HOSPITAL INDEMNITY PLAN 1
GCR16-COM TX
Page 1
METROPOLITAN LIFE INSURANCE COMPANY
NEW YORK, NEW YORK
Certificate Rider
Group Policy No.: 0148870
Policyholder:
Phillips 66 Company
Rider Effective Date: The later of April 1, 2023 or the date that applies to the insured’s
Certificate as shown in the insured’s Certificate or the Group
Policyholder’s participant file which has been provided to MetLife.
Your Certificate is changed as follows:
The following notices are added to the Notices section of Your Certificate:
NOTICES
GROUP HOSPITAL INDEMNITY INSURANCE
THERE MAY BE DIFFERENCES IN BENEFITS, ELIGIBILITY REQUIREMENTS, LIMITATIONS OR
EXCLUSIONS THAT APPLY BASED ON STATE REQUIREMENTS FOR THE STATE IN WHICH YOU
RESIDE ON THE INITIAL DATE OF YOUR COVERAGE.
PLEASE READ ANY NOTICE(S) THAT FOLLOW BELOW CAREFULLY. ANY SUCH NOTICE(S)
PROVIDE REQUIRED DISCLOSURES AND INFORMATION ABOUT SIGNIFICANT STATE
REQUIREMENTS.
PLEASE CONTACT US WITH QUESTIONS OR FOR ADDITIONAL INFORMATION.
ARKANSAS NOTICE:
IMPORTANT NOTICE
IF YOU HAVE A QUESTION CONCERNING YOUR COVERAGE OR A
CLAIM, FIRST CONTACT YOUR GROUP EMPLOYER OR GROUP
ACCOUNT ADMINISTRATOR. IF, AFTER DOING SO, YOU STILL HAVE
A CONCERN, YOU MAY CALL METLIFE’S TOLL-FREE TELEPHONE
NUMBER: 1-800-GET-MET8
IF YOU ARE STILL CONCERNED AFTER CONTACTING BOTH YOUR
GROUP EMPLOYER AND METLIFE, YOU SHOULD FEEL FREE TO
CONTACT:
ARKANSAS INSURANCE DEPARTMENT
1 COMMERCE WAY, SUITE 102
LITTLE ROCK, ARKANSAS 72202
(800) 852-5494 or (501) 371-2640
YOU HAVE THE RIGHT TO FILE A COMPLAINT WITH THE
ARKANSAS INSURANCE DEPARTMENT (AID).
YOU MAY CALL AID TO REQUEST A COMPLAINT FORM AT
(800) 852-5494 or (501) 371-2640
GCR16-COM TX
Page 2
COLORADO NOTICES:
THIS IS A LIMITED HEALTH BENEFIT COVERAGE POLICY AND IS NOT A SUBSTITUTE FOR
MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR MINIMUM
ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
In Colorado, the type of insurance provided under this Certificate is referred to as Group Accident
and Sickness Insurance.
COVERAGE FOR COLORADO RESIDENTS INCLUDES THE CONFINEMENT BENEFIT FOR
NEWBORN NURSERY CARE DESCRIBED IN THE OUTLINE OF COVERAGE.
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance
within the Department of Regulatory Agencies.
CONTACT US
If You have questions about Your insurance coverage You may contact MetLife at 1-800-GET-MET8.
MetLife Toll Free Number(s):
For Claim Information 1-800-GET-MET8
For General Information 1-800-GET-MET8
To make a complaint to MetLife, You may Write to:
Metropolitan Life Insurance Company
Attn: Consumer Relations Department
700 Quaker Lane, 2nd Floor
Warwick, Rhode Island 02886
Or call MetLife at 1-800-GET MET8 or 1-800-438-6388.
Appeals: If We deny Your claim, in whole or in part, Our denial letter will provide information on the
process to appeal the claim.
GCR16-COM TX
Page 3
CONNECTICUT NOTICES:
This Certificate does not replace or otherwise effect any statutorily required workers’
compensation insurance required to be provided to You by law.
BENEFITS FOR CONNECTICUT RESIDENTS ARE LIMITED TO THE BENEFITS LISTED IN YOUR
OUTLINE OF COVERAGE.
FLORIDA NOTICE:
IMPORTANT NOTICE
For information about coverage or assistance in resolving complaints
contact Us at 1-800-GET-MET8
GCR16-COM TX
Page 4
IDAHO NOTICES:
30-Day Right to Examine Certificate. Please read this Certificate carefully. If You are not satisfied
for any reason, You may notify Us that You are cancelling Your Certificate within 30 days from the
date of delivery by calling Us at the number set forth in the Certificate. If You notify Us that You
are cancelling within the 30 day period, this Certificate will be void from the beginning. We will
refund any premium or Contribution paid within 30 days after We receive Your notice of
cancellation.
You may contact the Idaho Department of Insurance at:
Idaho Department of Insurance
Consumer Affairs
700 W State Street, 3rd Floor
PO Box 83720
Boise, ID 83720-0043
1-800-721-3272 or 208-334-4250
www.doi.idaho.gov
Notice to Buyer: This is a Hospital Confinement Indemnity Certificate. This certificate provides
limited benefits. Benefits provided are supplemental and are not intended to cover all medical
expenses.
BENEFITS FOR IDAHO RESIDENTS ARE LIMITED TO THE HOSPITAL BENEFITS LISTED IN YOUR
OUTLINE OF COVERAGE.
GCR16-COM TX
Page 5
NEW HAMPSHIRE NOTICES:
THIS IS A LIMITED CERTIFICATE – READ IT
CAREFULLY
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A
SUBSITITUTE FOR MAJOR MEDICAL COVERAGE.
NOTICE TO BUYER: THIS IS A HOSPITAL CONFINEMENT INDEMNITY CERTIFICATE. THIS
CERTIFICATE PROVIDES LIMITED BENEFITS. BENEFITS PROVIDED ARE SUPPLEMENTAL
AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
This Certificate provides limited benefits. Benefits provided are not intended to cover
medical expenses.
Notice to Buyer: This is an ancillary health Certificate. This Certificate provides
limited benefits. Benefits provided are supplemental and are not intended to cover
all medical expenses.
This Certificate may, at any time within 30 days after its receipt by the Certificateholder, be returned by
delivering it or mailing it to Us or the agent through whom it was purchased or by calling Us at the number
set forth in the Certificate. Immediately upon such delivery, mailing or cancellation by phone, the
Certificate will be deemed void from the beginning, and any premium paid on it will be refunded.
This Certificate does not provide comprehensive health insurance coverage. It is not intended to satisfy
the individual mandate of the Affordable Care Act (ACA) or provide the minimum essential coverage
required by the ACA (often referred to as "Major Medical Coverage"). It does not provide coverage for
hospital, medical, surgical, or major medical expenses.
Patients' Bill of Rights
Pursuant to New Hampshire RSA 151:21, the rights and responsibilities of each patient admitted to a
facility, except those admitted by a home health care provider, shall include, as a minimum, the following:
I. The patient shall be treated with consideration, respect, and full recognition of the patient's
dignity and individuality, including privacy in treatment and personal care and including being
informed of the name, licensure status, and staff position of all those with whom the patient
has contact, pursuant to RSA 151:3-b.
II. The patient shall be fully informed of a patient's rights and responsibilities and of all
procedures governing patient conduct and responsibilities. This information must be provided
orally and in writing before or at admission, except for emergency admissions. Receipt of the
information must be acknowledged by the patient in writing. When a patient lacks the
capacity to make informed judgments the signing must be by the person legally responsible
for the patient.
III. The patient shall be fully informed in writing in language that the patient can understand,
before or at the time of admission and as necessary during the patient's stay, of the facility's
basic per diem rate and of those services included and not included in the basic per diem
rate. A statement of services that are not normally covered by Medicare or Medicaid shall
also be included in this disclosure.
IV. The patient shall be fully informed by a health care provider of his or her medical condition,
health care needs, and diagnostic test results, including the manner by which such results will
be provided and the expected time interval between testing and receiving results, unless
medically inadvisable and so documented in the medical record, and shall be given the
GCR16-COM TX
Page 6
opportunity to participate in the planning of his or her total care and medical treatment, to
refuse treatment, and to be involved in experimental research upon the patient's written
consent only. For the purposes of this paragraph "health care provider" means any person,
corporation, facility, or institution either licensed by this state or otherwise lawfully providing
health care services, including, but not limited to, a physician, hospital or other health care
facility, dentist, nurse, optometrist, podiatrist, physical therapist, or psychologist, and any
officer, employee, or agent of such provider acting in the course and scope of employment or
agency related to or supportive of health care services.
V. The patient shall be transferred or discharged after appropriate discharge planning only for
medical reasons, for the patient's welfare or that of other patients, if the facility ceases to
operate, or for nonpayment for the patient's stay, except as prohibited by Title XVIII or XIX of
the Social Security Act. No patient shall be involuntarily discharged from a facility because
the patient becomes eligible for Medicaid as a source of payment.
VI. The patient shall be encouraged and assisted throughout the patient's stay to exercise the
patient's rights as a patient and citizen. The patient may voice grievances and recommend
changes in policies and services to facility staff or outside representatives free from restraint,
interference, coercion, discrimination, or reprisal.
