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Quote or Apply - Supplemental Health Insurance

Sickness & Accident, Hospital & Medical Insurance

THIS POLICY PROVIDES LIMITED BENEFITS

• Benefits are Paid Directly to You*

• No Deductible or Co-pays

• Pays Benefits in Addition to any Other Insurance

• Issue Ages 18 through 64

• Dependent Child Coverage Available to Age 19 or 25 if a Full Time Student****

• Guaranteed Renewable to age 65

• Use any Doctor, Hospital or Licensed Provider

• Preexisting Conditions Incurred within the 12 Month Period Preceding the Effective Date are Covered after 12 Months**

• Your Rates Cannot Increase Due to Your Advanced Age or Declining Health***

VALUE MED PLAN BENEFIT SCHEDULE PAYS

Doctors Office Visits

Pays up to 10 Doctor Office visits per calendar year for each insured adult and up to 5 per calendar year for all insured children combined. Doctor Office visits are limited to one per week, except in Maryland.

$75 per visit

Outpatient Visits

Pays for X-ray, Lab Tests, Medical Supplies and & Much More. Pays in the Doctor's Office, Lab or any other Outpatient Facility. Outpatient Benefit maximum per calendar year is $200 per insured and $200 for each covered child.

$100 per visit sickness or accident

Ambulance Services

Pays ambulance expense per sickness or accident

$200 per sickness or accident

Hospital Confinement

Select $1000, $500 or $100 per day, beginning on the 1st day of hospital confinement, up to 365 days. (Dependent Children limited to $100 per day)

$1000, $500 or $100

Lump Sum Cancer Benefit

Pays $5000 directly to you on First Diagnosis of Cancer. Benefit for each covered adult. Option for $10,000 also available.
(cancer benefit not applicable in FL, OR, SD & WA)

$5000 or Optional $10,000 Lump Sum

* The benefits may be paid directly to the hospital or other health care facility if an assignment of benefits is made by the policyholder.

** Pre-existing conditions are those medical conditions disclosed or not disclosed on the application which were diagnosed or for which medical advice or treatment was recommended or received from a Doctor within a 12-month period immediately preceding the Effective Date of Your coverage. Any loss due to a pre-existing condition is not covered unless the loss begins more than 12 months* after the Effective Date of coverage. *The pre-existing condition waiting period is 6 months in Idaho, North Dakota and Oregon.

Wyoming Applicants Only - Your Pre-existing Conditions Limitation reads:
The policy will not cover loss resulting from pre-existing conditions during the first year that your policy is in force. A "pre-existing condition" is any sickness or injury diagnosed for which You received medical advice and /or treatment was received from or recommended by a Physician within the 90 day period immediately before the effective date of Your coverage, or the effective date of an increase in coverage, whichever is applicable

*** The insurer has the right to increase premium rates of all like policies in your state.

**** Instead of age 19 the following states have higher limits: Indiana age 24, New Mexico age 25, North Dakota age 22 and Utah age 26.

***** Hospital confinement must be medically necessary because of injury or sickness. Our definition of hospital excludes (a) a convalescent home, convalescent, rest or nursing facility; or, (b) a facility or portion thereof used primarily for the care of the aged, the terminally ill, drug or alcoholic rehabilitation, or primarily affording custodial, long-term nursing, convalescent or educational care.

Please Note this Policy contains a 10-Day Right to Examine Coverage:
You may cancel coverage under this Policy or Certificate within 10 days of receiving it by returning the Policy or Certificate to Us. If it is returned for cancellation, we will refund any premium paid for your coverage. The Policy or Certificate will then be void as of the Effective Date and there will be no coverage. The states of New Hampshire and Oklahoma have a 30-Day Right to Examine Coverage.

 

Underwritten by: Guarantee Trust Life Insurance Company
in All Other States Except NY. Group Policy #GP2005
LA Policy Form G0551-LA, ME Policy Form G0551-ME,
OR Policy Form G0551-OR, SC Policy Form G0551-SC,
MD Policy Form G0551-MD

 

Underwritten by: United National Life Insurance Company of America
in AR, ID, IL,KS, MN, MO, NE, NV, NM, ND, OK, SD, TN, TX.
Group Policy #UP2005, UT Policy Form U0552-UT,
AR Policy Form U0552-AR, OK Policy Form U0552-OK
SD Policy Form U0552-SD(R.3/09), WV Policy Form U0552

 

Guarantee Trust Life Insurance Company is licensed to do business in all states except New York.

 

Benefits Details

A. Daily Hospital Confinement Indemnity Benefit

We will pay the Daily Hospital Benefit Amount for each day when a Covered Person is Confined in a Hospital when such confinement is Medically Necessary because of an Injury or Sickness. Benefits will begin on the first day.

We won't pay more than a total of 365 days for Hospital Confinement during the Covered Person's lifetime. Choose either the $1000, $500 or $100 daily benefit.(Dependent Children limited to $100 per day)

 

B. Doctor's Office Visit Benefit

We will pay $75 as the Doctor's Office Visit Benefit when a Covered Person receives the medical services of a Doctor, limited to one visit to the Doctor's office per Week, except in Maryland.

We won't pay more than a total of 10 visits to the Doctor's office per Calendar Year per Covered adult and 5 per calendar year for all Covered children combined.

 

C. Outpatient Benefit

We will pay the Out-of-Pocket Costs incurred for care and services received in any outpatient facility. Care and services include medical supplies, x-rays or laboratory tests. Please see the Benefit Schedule on this site to view the state specific benefit amounts.

 

D. Ambulance Transportation Benefit

If a Covered Person requires the use of an ambulance for transportation to a Hospital for Medically Necessary care of a Sickness or Injury, We will pay the Ambulance Benefit shown in the Policy Schedule. This Benefit is limited to a single benefit payment for any one Sickness or Injury.

For purposes of this Benefit, "use of an ambulance service" means the physical transportation of the Covered Person in an ambulance or other appropriate vehicle registered to a licensed medical transportation service for which a charge is normally made.

Discount Benefits Are Not Insurance