $________
SicknessIndemnityRider $________ $________
InitialTotalPremium: $________ $________
______________________________ _______________________________
LicensedAgentsSignature Date
8227.OOCR.LA Page19OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.