VII. The patient shall be permitted to manage the patient's personal financial affairs. If the patient
authorizes the facility in writing to assist in this management and the facility so consents, the
assistance shall be carried out in accordance with the patient's rights under this subdivision
and in conformance with state law and rules.
VIII. The patient shall be free from emotional, psychological, sexual and physical abuse and from
exploitation, neglect, corporal punishment and involuntary seclusion.
IX. The patient shall be free from chemical and physical restraints except when they are
authorized in writing by a physician for a specific and limited time necessary to protect the
patient or others from injury. In an emergency, restraints may be authorized by the
designated professional staff member in order to protect the patient or others from injury. The
staff member must promptly report such action to the physician and document same in the
medical records.
X. The patient shall be ensured confidential treatment of all information contained in the patient's
personal and clinical record, including that stored in an automatic data bank, and the patient's
written consent shall be required for the release of information to anyone not otherwise
authorized by law to receive it. Medical information contained in the medical records at any
facility licensed under this chapter shall be deemed to be the property of the patient. The
patient shall be entitled to a copy of such records upon request. The charge for the copying of
a patient's medical records shall not exceed $15 for the first 30 pages or $.50 per page,
whichever is greater; provided, that copies of filmed records such as radiograms, x-rays, and
sonograms shall be copied at a reasonable cost.
XI. The patient shall not be required to perform services for the facility. Where appropriate for
therapeutic or diversional purposes and agreed to by the patient, such services may be
included in a plan of care and treatment.
XII. The patient shall be free to communicate with, associate with, and meet privately with
anyone, including family and resident groups, unless to do so would infringe upon the rights
of other patients. The patient may send and receive unopened personal mail. The patient has
the right to have regular access to the unmonitored use of a telephone.
XIII. The patient shall be free to participate in activities of any social, religious, and community
groups, unless to do so would infringe upon the rights of other patients.
XIV. The patient shall be free to retain and use personal clothing and possessions as space
permits, provided it does not infringe on the rights of other patients.
XV. The patient shall be entitled to privacy for visits and, if married, to share a room with his or
her spouse if both are patients in the same facility and where both patients consent, unless it
is medically contraindicated and so documented by a physician. The patient has the right to
reside and receive services in the facility with reasonable accommodation of individual needs
GCR16-COM TX
Page 7
and preferences, including choice of room and roommate, except when the health and safety
of the individual or other patients would be endangered.
XVI. The patient shall not be denied appropriate care on the basis of age, sex, gender identity,
sexual orientation, race, color, marital status, familial status, disability, religion, national
origin, source of income, source of payment, or profession.
XVII. The patient shall be entitled to be treated by the patient's physician of choice, subject to
reasonable rules and regulations of the facility regarding the facility's credentialing process.
XVIII. The patient shall be entitled to have the patient's parents, if a minor, or spouse, or next of kin,
unmarried partner, or a personal representative chosen by the patient, if an adult, visit the
facility, without restriction, if the patient is considered terminally ill by the physician
responsible for the patient's care.
XIX. The patient shall be entitled to receive representatives of approved organizations as provided
in RSA 151:28.
XX. The patient shall not be denied admission to the facility based on Medicaid as a source of
payment when there is an available space in the facility.
XXI. Subject to the terms and conditions of the patient's insurance plan, the patient shall have
access to any provider in his or her insurance plan network and referral to a provider or
facility within such network shall not be unreasonably withheld pursuant to RSA 420-J:8, XIV.
GCR16-COM TX
Page 8
NEW MEXICO NOTICES:
NOTICE TO CONSUMER: This is a limited benefits health plan. The
benefits provided are supplemental to, and not a substitute for,
major medical coverage, even in combination with other limited
benefits plans. To apply for an individual or small-group major
medical plan, please visit the website of the New Mexico Health
Insurance Exchange at www.bewellnm.com or call 1-833-862-3935
(TTY: 711).
Consumer Complaint Notice. If You are a resident of New Mexico, Your coverage will be administered
in accordance with the minimum applicable standards of New Mexico law. If You have concerns
regarding a claim, premium, or other matters relating to this coverage, You may file a complaint with the
New Mexico Office of Superintendent of Insurance (OSI) using the complaint form available on the OSI
website and found at: https://www.osi.state.nm.us/Consumer Assistance/index.aspx.
NORTH CAROLINA NOTICES:
IMPORTANT CANCELLATION INFORMATION: Please read the provision titled "Date Your
Insurance Ends".
UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER,
PRINCIPAL, AGENT, TRUSTEE OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR
THE PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS,
SHALL:
(1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE
INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN,
MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN
COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS
INSURED BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE
TERMS OF THE INSURANCE OR PLAN CONTRACT, AND
(2) WILLFULLY FAIL TO DELIVER AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE
COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE
OF THE PERSON’S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN
NOTICE MUST ALSO CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP
POLICY OF THEIR RIGHTS, IF ANY, TO HEALTH INSURANCE CONVERSION POLICIES
UNDER ARTICLE 53 OF CHAPTER 58 OF THE GENERAL STATUTES AND THEIR RIGHTS
TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF
THE GENERAL STATUTES.
VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT
TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR
EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.
GCR16-COM TX
Page 9
NORTH DAKOTA NOTICE(S):
30 Day Right to Examine Certificate:
Please read the Certificate carefully. If You are not satisfied for any reason, You may notify Us
that You are cancelling Your Certificate within 30 days from the date of delivery by calling Us at
the number set forth in the Certificate. If You notify Us that You are cancelling within the 30 day
period, the Certificate will be void from the beginning. We will refund any premium or
Contribution paid within 30 days after We receive Your notice of cancellation.
OHIO NOTICE:
COVERAGE FOR RESIDENTS OF OHIO INCLUDES THE FOLLOWING BENEFITS DESCRIBED IN
THE OUTLINE OF COVERAGE:
ANCILLARY CONFINEMENT BENEFIT FOR CHILDBIRTH
MATERNITY FOLLOW-UP CARE BENEFIT
OKLAHOMA NOTICE:
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
SOUTH DAKOTA NOTICE(S):
This limited health benefits plan does not provide comprehensive medical
coverage. It is a basic or limited benefits Certificate and is not intended to cover
all medical expenses. This plan is not designed to cover the costs of serious or
chronic illness.
GCR16-COM TX
Page 10
UTAH NOTICE(S):
Notice of Protection Provided by
Utah Life and Health Insurance Guaranty Association
This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the
Association") and the protection it provides for policyholders. This safety net was created under Utah law,
which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that Your life, health, or
annuity insurance company becomes financially unable to meet its obligations and is taken over by its
insurance regulatory agency. If this should happen, the Association will typically arrange to continue
coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other
insurance companies.
The basic protections provided by the Association are:
Life Insurance
o $500,000 in death benefits
o $200,000 in cash surrender or withdrawal values
Health Insurance
o $500,000 in hospital, medical and surgical insurance benefits
o $500,000 in long-term care insurance benefits
o $500,000 in disability income insurance benefits
o $500,000 in other types of health insurance benefits
Annuities
o $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts,
is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage
does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain
investment additions to the account value of a variable life insurance policy or a variable annuity contract.
Coverage is conditioned on residency in this state and there are substantial limitations and exclusions.
For a complete description of coverage, consult Utah Code, Title 3lA, Chapter 28.
Insurance companies and agents are prohibited by Utah law to use the existence of the
Association or its coverage to encourage You to purchase insurance. When selecting an
insurance company, You should not rely on Association coverage. If there is any inconsistency
between Utah law and this notice, Utah law will control.
To learn more about the above protections, as well as protections relating to group contracts or retirement
plans, please visit the Association's website at www.utlifega.org or contact:
Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department
60 East South Temple, Suite 500 3110 State Office Building
Salt Lake City UT 84111 Salt Lake City UT 84114-6901
(801) 320-9955 (801) 538-3800
A written complaint about misuse of this Notice or the improper use of the existence of the Association
may be filed with the Utah Insurance Department at the above address.
GCR16-COM TX
Page 11
VERMONT NOTICE:
THIS POLICY DOES NOT MEET THE MINIMUM COVERAGE REQUIREMENTS OF THE
AFFORDABLE CARE ACT. YOU SHOULD NOT PURCHASE THIS POLICY UNLESS YOU ARE
ALREADY COVERED BY COMPREHENSIVE MAJOR MEDICAL INSURANCE.
WASHINGTON NOTICE(S):
Benefits provided under this Certificate are non-coordinated - this means that benefits are payable
without regard to any other coverage that You may have.
WEST VIRGINIA NOTICE(S):
This is a supplement to health insurance and is not a substitute for major medical
coverage. Lack of major medical coverage (or other minimum essential
coverage) may result in an additional payment with Your taxes.
WISCONSIN NOTICE:
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or
agent, do not hesitate to contact the insurance company or agent to resolve Your problem.
