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.
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.
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.
You are eligible if:
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.
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.
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.
Successive confinements will be considered one confinement unless they are due to unrelated causes, or separated by at least three months.
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.
Each insured member will receive a Certificate of Insurance evidencing coverage is provided under Group Policy G-29315-3/Face Form GMR.
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. 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.
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.
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.
Surgical Conversion Factor: $12.50
New York Life will determine the surgical value for any procedure not shown above. This value will be consistent with the values shown.
Call the following toll-free number:
You must notify the Voluntary Benefits Plan of any address change, employment and union status change, life status change (i.e., marriage, divorce, beneficiary or name change), or benefit changes requested. Notice must be in writing.
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.
The Voluntary Benefits PlanP.O. Box 12009Cheshire, CT 06410Phone: 1-800-422-4492Fax: 1-203-754-7847
New York Life Insurance Company51 Madison AveNew York, NY 10010
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