Benefits for Members of the American Postal Workers Union

Products/Programs

Group Basic Care Hospital Insurance Plan

 
This Voluntary Benefits Plan Basic Care Hospital Insurance Plan pays a specific daily benefit if an insured person is hospitalized due to a covered injury or sickness or has a covered surgery which is required to diagnose or treat a non-job related injury or sickness.

 

PLAN HIGHLIGHTS
Pays up to $250 or $500 per day from the very first day of hospital confinement

Benefits from the first day of covered hospital confinement for injury or sickness in any hospital, up to a 180-day* maximum per confinement. You may collect benefits whenever you are confined to a hospital for at least a 24-hour period under a physician's recommendation for a covered injury or sickness.
*Confinement for treatment of psychiatric, mental, nervous or emotional disorders and alcoholism and drug addiction are limited to 30-days per confinement.

 


Pays scheduled surgical benefits, with a maximum of $2,500 per incident

You will receive a benefit amount according to a fixed surgical value assigned for specific surgeries. Surgeries must be performed by a physician and may be performed on an in-patient or out-patient basis.

Pays $25 per day for in-hospital physician visits

You may receive a benefit for an in-hospital physician visit up to $25 per day, limited to $4,500 per confinement, one visit per day, 180-day maximum.

Pays benefits for anesthesia for surgery as listed

You may receive a benefit up to 20% of the maximum amount per procedure up to $500 in any one period of diagnosis or treatment for a covered injury or sickness.

Definition of Hospital-  Hospital means a licensed institution, which is approved by the Joint Commission of Accreditation of Hospitals. Hospital does not mean an institution, or part of one, which is used mainly for the aged, the chronically ill, convalescents, drug addicts, alcoholics, a rest home, a nursing home, custodial, educational or rehabilitory care.
Pre-Existing Conditions Limitation
Pre-existing conditions are defined as an injury or sickness for which a person incurred charges, received medical treatment, consulted a physician, or took prescribed drugs within 12 months prior to the date his or her insurance took effect. Pre-existing conditions are not covered under this plan until the person has not incurred charges, received medical treatment, consulted a physician, or taken prescription drugs for such conditions, or any complication of it for 12 continuous months or the person stays insured under the plan for 24 continuous months.
Exclusions

Hospitalizations must begin while the covered person is being treated for a non-job related injury or sickness by a physician other than the member, a family member or a person residing in the member’s household.

Benefits are not payable for hospitalizations or charges due to: war or military service; cosmetic surgery (except for non-job related injuries while insured); dental care (except for non-job related injuries while insured and treated within 90 days); pregnancy (except complications of pregnancy are treated as any other illness); intentionally self-inflicted injury, whether sane or insane; or pre-existing conditions as indicated below.

In addition benefits for physician visits are not payable for any day there are no hospital room and board charges; dental work (except for non-job related injury);eye exams or fitting of eyeglasses; hearing aids or exam; x-rays, drugs, dressings, medicines and nursing services; or surgery (unless three months after surgery or by a physician other than the one who performed the surgery).

Benefits are not payable for confinements or service for which the covered person is not charged or not required to pay or if charges were not incurred while insured.
Benefits After Insurance Ends
If a person's insurance ends while he/she is totally disabled, the Basic Care Hospital benefits will be paid for covered charges if: 1. they are incurred to treat the injury or sickness which caused the total disability, 2. they are incurred within 3 months after insurance ends, 3. total disability is continuous from the day insurance ends to the day confinement begins, the procedure is performed, or the visit is made, as appropriate.
Limited Benefits for Hospital Indemnity Benefits
If you have more than one hospital indemnity type plan, your benefits may be limited. This limit will apply if an insured person has multiple Hospital Indemnity type coverages in force providing specified daily benefits with New York Life or any other insurance company. If you are insured for the $500 daily benefit under the Basic Care Plan and have other daily benefit coverage over $250 per day, benefits under the Basic Care Plan will be reduced. Likewise, if you are insured for the $250 benefit and you have other daily benefits coverage of over $125 per day, benefits under the Basic Care Plan will be reduced. The reductions will equal lesser of the amount that would have been paid under the Basic Care Plan, or the excess amount. This limitation does not apply to any type of expense incurred coverages such as Major Medical, HMO, or Basic Hospitalization Insurance. Benefits will be paid for the confinements for treatment of psychiatric, mental, nervous or emotional disorders, up to 30 days for each confinement, and for alcoholism and drug addiction, up to 30 days for each confinement.

Renewability
Coverage for you and your spouse is renewable to age 65, provided premiums are paid when due, you remain an eligible member of the APWU and the group policy remains in effect. Typically unmarried dependent children are eligible until age 26. If the child is retarded or handicapped, then coverage will not end at age 26, rather, it can continue as long as premiums are paid, and the child meets all the rules for dependents, except age limit.