Metropolitan Life Insurance Company
700 Quaker Lane, 2nd Floor
Warwick, Rhode Island 02886
Toll Free Telephone: 1-800-GET-MET8
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which
enforces Wisconsin's insurance laws, and file a complaint. You can file a complaint electronically with the
OFFICE OF THE COMMISSIONER OF INSURANCE at its website at http://oci.wi.gov/ , or by contacting:
Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517
608-266-0103
The Internal Grievance Review provision described below is added to Your coverage.
INTERNAL GRIEVANCE REVIEW
Expedited Grievance means a Grievance where any of the following applies:
the duration of the standard Grievance resolution process will result in serious jeopardy to the
life or health of the Covered Person or the ability of the Covered Person to regain maximum
function;
in the opinion of a Physician with knowledge of the Covered Person’s medical condition, the
Covered Person is subject to severe pain that cannot be adequately managed without the
care or treatment that is the subject of the Grievance; or
a Physician with knowledge of the Covered Person’s medical condition determines that the
Grievance shall be treated as an Expedited Grievance.
GCR16-COM TX
Page 12
Grievance means any dissatisfaction with the claims practices or administration of the insurance
provided under this Certificate that is expressed in Writing to Us by You or on Your behalf.
Grievance Procedure
If a claim for insurance benefits is denied, We will notify You of Your right to file a Grievance. You
can file a Grievance by Writing to MetLife at 700 Quaker Lane, 2nd Floor, Warwick, Rhode Island
02886, when We notify You of Your right to file a Grievance. You must do this within three years
of the date Your claim is denied. Within five business days of Our receipt of Your Grievance, We
will mail to You or Your authorized representative an acknowledgement confirming receipt.
Grievance Panel
Once a Grievance has been filed, a Grievance Panel will promptly investigate the Grievance. The
Grievance Panel will consist of at least one person with authority to take corrective action on the
claim, and may include at least one person, other than You, who is insured by Us. Prior to the
Grievance Panel making a final determination, You or Your authorized representative have the
right to appear in person before the Grievance Panel and to present Written questions. At least
seven calendar days prior to the Grievance Panel meeting, We will send You Written notification
providing information as to the time and place of the meeting. After a decision has been made, a
Written decision signed by one voting member of the Grievance Panel and a description of
position titles of panel members involved in making the decision will be mailed to You.
Grievance Panel Decision Notification
For Grievances that are subject to ERISA, the decision of the Grievance Panel will be mailed to
You within a reasonable period of time, no later than 60 days after the date on which We received
the Grievance. However, if We determine that special circumstances require an extension of time
for processing the Grievance, Written notice of such extension will be mailed to You within 60
days after the date on which We received the Grievance. The notice will explain the special
circumstances requiring the extension, and the date by which We expect the Grievance Panel to
reach a decision regarding the Grievance. In no event shall such an extension end later than 120
days from the date on which We received the Grievance.
For Grievances that are not subject to ERISA, the decision of the Grievance Panel will be mailed
to You no later than 30 calendar days after the date We receive the Grievance. However, if the
Grievance Panel is unable to resolve the Grievance within 30 days of the date We received the
Grievance, the time to resolve the Grievance may be extended by Us for an additional 30
calendar days if We provide Written notice to You or, if applicable, Your authorized
representative, of all of the following:
that the Grievance Panel has not resolved the Grievance;
when resolution of the Grievance may be expected; and
the reason additional time is needed.
Expedited Grievance Resolution
If Your Grievance qualifies as an Expedited Grievance, You can file the Expedited Grievance by
calling a number We will give You when We notify You of Your right to file a Grievance. An
Expedited Grievance will be reviewed by a medical director who works for Us. The medical
director will render a decision with respect to the Expedited Grievance within 72 hours of the date
You call Us to file the Expedited Grievance. You must file an Expedited Grievance within three
years of the date Your claim is denied.
This Certificate Rider is to be attached to and made a part of the Certificate.
GCERT16-HI-fp TX
Page 1
METROPOLITAN LIFE INSURANCE COMPANY
NEW YORK, NEW YORK
CERTIFICATE OF HOSPITAL INDEMNITY INSURANCE
Metropolitan Life Insurance Company (“MetLife”), a stock company, certifies that You and Your Dependents are insured
for the benefits described in this Certificate, subject to the provisions of this Certificate. References to coverage for
Your Dependents throughout this Certificate only apply if insurance is in effect for Your Dependents. Please refer to the
Covered Persons Specifications page and Eligibility Provisions: Dependent Insurance section for details.
This Certificate is issued to You under the Group Policy. This Certificate includes the terms and provisions of the
Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. The Group Policy is a
contract between MetLife and the Group Policyholder. It may be changed or ended without Your consent or notice to
You.
Group Policyholder: Phillips 66 Company
Group Policy Number: 0148870
MetLife Toll Free Number: 1-800-GETMET8
Important Notice: The insurance evidenced by this Certificate provides limited benefits.
The benefit amounts shown on the Schedule are not based on any medical expenses that
are incurred. You should have medical coverage in force when You enroll for this
insurance.
This is a supplement to health insurance and is not a substitute for major medical
coverage. Lack of major medical coverage (or other minimum essential coverage) may
result in an additional payment with Your taxes.
30-Day Right to Examine Certificate. Please read this Certificate carefully. If You are not
satisfied for any reason, You may notify Us that You are cancelling Your Certificate
within 30 days from the date of delivery by calling us at
1-800-GETMET8. If You notify Us
that You are cancelling within the 30 day period, this Certificate will be void from the
beginning. We will refund any premium or Contribution paid within 30 days after We
receive Your notice of cancellation.
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’
COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER
YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.
Florida Residents: The benefits of the policy providing Your coverage are governed primarily by
the laws of a state other than Florida.
Maryland Residents: The Group Policy providing coverage under this Certificate was issued in a
jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law.
WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE.
PLEASE READ THE(SE) NOTICE(S) CAREFULLY.
GCERT-TX-NOTICE 2020
Page 2
Have a complaint or need help?
If You have a problem with a claim or Your premium, call Your insurance company or HMO first. If You can't work
out the issue, the Texas Department of Insurance may be able to help.
Even if You file a complaint with the Texas Department of Insurance, You should also file a complaint or appeal
through Your insurance company or HMO. If You don't, You may lose Your right to appeal.
Metropolitan Life Insurance Company
To get information or file a complaint with Your insurance company or HMO:
Call: Corporate Consumer Relations Department at 1-800-438-6388
Toll-free: 1-800-438-6388
Email: Johnstown_Complaint_Referrals@metlife.com
Mail: Metropolitan Life Insurance Company
700 Quaker Lane, 2nd Floor
Warwick, Rhode Island 02886
The Texas Department of Insurance
To get help with an insurance question or file a complaint with the state:
Call with a question: 1-800-252-3439
File a complaint: www.tdi.texas.gov
Email: ConsumerPr[email protected]ov
Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091
¿Tiene una queja o necesita ayuda?
Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o
HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department
of Insurance, por su nombre en inglés) pueda ayudar.
Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a
través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su
derecho para apelar.
Metropolitan Life Insurance Company
Para obtener información o para presentar una queja ante su compañía de seguros o HMO:
Llame a: Departamento de Relaciones Corporativas del Consumidor al 1-800-438-6388
Teléfono gratuito: 1-800-438-6388
Correo electrónico: Johnstown_Complaint_Referrals@metlife.com
GCERT-TX-NOTICE 2020
Page 3
Dirección postal: Metropolitan Life Insurance Company
700 Quaker Lane, 2nd Floor
Warwick, Rhode Island 02886
El Departamento de Seguros de Texas
Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:
Llame con sus preguntas al: 1-800-252-3439
Presente una queja en: www.tdi.texas.gov
Correo electrónico: Consum[email protected].gov
Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091
GCERT16-HI-notice
Page 4
NOTICE FOR RESIDENTS OF FLORIDA
If You were a resident of Florida on Your Certificate effective date, this notice applies to You.
The following provision is added to the When Insurance Ends section of this Certificate if that section does not
include an Extension of Benefits provision. If the When Insurance Ends section includes an Extension of Benefits
provision, We will only pay benefits under one provision, which will be the one that pays the most.
EXTENSION OF BENEFITS
If a Covered Person is Confined on the date Your insurance ends, and You do not continue insurance under the At
Your Option: Continuation with Premium Payment provision, We will pay certain benefits for such Covered Person
if the Confinement continues after Your insurance ends, in accordance with, and subject to all of the following:
No benefits will be available under this Extension of Benefits provision if Your insurance ends due to non-
payment of premium.
The Confinement Benefit will be payable if requirements for payment of that benefit are met while the Covered
Person is Confined. No other benefits will be payable.
Benefits payable under this Extension of Benefits provision will be paid in accordance with and subject to the
terms and conditions of this Certificate, except as set forth in this provision.
Benefits under this Extension of Benefits provision will end on the earlier of:
the date the Covered Person is no longer Confined; or
the end of the number of days that Confinement Benefits are payable for the Confinement.
If the Covered Person is again Confined at any time after discharge, no further benefits will be payable.
GCERT16-HI-notice
Page 5
NOTICE FOR RESIDENTS OF MAINE
If You were a resident of Maine on Your Certificate effective date, this notice applies to You.
