READ YOUR OUTLINE OF COVERAGE · the important features of the group insurance coverage provided by...

READ YOUR OUTLINE OF COVERAGE Group Critical Illness Insurance is provided under a Group Policy that has been issued to the Policyholder. The Policyholder is your employer: Bentley University

The Outline of Coverage provides a very brief summary of the important features of the Group Critical Illness Insurance. The Outline of Coverage is not the insurance contract and only the actual provisions of the Group Policy and Certificate under which you have coverage will control.

To access and read your Outline of Coverage:

• If you are a RESIDENT of one of the following states, click on the box below thatshows the name of your state of residence: Alaska, Arkansas, Connecticut,Delaware, Idaho, Louisiana, Minnesota, Mississippi, Montana, Nebraska,New Hampshire, New Mexico, North Carolina, North Dakota, Ohio,Oklahoma, Oregon, South Carolina, South Dakota, Texas, Utah, Vermont,Washington, West Virginia, Wisconsin, Wyoming.

OR

• If you do not reside in one of the above listed states, click on the box below that shows the name of the GROUP POLICY ISSUANCE STATE. The GROUPPOLICY ISSUANCE STATE is: Massachusetts

It is important that you follow the above directions and click on the box for the state that applies to you. Some of the information in the Outline of Coverage varies by state.

Please contact MetLife at 1-800-GET-MET8 if you have any questions about this important coverage.

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METROPOLITAN LIFE INSURANCE COMPANY NEW YORK, NEW YORK

POLICYHOLDER: Your Employer Group Policy Form No: GPNP14-CI (Referred to as the “Group Policy”) Certificate Form No: GCERT14-CI (Referred to as the “Certificate”)

CRITICAL ILLNESS INSURANCE OUTLINE OF COVERAGE

THE CERTIFICATE PROVIDES LIMITED BENEFITS: THE CERTIFICATE ONLY PROVIDES CRITICAL ILLNESS COVERAGE IN THE EVENT THAT A COVERED PERSON IS DIAGNOSED WITH CERTAIN SPECIFIED DISEASES OR HAS CERTAIN

SURGICAL PROCEDURES PERFORMED. RECEIPT OF BENEFITS UNDER THE CERTIFICATE MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL BENEFITS AND ENTITLEMENTS.

ACCORDINGLY, PERSONS WHO WISH TO MAINTAIN ELIGIBILITY FOR SUCH BENEFITS SHOULD NOT PURCHASE THE COVERAGE MADE AVAILABLE UNDER THE GROUP POLICY WITHOUT

CONSULTING A LEGAL ADVISOR.

BENEFIT AMOUNTS ARE NOT BASED ON ANY MEDICAL EXPENSES INCURRED.

THE CERTIFICATE DOES NOT PROVIDE MEDICARE SUPPLEMENT COVERAGE – IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO

HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM METLIFE.

NOTE: The terms “You” and “Your” refer to the employee who becomes insured for the group insurance coverage described in this outline. The term “Covered Person” refers to a person for whom insurance is in effect under the Certificate.

1) READ YOUR CERTIFICATE CAREFULLY. This outline of coverage provides a very brief description ofthe important features of the group insurance coverage provided by the Group Policy and Certificate. Thisis not the insurance contract and only the actual provisions of the Group Policy and Certificate underwhich You have coverage will control. The Certificate sets forth in detail the rights and obligations of bothYou and MetLife with respect to the coverage. It is, therefore, important that You READ YOURCERTIFICATE CAREFULLY!

2) CRITICAL ILLNESS INSURANCE COVERAGE. Policies of this category are designed to provide a lumpsum payment if the Covered Person is diagnosed with certain specified diseases for the first time afterinsurance takes effect under the Group Policy, or has certain specified surgeries for the first time afterinsurance takes effect under the Group Policy.

3) THE GROUP POLICY DOES NOT PROVIDE ANY TYPE OF MEDICAL COVERAGE AND IS NOT ASUBSTITUTE FOR MEDICAL COVERAGE OR DISABILITY INSURANCE. YOU SHOULD HAVEMEDICAL INSURANCE IN PLACE WHEN YOU ENROLL FOR THIS COVERAGE.

4) COVERAGE UNDER THE CERTIFICATE IS GUARANTEED RENEWABLE. This means that althoughMetLife reserves the right to change any or all premium rates as provided in the Group Policy, MetLifecannot end Your coverage under the Certificate except for reasons stated in the Certificate.