Dependents insurance will end at the earliest of the date your insurance ends under the group policy, the dependent, spouse or child ceases to be a dependent, or the premium is not paid when due for the dependent spouse or child.
Successive Confinements
Successive confinements will be considered one confinement unless they are due to unrelated causes, or separated by at least three months.
Successive Procedures

Successive procedures will be considered to be performed in one period of diagnosis or treatment for an injury or sickness unless they are due to unrelated causes, or separated by at least 3 months.
 You Will Receive a Separate Certificate

Each insured member will receive a Certificate of Insurance evidencing coverage is provided under Group Policy G-29315-3/Face Form GMR.
Pays Benefits Directly To You
Your benefit checks will be paid directly to you. The cash is yours to use as you wish. You do have the option of assigning your benefits.

Effective Date: Coverage for members and eligible dependents will become effective on the first day of the pay period for which the premium is paid following the date your application is received and upon receipt of the first premium, provided a person is not hospitalized on the date his/her insurance will take effect. If he/she is, such insurance will take effect on the day after the person is discharged.
It's Easy To Apply

  1. Simply complete the enrollment form authorizing payroll deductions.   Click here   for enrollment form.
    Please make sure you complete all the information requested. An incomplete enrollment form will be returned, resulting in a delay in processing your enrollment form.
  2. Send no money.
  3. Return your enrollment form to: The Voluntary Benefits Plan, P.O. Box 1471, Waterbury, CT 06721 or fax to 1-203-754-7847
Who May Apply For The Plan
You are eligible if:
  • You are an APWU Member
  • You are under the age of 60
  • Your lawful spouse may also apply for coverage, if spouse is under age 60
  • Dependent children may apply up to age 26.
  • Transitional Employees are eligible
Here's How To Figure Your Cost

  1. Determine which Hospital Daily Benefit you want.
  2. Locate the premium according to your sex and age.
  3. Locate the premium for your spouse if applicable.
  4. Locate the premium for children's coverage if applicable.
  5. Add these rates together. This is your deduction amount per pay period.

Complete and sign the application and return it. It's that easy!

Once you receive your certificate of insurance, if you're not 100% satisfied within the first 30 days, we'll send you a full refund of any premiums paid during that period and your certificate will be considered never issued. You will be under no further obligation.


Rates Per Bi-Weekly Pay Period: $250 Daily Benefit

As of January, 2010



  Male Female
Under 30 $9.34 $24.42
30-39 13.08 33.71
40-49 23.24 38.94
50-59 39.19 47.10
*60-64 53.58 50.16
All Children $15.90


Rates Per Bi-Weekly Pay Period: $500 Daily Benefit

  Male Female
Under 30 $12.70 $33.21
30-39 17.79 45.84
40-49 31.61 52.96
50-59 53.30 64.06
*60-64 72.87 68.21
All Children $21.62


*For renewal only. New York Life reserves the right to change rates and will notify you in writing of any changes. Rates are based on each individual's attained age. The rate will increase as you enter the next age category. Coverage terminates at age 65.
Surgical Schedule

Surgical Conversion Factor: $12.50       

PROCEDURE

Appendectomy                                                          40

Breast, total removal of                                            30

Breast, biopsy of                                                       15

Cystoscopy

Diagnostic office, initial                                            5

Hospital with urethral catheterization                      15

Dilation and curettage                                              15

Detached retina                                                        100

Dislocation of hip, simple, closed reduction          20

Dislocation of shoulder, open reduction                 55

Fenestration                                                              100

Fracture, simple, closed reduction

Ankle                                                                          25

Clavicle                                                                      15

Nose                                                                           5

Hemorrhoidectomy, internal and external   30

Hernia, inguinal, unilateral                                        35

Hysterectomy                                                             60

Kidney, removal of cyst                                            70

Nasal septum, sub mucous resection of                30

Pilonidal cyst or sinus, removal of                           30

Repair of atrial septal defect                                   200

Stomach, total removal of                                        100

Thyroidectomy                                                           70

Tonsillectomy, with or without adenoidectomy

Under age 18                                                            15

Age 18 and over                                                       20

Tracheotomy, total                                                    20

 

New York Life will determine the surgical value for any procedure not shown above.  This value will be consistent with the values shown.
Any Questions?
Call the following toll-free number
1-800-422-4492
• TDD 1-203-754-4410
Please Note
You must notify the Voluntary Benefits Plan of any address change, employment status change, life status change (i.e., marriage, divorce, beneficiary or name change), or benefit changes requested. Notice must be in writing.
New York Disclosure

The insurance described in this brochure meets the minimum standards for limited benefit health insurance as defined by the New York State Insurance Department.  It does NOT provide basic hospital, basic medical, major medical, nursing home and/or home care, or long term care insurance as defined by the New York State Insurance Department.

This is a summary of benefits only and is subject to the terms, conditions, exclusions and limitations of Group Policy #G-29315-5/FACE Form GMR.
Coverage my vary or may not be available in all states.
(Not available in PR, VI, GU & AS)
Administered By
The Voluntary Benefits Plan
P.O. Box 1471
Waterbury, CT 06721

Phone: 1-800-422-4492
Fax: 1-203-754-7847
Underwritten By
New York Life Insurance Company
51 Madison Ave

New York, NY 10010
To find out more about your member benefits today, click here.