You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a
default on Your part, such as non-payment of a Contribution that is due. You may make this designation by
completing a "Third Party Notice Request Form" and sending it to MetLife. Once You have made a designation,
You may cancel or change it by filling out a new Third Party Notice Request Form and sending it to MetLife. The
designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number
shown on the face page of this Certificate to obtain a Third Party Notice Request Form.
Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on
Your behalf, or any covered Dependent may request reinstatement of the Certificate on the basis that You suffered
from cognitive impairment or functional incapacity at the time of cancellation.
GCERT16-HI-toc
Page 6
TABLE OF CONTENTS
Section Page
NOTICE FOR RESIDENTS OF FLORIDA ............................................................................................................. 4
NOTICE FOR RESIDENTS OF MAINE ................................................................................................................. 5
COVERED PERSON SPECIFICATIONS ............................................................................................................... 7
SCHEDULE OF INSURANCE ................................................................................................................................ 8
DEFINITIONS ......................................................................................................................................................... 9
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU......................................................................................... 15
Eligible Class..................................................................................................................................................... 15
Date You Are Eligible For Insurance ................................................................................................................ 15
Enrollment Process ........................................................................................................................................... 15
Date Your Insurance Takes Effect .................................................................................................................... 15
Benefit Changes ............................................................................................................................................... 15
ELIGIBILITY PROVISIONS: DEPENDENT INSURANCE ................................................................................... 16
Eligible Class For Dependent Insurance .......................................................................................................... 16
Date You Are Eligible For Dependent Insurance .............................................................................................. 16
Enrollment Process ........................................................................................................................................... 16
Date Dependent Insurance Takes Effect .......................................................................................................... 16
Benefit changes ................................................................................................................................................ 17
SPECIAL RULES FOR COVERED PERSONS PREVIOUSLY INSURED UNDER ANOTHER INSURANCE
POLICY ISSUED TO THE GROUP POLICYHOLDER ........................................................................................ 18
HOSPITAL BENEFITS ......................................................................................................................................... 20
Hospital Admission Benefits ............................................................................................................................. 20
Hospital Confinement Benefits.......................................................................................................................... 21
Inpatient Rehabilitation Benefit ......................................................................................................................... 21
EXCLUSIONS ....................................................................................................................................................... 22
WHEN INSURANCE ENDS .................................................................................................................................. 24
Date Your Insurance Ends ................................................................................................................................ 24
Date Dependent Insurance Ends ...................................................................................................................... 24
Change in Class ................................................................................................................................................ 25
CONTINUATION OF INSURANCE ...................................................................................................................... 26
At Your Option: Continuation With Premium Payment ..................................................................................... 26
For Mentally Or Physically Handicapped Children ........................................................................................... 27
For Family And Medical Leave ......................................................................................................................... 27
CLAIMS ................................................................................................................................................................ 28
Notice of Claim .................................................................................................................................................. 28
Claim Form........................................................................................................................................................ 28
Proof of Loss ..................................................................................................................................................... 28
Payment Of Benefits ......................................................................................................................................... 28
Your Beneficiary ................................................................................................................................................ 28
Authorizations ................................................................................................................................................... 29
Examinations..................................................................................................................................................... 29
Autopsy ............................................................................................................................................................. 29
Time Limit on Legal Actions .............................................................................................................................. 29
Refund To Us For Overpayment of Benefits ..................................................................................................... 29
GENERAL PROVISIONS ..................................................................................................................................... 30
Entire Contract .................................................................................................................................................. 30
Incontestability: Statements Made By You ....................................................................................................... 30
Misstatements ................................................................................................................................................... 30
Assignment ....................................................................................................................................................... 30
Conformity with Law .......................................................................................................................................... 30
Standard of Time .............................................................................................................................................. 30
GCERT16-HI-cps
Page 7
COVERED PERSON SPECIFICATIONS
Certificate Effective Date: The later of April 1, 2023 or the date that applies to the
insured’s Certificate as shown in the insured’s Certificate
or the Group Policyholder’s participant file which has been
provided to MetLife
Group Policyholder: Phillips 66 Company
Group Policy Number: 0148870
MetLife Contact Information: 1-800-GETMET8
Your Name: See Insured’s Certificate or the Group Policyholder’s
participant file which has been provided to MetLife
Your Certificate Number: See Insured’s Certificate or the Group Policyholder’s
participant file which has been provided to MetLife
Coverage for Your Dependents See Insured’s Certificate or the Group Policyholder’s
participant file which has been provided to MetLife
This Covered Person Specifications page is part of Your Certificate. Please keep it with Your Certificate.
GCERT16-HI-sched
Page 8
SCHEDULE OF INSURANCE
IMPORTANT NOTE: Payment of the benefits listed in this Schedule is subject to all of the conditions,
maximums, limitations, exclusions and Proof requirements contained in the provisions of this Certificate.
PLEASE READ THE ENTIRE CERTIFICATE CAREFULLY.
The benefits listed only apply to Dependents if insurance is in effect for Your Dependents under this Certificate.
Please refer to the Covered Person Specifications page and the Eligibility Provisions: Dependent Insurance section
of this Certificate for details.
HOSPITAL BENEFITS Benefit / Limit
Admission Benefit $1,000 for the day of admission
We will pay the Admission Benefit no more than:
one time per Confinement; and 4 time per
Covered Person, per calendar year
ICU Supplemental Admission Benefit $1,000 for the day of admission
Confinement Benefit
$200 per day
We will pay the Confinement Benefit
for no more than:
31 days per Covered Person, per calendar year
ICU Supplemental Confinement Benefit
$200 per day
We will pay the ICU Supplemental Confinement
Benefit for no more than:
31 days per Covered Person, per calendar year
Inpatient Rehabilitation Benefit $200 per day
We will pay the Inpatient Rehabilitation
Benefit for no more than:
15 days per Covered Person, per calendar year
GCERT16-HI-def
Page 9
DEFINITIONS
As used in this Certificate, the terms listed below will have the meanings set forth below. Other terms may be
defined where they are used. When defined terms are used in this Certificate, they will appear with initial
capitalization. The plural use of a term defined in the singular will share the same meaning.
Accident means an act or event which:
is unforeseen, unexpected and unanticipated;
is definite as to time and place;
is not a Sickness; and
occurs while insurance is in effect under this Certificate.
The term Accident includes unavoidable exposure to the elements if such exposure was a direct result of an
Accident.
Accidental means happening by Accident.
Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job
on a Full-Time or a Part-Time basis. This must be done at:
the Group Policyholder's place of business;
an alternate place approved by the Group Policyholder; or
a place to which the Group Policyholder's business requires You to travel.
You will be deemed to be Actively at Work during weekends or Group Policyholder approved vacations, holidays or
temporary business closures if You were Actively at Work on the last scheduled work day preceding such time off.
Certificate means this Certificate including any riders attached to it.
Complications of Pregnancy means diseases or conditions, the diagnoses of which are distinct from pregnancy
and not associated with normal pregnancy or Routine Childbirth, but are adversely affected or caused by
pregnancy, such as: acute nephritis; nephrosis; cardiac decompensation; non-elective or emergency Caesarean
section; ectopic pregnancy which is terminated; a spontaneous termination of pregnancy when a viable birth is not
possible; puerperal infection; eclampsia; hyperemesis gravidarum and pre-eclampsia requiring Confinement;
toxemia; missed abortion; or disease of the vascular, hemopoietic, nervous or endocrine systems.
The term Complications of Pregnancy does not include: false labor; occasional spotting; doctor prescribed rest
during the period of pregnancy; morning sickness; multiple gestation pregnancy; elective abortion; or conditions of
comparable severity associated with management of a difficult pregnancy.
Confined or Confinement means the assignment to a bed as a resident inpatient in a Hospital (including an
Intensive Care Unit of a Hospital) on the advice of a Physician or confinement in an observation area within a
Hospital for a period of no less than 20 continuous hours on the advice of a Physician.
Contribution means the amount You must pay towards the total premium charged by Us for insurance under this
Certificate.
Covered Person means You and, if insured under the Group Policy for the insurance described in this Certificate,
Your Dependents.
Dependent means Your Spouse, and/or Dependent Child. No person can be insured for Hospital Indemnity
Insurance under the Group Policy as both an employee and a Dependent.
GCERT16-HI-def
Page 10
DEFINITIONS (Continued)
Dependent Child
means the following:
Your biological child, while such child is younger than the Dependent Child Age Limit;
Your adopted child, while such child is younger than the Dependent Child Age Limit;
Your stepchild, including a child of Your Domestic Partner, while such child is younger than the Dependent
Child Age Limit;
Your grandchild, while such child is younger than the Dependent Child Age Limit and who was able to be
claimed by You as a dependent for Federal Income Tax purposes at the time You enrolled such grandchild; or
a child for whom You must provide medical support under an order: issued under Texas Statutes, Chapter 154,
Family Code; or enforceable by a court in the State of Texas.
The term Dependent Child does not mean an unborn or stillborn child.
A person cannot be insured for Hospital Indemnity Insurance as a Dependent Child of more than one employee
under the Group Policy.
Dependent Child Age Limit means:
the end of the calendar month in which the Dependent Child reaches age 26.
Dependent Insurance means insurance under this Certificate for Your Dependents.