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5) BENEFITS

Please be aware that the Certificate contains specific definitions, conditions, maximums, limitations,exclusions and proof requirements for the benefits described below.

The Benefit Amount that determines the amount we will pay for a first occurrence of a Covered Conditionis shown on Your enrollment form. (Note that Major Organ Transplant has its own benefit amount). TheTotal Benefit Amount is the maximum aggregate amount that we will pay for any and all CoveredConditions combined, per Covered Person. The Total Benefit Amount does not include SupplementalBenefits.

Benefits for Covered Conditions:

Covered Condition Initial Benefit Recurrence Benefit For First Occurrence

Alzheimer’s Disease 100% of Benefit Amount Coronary Artery Bypass Graft 100% of Benefit Amount Full Benefit Cancer 100% of Benefit Amount Partial Benefit Cancer 25% of Benefit Amount Heart Attack 100% of Benefit Amount Kidney Failure 100% of Benefit Amount Stroke 100% of Benefit Amount Listed Conditions 25% of Benefit Amount Major Organ Transplant 100% of Major Organ

NONE 50% of Benefit Amount 50% of Benefit Amount 12.5% of Benefit Amount50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE

Transplant Benefit Amount

Recurrence Benefit:

We will pay the Recurrence Benefit shown above for a “Recurrence”, as defined in the Certificate, subject to the following limitations:

we will not pay a Recurrence Benefit for a Covered Condition that recurs during a Benefit SuspensionPeriod; and

we will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancerunless the Covered Person has not, for a period of 180 days, had symptoms of or been treated forthe Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit.

Supplemental Benefits:

Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay a health screening benefit depending on the plan you select.

We will pay one health screening benefit per Covered Person per calendar year.

6) DEFINITIONS

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person.Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has determined that:

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surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis

and will not benefit from, or has exhausted, curative therapy. Listed Conditions means any of the following diseases: Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis. Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below: carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has

been determined to be medically necessary by a physician who is board certified in the medical specialty that is appropriate for the type of carcinoma in situ involved;

malignant tumors classified as T1N0M0 or greater which are treated by endoscopic procedures alone;

malignant melanomas classified as T1N0M0, for which a pathology report shows maximum thickness less than or equal to 0.75 millimeters using the Breslow method of determining tumor thickness; and

tumors of the prostate classified as T1bN0M0, or T1cN0M0, provided that they are treated with a radical prostatectomy or external beam radiotherapy.

7) EXCLUSIONS

Exclusions Related to Covered Conditions: We will not pay benefits for a diagnosis of Alzheimer’s Disease for: other central nervous system conditions that may cause deficits in memory and cognition (e.g.,

cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus); systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid

deficiency, niacin deficiency, hypercalcemia, neurosyphilis); substance-induced conditions; or any form of dementia that is not diagnosed as Alzheimer’s Disease.

We will not pay benefits for Coronary Artery Bypass Graft: performed outside the United States; or that does not involve median sternotomy (a surgical incision in which the sternum, also known as the

breastbone, is divided down the middle from top to bottom). We will not pay benefits for a diagnosis of Full Benefit Cancer for: any condition that is Partial Benefit Cancer; any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1N0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter unless there is metastasis; any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known

increased risk due to the presence of Acquired Immune Deficiency Syndrome (AIDS) or the presence of HIV;

any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for:

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any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter; any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known


any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving organs received from non-human donors; involving implantation of mechanical devices or mechanical organs; involving stem cell generated transplants; or involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:

taken or used as prescribed by a physician; an “over the counter” drug, medication or sedative taken according to package directions;

engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident.

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Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage: medical advice, treatment or care was sought by such Covered Person, or recommended by,

prescribed by or received from a physician or other practitioner of the healing arts; or symptoms, or any medical or physical conditions existed that would cause an ordinarily prudent

person to seek diagnosis, care or treatment. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.

8) LIMITATIONS Reduction of Benefits On Account of Prior Claims Paid We will reduce what we pay for a claim so that the amount we pay, when combined with amounts for all claims we have previously paid for the same Covered Person, does not exceed the Total Benefit Amount that was in effect for that Covered Person on the date of the most recent Covered Condition. This provision does not apply to claim payments for Supplemental Benefits. Benefit Reduction Due to Age The Benefit Amount and the Total Benefit Amount will each be reduced by: 25% when the Covered Person reaches age 65; and, by 50% when the Covered Person reaches age 70. If the Total Benefit Amount, when reduced under the Benefit Reduction Due to Age, is less than or equal to the sum of all benefits previously paid under the Certificate, insurance under the Certificate will end on the date of such reduction.

