Page 11 - ACT Benefits Enrollment Kit (2)

Limitations and Exclusions
TransDI Plus
The sum of the disability bene ts paid to the insured together with the payments the insured is entitled to receive from the sources described below, may not exceed the monthly percent shown on the Product Details page:
a. Group insurance or like insurance for persons in a group;
b. Federal Social Security Act (this includes bene ts paid to the insured employee and his or her dependents on account of the insured’s disability);
c. State or federal government disability or retirement plan, or increases thereof, which begin on or after the date of total disability
d. Pension plan to which the policyholder or the insured’s employer contributes or makes payroll deductions;
e. Salary or wage continuance plans such as sick leave paid for by the policyholder or the insured’s employer which extend beyond the period stated in the contract;
f. and Federal Old Age Bene ts or increases which begin on or after the date of total disability, under the Federal Social Security Act on the insured employee’s behalf.
With respect to items (b) and (f) only, unless we receive proof that payments under these applicable programs or acts have been applied for but will not be paid, we: a. will assume such payments are being received if the insured is covered under the Federal Social Security Act; and
b.may require re-application (but not more frequently than annually) once a Social Security denial has been received and all appeals have been pursued. Failure to re-apply for bene ts when required by us will result in our estimation of payment under those acts. Bene ts will not be reduced due to a cost of living increase in Social Security if the increase takes place while bene ts are payable under the policy.
With respect to any and all of the above sources, if the insured or his or her dependent receives a lump sum payment for a period previously paid by us, any resulting overpayment must be repaid on a lump sum basis. If the insured has the option of taking retirement bene ts on a monthly basis but chooses to receive retirement bene ts in a lump sum, we may assume he
or she is receiving retirement bene ts based upon the lowest monthly retirement plan bene t available to the insured prior to lump sum withdrawal.
If the insured is totally disabled and receiving regular treatment due to a covered mental illness, regardless of the cause, monthly disability bene ts will be paid for one-half (1/2) of the bene t. The lifetime maximum is 12 months of disability payments.
Exclusions
The policy does not pay bene ts for any loss, fatal or non-fatal, which results from:
• intentionally self-in icted injury while sane or insane;
• any act of war, declared or undeclared;
• accident sustained or sickness contracted while in the service of the armed forces of any country;
committing a felony;
• operating, learning to operate or having any duty in the operation of any device or vehicle intended or designed for
• ight in the air including boarding, alighting or descending therefrom;
• accident or sickness arising out of and in the course of the insured’s occupation for wage or pro t. This exclusion applies even if Workers’ Compensation is not paid for the on-the-job injury.
Pre-Existing Conditions
There will be no disability bene t payable for a pre-existing condition until the insured has been continuously insured under the Policy for 12 consecutive months and has returned to performing the duties of his or her occupation for 30 continuous days after the rst 12 months of insurance. “Pre-Existing Condition” means sickness or physical condition for which the insured had treat- ment, incurred expense, took medication, or received a diagnosis or advice from a physician, during the 12-month period immediately before the effective date of insurance.
The term “Pre-Existing Condition” will also include a condition that manifests itself in a way that would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment.
Termination of Insurance
Employee insurance will terminate on the earliest of:
• the date the insured does not qualify as an insured;
• the date the insured retires;
• the date the insured ceases to be on active service;
• the end of the last period for which premium has been paid, subject to the Grace Period; • the date the group master policy is discontinued.
Termination will have no effect on payment of bene ts for a total disability that begins before such termination. We will have the right to terminate the insurance of any insured person who submits a fraudulent claim under the policy.
Termination of the Group Master Policy
The policyholder may end the policy on any premium due date by submitting a 60-day advance written notice. A group will not be continued if it drops below the minimum required participation. The group master policy will be terminated and the insurance of all remaining insureds will end, subject to any portability option.
Other Insurance with Us
An individual can only have one disability income policy or certi cate with us. If a person already has disability income insurance with us, such person is not eligible to apply for this insurance.
Trans Select
Accelerated Death Bene t for Critical Care
We will not pay for conditions diagnosed prior to the effective date of the rider.
Cancer requires histological evidence of malignancy and does not cover skin cancer other than malignant melanomas, all tumors that are histologically described as pre-malignant or are only showing early malignant change, cancer in-situ, and papillary cancer of the bladder.
Heart Attack must be based on new EKG changes consistent with injury, elevation of cardiac enzymes, and con rmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms.
Major Organ Transplant Surgery is limited to heart, lung, liver or bone marrow transplants.
Renal Failure is limited to end stage renal failure resulting in chronic and irreversible failure of both kidneys to function requiring renal dialysis.
Stroke requires evidence of permanent neurological damage and does not cover Transient Ischemic Attacks (TIAs) or attacks of Vertebrobasilar Ischemia.
Accelerated Death Bene t for Terminal Illness Rider
We will not pay for conditions diagnosed prior to the effective date of the rider.
Termination of Insurance
Member insurance will terminate on the earliest of:
• The date the member sends us a written notice to cancel insurance;
• The certi cate anniversary date following the member’s 100th birthday;
• The date the member dies;
• The date the certi cate lapses;
• The date the group master policy terminates.
Dependent insurance will terminate on the earliest of:
• The date the member’s insurance terminates;
• The date the dependent no longer meets the de nition of dependent;
• The date the group master policy is modi ed so as to exclude dependent insurance; • The date the member sends us a written notice to cancel dependent insurance.
Portability Option
If an member loses eligibility for this insurance for any reason other than nonpayment of premi- ums, insurance can be continued by paying the premiums directly to us. We will bill the member directly once we receive noti cation to continue insurance.
Conversion Option
An insured person can convert his or her insurance to permanent life insurance on a policy
form that we then issue, without any optional riders, in an amount not to exceed the amount of insurance terminating under the policy. The premium will be based on the insured person’s age and class of risk at the time of conversion. We must receive a completed conversion application and any required premium within 31 days of termination. If the insured person dies within the 31- day conversion period, bene ts will be paid as if insurance had continued, regardless of whether conversion was applied for.
Termination of the Group Master Policy
The group master policy will end on the earliest of the following events:
• The date you submit a 60-day advance written request to us to terminate, the group master policy will terminate on the date speci ed in that request;
• If we give a 60-day advance written notice to you that we intend to terminate, the group mas- ter policy will terminate on the date speci ed in that notice;
• If any premium payable by you is not paid within its grace period, the group master policy will terminate on the day after the end of the grace period;
• If you fail to comply with any terms of the group master policy or the policyholder application, or otherwise fail to ful ll any obligations or duties under or pertaining to this insurance, or fail to comply with or cooperate with us in satisfying the requirements of any applicable law or regula- tion pertaining to this insurance, the group master policy will terminate on the 32nd day after we have given you written notice of our intent to terminate;
or
• If the number of insureds during any 12-month period does not meet the minimum participa- tion requirement shown in this proposal, the group master policy may terminate at our discretion on the 32nd day after we have given you written notice of our intent to terminate.
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