Domestic Partner means each of two people, one of whom is You, who:
1. have registered as each other’s domestic partner or civil union partner with a government agency where such
registration is available (registration of civil union partners is not currently available in Texas); or
2. are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable
interest in the life of the other. Each person must be:
18 years of age or older;
unmarried;
the sole domestic partner of the other;
sharing a Primary Residence with the other; and
not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside.
A Domestic Partner declaration attesting to the existence of an insurable interest in one another’s lives must be
completed and Signed by You.
GCERT16-HI-def
Page 11
DEFINITIONS (Continued)
Emergency Room means an area within a Hospital that is dedicated to the provision of emergency care. This area
must:
be staffed and equipped to handle trauma;
be supervised and provide treatment by Physicians; and
provide care seven days per week, 24 hours per day.
The term Emergency Room includes short stay observation units or clinical decision units within a Hospital that
assess, within a period of less than 20 continuous hours, whether to discharge or admit patients.
Full-Time means Active Work on the Group Policyholder’s regular work schedule for the class of employees to
which You belong. The work schedule must be at least 40 hours per week.
Group Policy means the policy of insurance issued by Us to the Group Policyholder under which this Certificate is
issued.
Group Policyholder means Phillips 66 Company.
Hospice Facility means a facility, unit of a facility, public or private agency, or unit of a public or private agency
that:
is separate from a Hospital or is a separately designated unit within a Hospital; and
meets federal certification requirements as a hospice, or is comparably licensed under the laws where it is
located, to provide care or management of persons who are diagnosed with a Terminal Illness.
Hospital means a short-term, acute care, general facility which:
is primarily engaged in providing, by or under the continuous supervision of Physicians, to inpatients, diagnostic
and therapeutic services for diagnosis, treatment and care of injured or sick persons;
has organized departments of medicine;
has facilities for major Surgery either on its premises or through contractual arrangement with another Hospital;
has a requirement that every patient must be under the care of a Physician or dentist;
provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);
is duly licensed by the agency responsible for licensing such Hospitals; and
is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the
aged, a place for drug addicts or alcoholics, or a place for convalescent, custodial, educational or rehabilitative
care.
The term Hospital does not include a separate unit of a Hospital that is licensed as a hospice facility, nursing home,
skilled nursing facility, assisted living facility, rehabilitation facility or an outpatient Surgery facility.
Injury means any bodily harm that results directly from an Accident.
GCERT16-HI-def
Page 12
DEFINITIONS (Continued)
Intensive Care Unit or ICU means a place which:
is a specifically dedicated area of a Hospital that is restricted to patients who are critically ill or injured and who
require intensive, comprehensive monitoring and care;
is separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for
patient Confinement;
is permanently equipped with special lifesaving equipment for the care of the critically ill or injured;
is under close observation by a specially trained nursing staff assigned exclusively to the intensive care unit on
a 24 hour basis; and
has a Physician assigned to the intensive care unit on a full-time basis.
The term Intensive Care Unit includes Hospital units with the following names: intensive care unit; coronary care
unit; neonatal intensive care unit; pulmonary care unit; burn unit; or transplant unit.
Medical Restriction means a person is:
restricted to the person’s home under a Physician’s care;
receiving or applying to receive disability benefits from any source;
an inpatient in a Hospital;
receiving care in a hospice facility, an intermediate care facility or a long-term care facility; or
receiving chemotherapy, radiation therapy or dialysis.
Nurse means a registered professional nurse (R.N.), licensed practical nurse (L.P.N.) or licensed vocational nurse
(L.V.N.) who is licensed under the laws where the services are performed.
The term Nurse does not include:
You;
Your Spouse or anyone to whom You are related by blood or marriage;
anyone with whom You are residing;
Your adopted or stepchild;
anyone with whom You share a business interest; or
Your employee.
Part-Time means Active Work on the Group Policyholder’s regular work schedule for the class of employees to
which You belong. The work schedule must be at least 20 hours per week.
GCERT16-HI-def
Page 13
DEFINITIONS (Continued)
Physician means:
a person licensed to practice medicine and prescribe and administer drugs or to perform Surgery in the
jurisdiction where such services are performed; or
a medical practitioner who is licensed to provide a service for which a benefit is payable under this Certificate,
according to the laws and regulations of the jurisdiction where such service is performed, and who is acting
within the scope of such license.
The term Physician (for other than a dentist) does not include:
You;
Your Spouse or anyone to whom You are related by blood or marriage;
anyone with whom You are residing;
Your adopted or stepchild;
anyone with whom You share a business interest; or
Your employee.
Primary Residence means the dwelling where a person lives for the majority of the time, whether the person owns
or rents the dwelling.
Proof means Written evidence satisfactory to Us that a claimant has satisfied the conditions and requirements for
any benefit described in this Certificate. When a claim is made for any benefit described in this Certificate, Proof
must establish:
the nature and extent of the loss or condition;
Our obligation to pay the claim; and
the claimant’s right to receive payment.
Except as provided in the Examinations and Autopsy provisions of this Certificate, Proof must be provided at the
claimant’s expense.
Rehabilitation Facility means a facility that:
provides rehabilitation care services on an inpatient basis;
is separate from a Hospital or is a separately designated unit within a Hospital; and
maintains all required licenses and certifications.
Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to
enable patients disabled by an Injury or Sickness to achieve the highest possible functional ability. Services are
provided by or under the supervision of an organized staff of Physicians.
The term Rehabilitation Facility does not include:
a nursing home;
an extended care facility, unless the Covered Person is receiving rehabilitation care services on an inpatient
basis at the extended care facility;
a Skilled Nursing Facility, unless the Covered Person is receiving rehabilitation care services on an inpatient
basis at the facility;
a rest home or home for the aged;
a Hospice Facility;
an assisted living facility.
Routine Childbirth means the vaginal delivery of a child or children or the delivery of a child or children by elective
Cesarean section.
Routine Pregnancy means a normal pregnancy that does not have Complications of Pregnancy.
GCERT16-HI-def
Page 14
DEFINITIONS (Continued)
Schedule means the Schedule of Benefits that appears in this Certificate, and the Covered Person Specifications
page.
Sickness means:
a physical illness, physical infirmity or physical disease;
Complications of Pregnancy; or
Routine Childbirth.
The term Sickness does not include:
Routine Pregnancy; or
routine nursery care or well-baby care for a newborn child.
Signed means any method executed or adopted by a person with the present intention to authenticate a record.
The signature may be transmitted by paper or electronic media, provided it is consistent with applicable law.
Skilled Nursing Facility means a facility that provides nursing care that meets all of the following requirements:
if licensing or certification is required, maintains all appropriate licensing or certification under the laws where it
is located as a skilled or intermediate nursing facility;
has 24 hour a day care performed by an awake, and trained or certified staff supervised by a Nurse;
is separate from a Hospital or is a separately designated unit within a Hospital;
keeps a Written record of services performed for each client;
has established procedures to obtain emergency medical care; and
services are not limited to provision of food, shelter, and other residential services such as laundry.
The term Skilled Nursing Facility does not include a Hospice Facility.
Spouse means Your lawful spouse or Your Domestic Partner.
Surgery means a procedure performed by a Physician involving an incision of the Covered Person’s skin or tissue
that, in and of itself, is intended to be curative, palliative or exploratory.
United States means the United States of America, its territories and its possessions.
We, Us and Our mean Metropolitan Life Insurance Company.
Write, Written or Writing means a record that may be transmitted by paper or electronic media, and that is
consistent with applicable law.
You and Your means an employee who is insured under the Group Policy for the insurance described in this
Certificate.
GCERT16-HI-elig-ee
Page 15
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
ELIGIBLE CLASS
CLASS 1
All Active Full-Time and Part-Time Employees
DATE YOU ARE ELIGIBLE FOR INSURANCE
You may only become eligible for the Hospital Indemnity Insurance available for Your eligible class.
If You are in an eligible class on the date insurance becomes available for the class, You will be eligible for
insurance on the date You complete any applicable eligibility waiting period set by the Group Policyholder.
If you enter an eligible class after the date insurance becomes available to members of that class, You will be
eligible for insurance on the date You complete any applicable eligibility waiting period set by the Group
Policyholder.
ENROLLMENT PROCESS
If You are eligible for insurance, You may enroll for such insurance by completing the required form. You must also
provide Written permission to deduct Contributions from Your pay for such insurance, if You are required to make
such Contributions.
DATE YOUR INSURANCE TAKES EFFECT
Provided that You are Actively at Work in an eligible class, insurance under this Certificate will take effect for You
on the Certificate effective date. If You are not Actively at Work in an eligible class on the date insurance would
otherwise take effect, insurance will take effect on the date You return to Active Work in an eligible class.
BENEFIT CHANGES
Once Your insurance takes effect, You may only change Your benefits in accordance with the options available
through the Group Policyholder. Please contact Us or the Group Policyholder for more information.
If You are not Actively at Work in an eligible class on the date an increase in benefits would otherwise take effect,
the increase will not take effect until You return to Active Work in a class that is eligible for the increase.
