Page 61 - Tampa Bay Rays 2022 Flipbook

In-Hospital Benefit: When an insured person is confined to a hospital as an inpatient due to an eligible sickness or injury, the
Kemper Health Gap insurance plan will pay your eligible deductibles and coinsurance up to the selected benefit year maximum per
person.
Outpatient Hospital Benefit: When an insured person receives treatment as an outpatient due to an eligible sickness or injury, the
Kemper Health Gap insurance plan will pay up to the selected percentage of the in-hospital benefit year maximum per person.
Ambulance Benefit – Accident Only: When an insured person requires ambulance transportation (ground or air) to a hospital or
emergency center for injuries sustained in an accident, the Kemper Health Gap insurance plan will pay up to $350 per insured
person, per benefit year.
PRODUCT FEATURES AND BENEFITS

Covered Benefits Gap Plan
In-Patient Hospital Benefit
Benefit Amount $2,000
Eligibility Per insured, up to 3 times per benefit year
Frequency Per calendar year
Eligible Type of Condition Eligible sickness or injury
Eligible Type of Expense Any eligible expense of an inpatient confinement, inpatient surgery, physician’s in-hospital
charges and routine nursery care for covered dependents
Outpatient Hospital Benefit
Benefit Amount $1,000
Eligibility Per insured, up to 3 times per benefit year
Frequency Per calendar year
Eligible Type of Condition Surgery, radiological diagnostic testing, emergency room for accident only
Eligible Type of Expense Any eligible expense in a hospital outpatient facility or a free-standing outpatient surgery
center, emergency room (Accident Only) or MRI facility
Ambulance Benefit (Accident Only)

Benefit Amount Up to $350
Eligibility Per insured, up to 3 times per benefit year
Frequency Per calendar year
Eligible Type of Condition Accident only within 72 hours
Eligible Type of Expense Air or ground

Frequently Asked Questions
Are there some procedures and services that are not covered under the Kemper Health Gap insurance plan?
Yes. Examples are mental and nervous conditions, alcoholism or drug abuse claims, prescription drugs (unless prescribed while an
inpatient), and chemotherapy/radiation therapy treatments received on an outpatient basis.
A complete list of Exclusions and Limitations is shown on page 4.
From which medical facilities may I receive treatment?
You must receive treatment from a hospital (if an inpatient), the outpatient facility of a hospital, a freestanding surgical center, or an
MRI facility. Surgical procedures in a physician’s office are not reimbursable. Clinics and urgent care facilities are not covered facilities
under the in-hospital or outpatient hospital Benefit.
How do I file a claim?
Mail or fax the following items to:

Mail: Kemper Health Gap Insurance Plan, P.O. Box 3252 / Milwaukee, WI 53201-3252 Fax: 844.613.3451
Please include*: 1. A Kemper Health Gap Insurance claim form
2. A copy of the explanation of benefits (EOB) that you receive from your comprehensive major medical
carrier after they have processed your medical claim.
3. The itemized bill/physician’s statement from the provider, including diagnostic codes.
*Additional information may be required or requested.