GCERT16-HI-elig-dep
Page 16
ELIGIBILITY PROVISIONS: DEPENDENT INSURANCE
ELIGIBLE CLASS FOR DEPENDENT INSURANCE
All Class 1 employees of the Group Policyholder as specified in the Eligibility Provisions: Insurance For You section of
this Certificate are eligible for Dependent Insurance.
DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE
If You are in a class of employees who are eligible for Dependent Insurance on the date Your insurance takes effect, You
will be eligible for Dependent Insurance on the later of the following:
the date Your insurance takes effect; and
the date an individual becomes Your first Dependent.
If You enter a class of employees who are eligible for Dependent Insurance after the date Your insurance takes effect,
You will be eligible for Dependent Insurance on the later of the following:
the date You enter a class eligible for Dependent Insurance; and
the date an individual becomes Your first Dependent.
ENROLLMENT PROCESS
If You become eligible for Dependent Insurance, You may enroll for such insurance by providing Us with any information
We require for each Dependent to be insured. You must also provide Written permission to deduct Contributions from
Your pay for Dependent Insurance, if You are required to make such Contributions.
DATE DEPENDENT INSURANCE TAKES EFFECT
Newborn Children
A Dependent Child born to You while insurance is in effect under the Certificate will be covered:
from the moment of birth and does not need to be enrolled if Dependent Insurance is already in effect for at least one
other Dependent Child; or
for 31 days from the moment of birth if Dependent Insurance is not already in effect for at least one other Dependent
Child. To continue coverage beyond the first 31 days You must notify Us of the child’s birth and give Written
permission to deduct Contributions from Your pay for Dependent Insurance for the newborn child.
The effective date of insurance for a newborn child will be determined without regard to whether the child is under a
Medical Restriction.
GCERT16-HI-elig-dep
Page 17
ELIGIBILITY PROVISIONS: DEPENDENT INSURANCE (Continued)
Adopted Children
A Dependent Child adopted by You or Placed for Adoption with You while insurance is in effect under the Certificate will
be covered:
from the moment of birth if Placement for Adoption or adoption occurs within 31 days after the child’s birth; or
from the date of adoption or Placement for Adoption if the child is adopted by You or Placed for Adoption with You
more than 31 days after the child’s birth.
The child does not need to be enrolled if Dependent Coverage is already in effect for at least one other Dependent Child.
If Dependent Coverage is not already in effect for at least one other Dependent Child, then to continue the child’s
coverage beyond the first 31 days of coverage, You must notify Us of the child’s adoption or Placement for Adoption and
give Written permission to deduct Contributions from Your pay for Dependent Insurance for the adopted child. You must
do this within 31 days of the date the child is adopted by You or Placed for Adoption with You.
The effective date of insurance for a newly adopted child will be determined without regard to whether the child is under a
Medical Restriction.
Placed for Adoption or Placement for Adoption means:
the assumption and retention by You of a legal obligation for total or partial support of a child in anticipation of Your
adoption of the child; or
that there is a suit to which You are a party, in which You seek to adopt the child.
A Child Covered Pursuant to a Medical Support Order
A child for whom You are required to provide insurance pursuant to a medical support order issued under Texas Statutes
Chapter 154, Family Code; or enforceable by a court in the State of Texas, that is entered while insurance is in effect
under the Certificate will be covered from the date specified in the order.
The child does not need to be enrolled if Dependent Coverage is already in effect for at least one other Dependent Child.
If Dependent Coverage is not already in effect for at least one other Dependent Child, then to continue the child’s
coverage beyond the first 31 days of coverage, You must notify Us of Your obligation to cover the child and give Written
permission to deduct Contributions from Your pay for Dependent Insurance for the child. You must do this within 31 days
of the date You become obligated to cover the child.
The effective date of insurance for a child who becomes covered under this Certificate pursuant to a medical support
order while this insurance is in effect under the Certificate will be determined without regard to whether the child is under a
Medical Restriction.
Other Dependents
Dependent Insurance for a Dependent who is not under a Medical Restriction will take effect on the later of:
the date You are enrolled for Dependent Insurance for such Dependent; or
the date a person becomes Your Dependent.
If a Dependent is under a Medical Restriction on the date insurance for such Dependent would otherwise take effect,
insurance for the Dependent will take effect on the date the Dependent is no longer under a Medical Restriction.
BENEFIT CHANGES
Benefit changes with respect to a Dependent are subject to the Benefit Changes provision in the Eligibility Provisions:
Insurance for You section of this Certificate.
GCERT16-HI-gdr
Page 18
SPECIAL RULES FOR COVERED PERSONS PREVIOUSLY INSURED UNDER ANOTHER
INSURANCE POLICY ISSUED TO THE GROUP POLICYHOLDER
The Group Policy is replacing another policy of group insurance that provided similar benefits, that was issued to
the Group Policyholder. This section explains how the replacement of that other group insurance policy will affect
people who were covered under that policy.
In this section, the terms listed below will have the meanings listed below.
New Policy means the Group Policy under which this Certificate is issued.
Old Policy means the policy of group insurance that was replaced by the New Policy.
Replacement Date means the effective date of the New Policy.
Transferring Dependents means each of Your Dependents who:
was insured under the Old Policy on the date it ended; and
meets the requirements to be eligible for insurance under the New Policy, or is a Disabled Child.
If You were insured under the Old Policy on the date it ended and, You meet the requirements to be eligible for
insurance under the New Policy (without regard to any requirement that You be Actively at Work), You, and each of
Your Transferring Dependents will be insured under the New Policy on the Replacement Date subject to and in
accordance with the provisions of this section.
You and each of Your Transferring Dependents will be automatically enrolled and insured under the New Policy on
the Replacement Date.
Benefits for Confinement in Progress on the Replacement Date
If You were or a Transferring Dependent was Confined on the last day that the Old Policy was in effect for
treatment of an Injury or a Sickness and such person remains Confined on the Replacement Date, We will pay the
Confinement Benefit shown on the Schedule for each day of continuous Confinement after the Replacement Date
for up to 31 days - the Confinement Benefit will be determined as if the first day coverage is effective under the
New Policy is the day of Confinement.
GCERT16-HI-gdr
Page 19
SPECIAL RULES FOR COVERED PERSONS PREVIOUSLY INSURED UNDER ANOTHER INSURANCE
POLICY ISSUED TO THE GROUP POLICYHOLDER (Continued)
The following limitations and requirements apply to this provision:
The requirements for payment of benefits specified in this Certificate must be met, except as described in this
provision.
The requirement that an Accident must occur while insurance is in effect under this Certificate does not apply to
payment of benefits under this provision.
The Admission Benefit is not payable under this provision.
If the person who was Confined and receiving payment of benefits under this provision is discharged and within
180 days is again Confined for the same or related Injury or Sickness, We will treat the subsequent
Confinement as a continuation of the previous Confinement for purposes of determining the benefits payable
under this Certificate.
We may reduce any amounts payable under this provision, by any amounts payable under the Old Policy for
the same services. In no case will the benefits payable under both the Old Policy and the New Policy exceed
the benefits payable under the New Policy.
The only benefits available under this Certificate for a Confinement that was in progress when the Old Policy
ended and the New Policy began are those that are described in this provision.
We will not pay any benefits which require payment of a Confinement Benefit if the Confinement Benefit that
would be the basis of the payment is paid under this provision.
Disabled Child means a child who:
has attained the Dependent Age Limit but otherwise meets the definition of Dependent Child;
is incapable of self-sustaining employment by reason of developmental disability, mental impairment or
disorder, or physical disability; and
is chiefly dependent on You for support and maintenance.
GCERT16-HI-hosp
Page 20
HOSPITAL BENEFITS
Payment of the Hospital Benefits described in this section are subject to all of the conditions, maximums,
limitations, exclusions and Proof requirements contained in the provisions of this Certificate.
HOSPITAL ADMISSION BENEFITS
Admission Benefit
If a Covered Person is admitted for Confinement to a Hospital for treatment of an Injury or Sickness, We will pay
the Admission Benefit shown on the Schedule for the day of admission, subject to all of the following:
The admission must occur on or after the date that coverage took effect under this Certificate for such Covered
Person.
The Admission Benefit is not payable for Emergency Room treatment or outpatient treatment.
We will only pay the Admission Benefit for a Covered Person for one Hospital admission at a time, even if the
admission is caused by more than one Injury or Sickness or a combination of Injury and Sickness.
For Hospital admission for treatment of an Injury, the admission must occur within 180 days after the Accident
occurs.
If a Covered Person is discharged from a Confinement for which We paid an Admission Benefit and, within 90
days is again Confined for the same or related Injury or Sickness, We will treat the subsequent Confinement as
a continuation of the previous Confinement (and an additional Admission Benefit will not be payable).
We will only pay an Admission Benefit for a newborn baby who is born in a Hospital if, due to a Sickness or
Injury, the newborn baby is admitted to the Intensive Care Unit.
If a Covered Person is admitted to a Hospital and is then transferred to another Hospital, We will not pay an
additional Admission Benefit.
We will pay the Admission Benefit no more than the number of times shown on the Schedule.
ICU Supplemental Admission Benefit
We will pay the ICU Supplemental Admission Benefit shown on the Schedule, in addition to the Admission Benefit,
if a Covered Person, upon initial admission for Confinement to a Hospital for treatment of an Injury or Sickness, is
admitted to an ICU, subject to all of the following:
●
The admission must meet the requirements for payment of the Admission Benefit.
For an ICU admission for treatment of an Injury, the admission must occur within 180 days after the Accident
occurs.
If the Covered Person moves to an ICU after initial admission to a Hospital, We will not pay the ICU
Supplemental Admission Benefit.
GCERT16-HI-hosp
Page 21
HOSPITAL BENEFITS (Continued)
HOSPITAL CONFINEMENT BENEFITS
Confinement Benefit
If a Covered Person is Confined in a Hospital for treatment of an Injury or Sickness, We will pay the Confinement
Benefit shown on the Schedule for each day of Confinement, subject to all of the following:
The Confinement must begin while coverage is in effect under this Certificate for such Covered Person. For
Confinement for treatment of an Injury, the Confinement must begin within 180 days after the Accident occurs.
If a Covered Person is Confined in a Hospital and is then transferred to another Hospital, We will treat the
transfer as a continuation of the prior Confinement.
We will only pay one Confinement Benefit per Covered Person, per day.
We will pay the Confinement Benefit for no more than the number of days shown on the Schedule.
ICU Supplemental Confinement Benefit
We will pay the ICU Supplemental Confinement Benefit shown on the Schedule, in addition to the Confinement
Benefit, for each day a Covered Person is Confined in an ICU for treatment of an Injury or Sickness, subject to all
of the following:
The ICU Confinement must meet the requirements for payment of the Confinement Benefit.
We will only pay the ICU Supplemental Confinement Benefit for a day on which the Confinement Benefit is
payable.
For an ICU Confinement for treatment of an Injury, Confinement in the Intensive Care Unit must begin within
180 days after the Accident occurs.
We will pay the ICU Supplemental Confinement Benefit for no more than the number of days shown on the
Schedule.
INPATIENT REHABILITATION BENEFIT
If a Covered Person is transferred to a Rehabilitation Facility, as a resident inpatient, immediately after a period of
Confinement for treatment of an Injury or Sickness for which We paid an Admission Benefit or Confinement
Benefit, We will pay the Inpatient Rehabilitation Benefit shown on the Schedule for the period of the continuous
stay, subject to all of the following:
For treatment of an Injury, the Covered Person’s inpatient stay in the Rehabilitation Facility must start within
365 days after the Accident occurs.
If the Covered Person is discharged from the Rehabilitation Facility and, within 14 days is again admitted to a
Rehabilitation Facility as a resident inpatient for treatment of the same or related Injury or Sickness, We will
treat the subsequent Rehabilitation Facility stay as a continuation of the previous stay.
We will not pay the Inpatient Rehabilitation Benefit for any day for which We paid an Admission Benefit or a
Confinement Benefit.
We will only pay one Inpatient Rehabilitation Benefit per Covered Person, per day.
We will pay the Inpatient Rehabilitation Benefit for no more than the number of days shown on the Schedule.
GCERT16-HI-excl
Page 22
EXCLUSIONS
We will not pay benefits for any loss due to an Accident or Sickness for a Covered Person caused or contributed to
by:
war, whether declared or undeclared; or act of war;
the Covered Person’s active participation in an insurrection, rebellion, riot, or terrorist act;
the Covered Person’s engagement in any activity that constitutes a felony under the laws of the jurisdiction in
which the activity occurred;
dental procedures or Surgery except as the result of an Accident causing Injury to a sound natural tooth;
cosmetic Surgery, except when such Surgery is performed to:
treat an Injury or Sickness;
correct a disorder of normal bodily function or structure that was caused by an Injury or Sickness for which
coverage is not otherwise excluded under this Certificate; or
reconstruct a part of the body which was disfigured or removed as a result of an Injury or Sickness for
which coverage is not otherwise excluded under this Certificate; or
activities required by the Covered Person’s service in the armed forces or any auxiliary unit of the armed forces
of any country or international authority.
In addition, We will not pay benefits for:
a Covered Person while incarcerated in any type of penal or detention facility; or
any of the following outside of the United States, Canada or Mexico:
any medical or healthcare treatment, services or transportation; or
any inpatient admission or stay in any medical or health care facility.
The following additional exclusions apply to payment of benefits for any loss due to an Accident:
We will not pay benefits for any loss due to an Accident for a Covered Person caused or contributed to by:
the Covered Person’s operation, while intoxicated, of a motor vehicle involved in the incident. For purposes of
this exclusion:
intoxicated means that the Covered Person’s blood alcohol level met or exceeded .08%; and
motor vehicle means any vehicle that is powered by a motor, including, but not limited to: an automobile; a
boat; a motorcycle; a truck; an all-terrain vehicle; or a snow mobile;
the Covered Person’s travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled
charter or commercial flight;
the Covered Person parachuting or otherwise exiting from a motorized or non-motorized aircraft while such
aircraft is in flight, except for self-preservation;
the Covered Person riding in or driving any motor-driven vehicle in a race, stunt show or speed test;
the Covered Person participating in any semi-professional or professional competitive athletic activity for which
any type of compensation or remuneration is received; or
the Covered Person bungee jumping, base jumping, hang gliding, para-kiting, sail-gliding, scuba diving deeper
than 130 feet; spelunking; or mountaineering including rock climbing using ropes and any other climbing
equipment. For the purposes of this exclusion the term mountaineering does not include backpacking,
mountain biking, hiking or trail running.
GCERT16-HI-excl
Page 23
EXCLUSIONS (Continued)
The following additional exclusions applies to payment of benefits for any loss due to a Sickness:
We will not pay benefits under this Certificate for a Dependent Child’s Routine Childbirth.
.
GCERT16-HI-term
Page 24
WHEN INSURANCE ENDS
Please Note: If insurance ends under this section, in certain cases it may be continued as stated in the
Continuation of Insurance section of this Certificate. Please see that section for details.
DATE YOUR INSURANCE ENDS
Your insurance under this Certificate will end on the earliest of:
the date the Group Policy ends;
the date You die;
the date insurance ends for Your class;
the end of the period for which the last full premium has been paid for Your insurance;
the end of the calendar month in which You notify Us that You wish to cancel Your insurance;
the end of the calendar month in which You cease to be in an eligible class, subject to the Change in Class
provision of the Eligibility Provisions: Insurance for You section; or
the end of the calendar month in which Your employment ends.
For residents of Massachusetts:
If You are a resident of Massachusetts and Your insurance under this Certificate is ending under the above
provision because Your employment has ended, instead of insurance ending on the date Your employment ends,
the following timelines apply:
If Your employment ends for any reason other than a Plant Closing or a Partial Plant Closing, Your insurance
will end 31 days after the date Your employment ends. However, if during such 31 day period You become
entitled to benefits under another policy that are similar to the benefits provided under this Certificate, insurance
under this Certificate will end on the date You become entitled to such other benefits.
If Your employment ends due to a Plant Closing or a Partial Plant Closing Your insurance will end 90 days after
the date Your employment ends. However, if during such 90 day period, You become entitled to benefits under
another policy that are similar to the benefits provided under this Certificate insurance under this Certificate will
end on the date You become entitled to such other benefits.
DATE DEPENDENT INSURANCE ENDS
A Dependent’s insurance under this Certificate will end on the earliest of:
the date Your insurance under this Certificate ends;
the date Dependent Insurance ends under the Group Policy for all employees or for Your class;
the end of the calendar month in which the person ceases to be a Dependent;
the end of the calendar month in which You cease to be in a class that is eligible for Dependent Insurance;
the end of the calendar month in which the Dependent is no longer eligible as described in the Eligible Classes
for Dependent Insurance provision; or
the end of the period for which the last full premium has been paid for insurance for the Dependent.
GCERT16-HI-term
Page 25
WHEN INSURANCE ENDS (Continued)
CHANGE IN CLASS
If there is more than one class eligible for insurance under the Group Policy, and each class has its own certificate,
instead of receiving a new certificate when You move between classes, You will remain insured under this
Certificate if:
You move to a class that is eligible for Hospital Indemnity Insurance under the Group Policy; and
the benefits available to Your new class are identical to the benefits available under this Certificate.
In all other cases when You move between classes, Your insurance under this Certificate will end on the date You
are no longer a member of the class eligible for insurance under this Certificate.
GCERT16-HI-coi
Page 26
CONTINUATION OF INSURANCE
AT YOUR OPTION: CONTINUATION WITH PREMIUM PAYMENT
If Your insurance ends under the Date Your Insurance Ends provision of this Certificate, in certain situations, it may
be continued for You and Your Dependents, as described in this provision. This is referred to in this provision as
"Continued Insurance". Evidence of insurability will not be required to obtain Continued Insurance. For purposes
of this provision, insurance in effect under the Group Policy for which the Group Policyholder remits premium is
referred to in this provision as "Group Billed Insurance".
Except as described below, Continued Insurance is subject to all of the conditions, maximums, limitations,
exclusions and Proof requirements contained in the provisions of this Certificate.
Requirements for Continued Insurance
Continued Insurance will be available to You if:
Your Group Billed Insurance ends for any reason other than:
non-payment of premium or Contribution; or
the end of the Group Policy, provided that Continued Insurance will be available to You if You do not
become eligible, within 30 days after the end of the Group Policy, for hospital indemnity insurance under
another policy of group insurance available through the Group Policyholder;
We receive Your completed Written request for Continued Insurance on a form approved by Us within 31
calendar days after Your Group Billed Insurance ends; and
You pay premiums required for Continued Insurance by the due date specified in the premium notice sent to
You.
Changes in Continued Insurance
You may elect to decrease Your insurance after the date that Continued Insurance goes into effect for You if a
lower benefit option is available. In addition, You may end insurance for any or all of Your Dependents. Please
contact Us for information. You may not increase insurance once Continued Insurance goes into effect.
Contributions for Continued Insurance
The Contribution that You must pay for Continued Insurance is the amount of Your Contribution for Your Group
Billed Insurance before it ended, plus any amount of premium that the Group Policyholder paid. The Contribution
that You must pay for Continued Insurance will be determined on the same basis as premium rates charged for
Group Billed Insurance. We have the right to change premium rates in accordance with the terms set forth in the
Group Policy. All payments for Continued Insurance must be made directly to Us by the due date specified in the
premium notice We send to You.
GCERT16-HI-coi
Page 27
CONTINUATION OF INSURANCE (Continued)
End of Continued Insurance
Continued Insurance will end on the earliest of the following dates:
the date You die;
if You do not pay a Contribution that is required for Continued Insurance, the end of the period for which the
last full premium has been paid for Your insurance;
with respect to Continued Insurance for a Dependent:
the date Continued Insurance for You ends for any reason;
the end of the calendar month in which the Dependent no longer meets the definition of a Dependent; or
the end of the calendar month in which the Dependent is no longer eligible as described in the Eligibility
Provisions: Dependent Insurance section of this Certificate.
FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN
Insurance for a Dependent Child may be continued past the age limit if that child is incapable of self-sustaining
employment and is chiefly dependent on You for support and maintenance because of a mental or physical
handicap as defined by applicable law. Proof of such handicap must be sent to Us within 31 days after the date the
Dependent Child attains the age limit and at reasonable intervals after such date, but no more often than annually
after the two year period following such Dependent Child’s attainment of the limiting age.
Except as stated in the Date Dependent Insurance Ends provision of the When Insurance Ends section of this
Certificate, insurance will continue while such Dependent Child:
remains incapable of self-sustaining employment because of a mental or physical handicap;
remains chiefly dependent on You for support and maintenance; and
continues to qualify as a Dependent Child, except for the age limit.
FOR FAMILY AND MEDICAL LEAVE
Certain leaves of absence may qualify under the Family and Medical Leave Act of 1993 (FMLA) or similar state
laws for continuation of insurance. Please contact the Group Policyholder for information regarding the FMLA or
any similar state law.
GCERT16-HI-claim
Page 28
CLAIMS
NOTICE OF CLAIM
You must give Us notice of a claim under this Certificate by Writing to Us or calling Us at the toll free number shown
on the face page of this Certificate within 30 days of the date of the loss.
CLAIM FORM
When We receive notice of a claim under this Certificate, We will provide You or the claimant with a claim form. If
We do not provide the claim form before the 16
th
day from the date We received notice of claim, Our claim form
requirements will be satisfied if We are provided with the required Proof in support of the claim.
PROOF OF LOSS
Proof must be provided to Us not later than 90 days after the date of the loss. If notice of claim or Proof is not given
within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such
notice and Proof are given as soon as is reasonably possible, but in no event, other than in the absence of the legal
capacity of the claimant, later than15 months from the date Proof of the loss is required. When We receive the
claim form and Proof, We will review the claim and, provide notification in Writing of Our approval or denial of the
claim no later than the 15
th
business day after the date We receive documentation in support of the claim.
PAYMENT OF BENEFITS
If We approve a claim, We will pay benefits no later than 60 days after the date We receive Proof, subject to the
terms and provisions of this Certificate and the Group Policy. If We deny the claim, Our notice will state the
reason(s) for the denial. If We cannot approve or deny the claim within 15 business days after We receive
documentation in support of the claim, We will provide notification within 15 business days, stating that We need
additional time to review the claim and the reason(s) why. We will notify You or the claimant of Our decision to
approve or deny the claim within 45 days after the date that We provide notification that We that We need
additional time to review the claim.
Unless You have assigned this insurance, all benefits to be paid under this Certificate will be paid to You, except as
follows:
If You are not alive to receive benefits that are payable to You, We will pay any benefits in accordance with the
provision below titled Your Beneficiary.
If You are living when benefits are to be paid to You, but You are not legally competent to claim or receive the
benefits, We may pay up to $10,000 to anyone related to You by blood or marriage who We believe is entitled
to payment of the benefits. If We make such a payment in good faith, We will not be liable to anyone for the
amount We pay. Any remaining benefits will be paid to Your legal representative.
If benefits have been assigned, We will pay benefits in accordance with the Assignment provision of the General
Provisions section.
YOUR BENEFICIARY
A beneficiary may be named by You to receive any benefit that becomes payable to You under this Certificate that
You are not alive to receive.
You may request to change Your beneficiary at any time. A beneficiary change request must be made to Us in
Writing. Once the request is recorded, the change will take effect as of the date You sign the request, whether or
not You are living when We receive the request. The change will be subject to any legal restrictions. It will also be
subject to any payment We made or action We took before We recorded the change. If You designated two or
more beneficiaries and their shares are not specified, they will share the benefit payable equally.
If there is no beneficiary designated or no surviving beneficiary at Your death, We will determine the beneficiary
according to the following order:
1. Your Spouse, if alive;
2. Your child(ren), if there is no surviving Spouse;
3. Your parent(s), if there is no surviving child;
4. Your sibling(s), if there is no surviving parent; or
5. Your estate, if there is no surviving sibling.
GCERT16-HI-claim
Page 29
CLAIMS (Continued)
Instead of making payment in the order above, We may pay Your estate. Any payment made in good faith will
discharge our liability to the extent of such payment. If a beneficiary or a Payee is a minor or incompetent to
receive payment, We will pay that person's guardian.
AUTHORIZATIONS
We may require that You provide authorization for Us to obtain medical information and any other information
pertinent to Your claim.
EXAMINATIONS
During the pendency of a claim, at Our expense and as often as is reasonably necessary, We may require a
Covered Person to have an independent examination by a Physician of Our choice.
During the pendency of a claim, at Our expense and as often as is reasonably necessary, We may have Our
representatives conduct telephone or in-person interviews with You regarding Your claim.
AUTOPSY
At Our expense, We have the right to make a reasonable request for an autopsy and/or exhumation where
permitted by law. Any such request will set forth the reasons We are requesting the autopsy or exhumation.
TIME LIMIT ON LEGAL ACTIONS
A legal action on a claim may only be brought against Us during a certain period. This period begins 60 days after
the date Proof is filed and ends three years after the date such Proof is required to be filed.
REFUND TO US FOR OVERPAYMENT OF BENEFITS
If, at any time, We determine that the benefits paid under this Certificate were more than the benefits due:
You, or any other person, entity or health care provider to whom We over paid benefits have the obligation to
reimburse Us for the amount of such overpayment; and
We have the right to recover the amount of such overpayment from You, or any other person, entity or health
care provider to whom We over paid benefits, including offsetting future benefits payable to You or such other
person, entity or health care provider by an amount equivalent to the overpayment.
GCERT16-HI-gpro
Page 30
GENERAL PROVISIONS
ENTIRE CONTRACT
Your insurance is provided under a contract of group insurance with the Group Policyholder. The entire contract
with the Group Policyholder is made up of the following:
the Group Policy and its Exhibits, which include the Certificate(s);
the Group Policyholder’s application; and
any amendments and/or endorsements to the Group Policy.
INCONTESTABILITY: STATEMENTS MADE BY YOU
Any statement made by You will be considered a representation and not a warranty. We will not use such a
statement to void insurance, reduce benefits or defend a claim unless the following requirements are met:
the statement is in a form that is in Writing;
You have Signed the form; and
a copy of the form has been given to You or Your beneficiary.
We will not use Your statements which relate to insurability to contest this insurance after it has been in force for 2
years, unless the statement is fraudulent. In addition, We will not use such statements to contest a benefit increase
after the benefit increase has been in force for 2 years, unless such statement is fraudulent.
MISSTATEMENTS
If Your or Your Dependent’s age is misstated, the correct age will be used to determine if insurance is in effect and,
as appropriate, We will adjust the benefits and/or Contributions.
ASSIGNMENT
The benefits under the Group Policy are not assignable prior to a claim for benefits, except to a Physician or other
health care provider who provides health care services to You, or except as required by law.
CONFORMITY WITH LAW
If the terms and provision of this Certificate do not conform to any applicable law, this Certificate shall be
interpreted to so conform.
STANDARD OF TIME
All insurance becomes effective and terminates at 12:01 A.M. Eastern Standard Time, or at 12:01 A.M. Eastern
Daylight Time if Daylight Savings Time is then being observed.