9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 You; the date You cease to be in an eligible class; or the date Your employment ends for any reason.

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10) CONTINUATION OF INSURANCE

Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends except as described below. Continued Insurance is not available if: Your Group Billed insurance ends due to Your failure to make a required premium payment; or Your insurance ends because the Group Policy ends and, within 30 days of the day that the Group

Policy ends, You become eligible for insurance under another group policy of critical illness or specified disease insurance issued to or provided through the group policyholder.

11) PREMIUMS

Premium rates are based on your age on the effective date of coverage and are shown in the enclosed materials. Premium rates are subject to change as stated in the Group Policy.

This is the end of the Outline of Coverage that applies to you.

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METROPOLITAN LIFE INSURANCE COMPANY

NEW YORK, NEW YORK


CRITICAL ILLNESS INSURANCE

OUTLINE OF COVERAGE






THE CERTIFICATE DOES NOT PROVIDE MEDICARE SUPPLEMENT COVERAGE –

IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM METLIFE.


1) READ YOUR CERTIFICATE CAREFULLY. This outline of coverage provides a very brief description of the important features of the group insurance coverage provided by the Group Policy and Certificate. This is not the insurance contract and only the actual provisions of the Group Policy and Certificate under which You have coverage will control. The Certificate sets forth in detail the rights and obligations of both You and MetLife with respect to the coverage. It is, therefore, important that You READ YOUR CERTIFICATE CAREFULLY!

2) CRITICAL ILLNESS INSURANCE COVERAGE. Policies of this category are designed to provide a lump sum payment if the Covered Person is diagnosed with certain specified diseases for the first time after insurance takes effect under the Group Policy, or has certain specified surgeries for the first time after insurance takes effect under the Group Policy.

3) THE GROUP POLICY DOES NOT PROVIDE ANY TYPE OF MEDICAL COVERAGE AND IS NOT A

SUBSTITUTE FOR MEDICAL COVERAGE OR DISABILITY INSURANCE. YOU SHOULD HAVE MEDICAL INSURANCE IN PLACE WHEN YOU ENROLL FOR THIS COVERAGE.

4) COVERAGE UNDER THE CERTIFICATE IS GUARANTEED RENEWABLE. This means that although

MetLife reserves the right to change any or all premium rates as provided in the Group Policy, MetLife cannot end Your coverage under the Certificate except for reasons stated in the Certificate.

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5) BENEFITS






NONE 50% of Benefit Amount 50% of Benefit Amount 12.5% of Benefit Amount 50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:


• we will not pay a Recurrence Benefit for a Covered Condition that recurs during a Benefit SuspensionPeriod; and

• we will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancerunless the Covered Person has not, for a period of 180 days, had symptoms of or been treated forthe Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit.




6) DEFINITIONS

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person.Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has determined that:

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• surgery, radiotherapy, or chemotherapy is medically necessary; • there is metastasis; or • the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis

and will not benefit from, or has exhausted, curative therapy. Listed Conditions means any of the following diseases: Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis. Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below: • carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has


• malignant tumors classified as T1N0M0 or greater which are treated by endoscopic procedures alone;

• malignant melanomas classified as T1N0M0, for which a pathology report shows maximum thickness less than or equal to 0.75 millimeters using the Breslow method of determining tumor thickness; and

• tumors of the prostate classified as T1bN0M0, or T1cN0M0, provided that they are treated with a radical prostatectomy or external beam radiotherapy.

7) EXCLUSIONS

Exclusions Related to Covered Conditions: We will not pay benefits for a diagnosis of Alzheimer’s Disease for: • other central nervous system conditions that may cause deficits in memory and cognition (e.g.,

cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus); • systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid

deficiency, niacin deficiency, hypercalcemia, neurosyphilis); • substance-induced conditions; or • any form of dementia that is not diagnosed as Alzheimer’s Disease.

We will not pay benefits for Coronary Artery Bypass Graft: • performed outside the United States; or • that does not involve median sternotomy (a surgical incision in which the sternum, also known as the

breastbone, is divided down the middle from top to bottom). We will not pay benefits for a diagnosis of Full Benefit Cancer for: • any condition that is Partial Benefit Cancer; • any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; • any papillary tumor of the bladder classified as Ta under TNM staging; • any tumor of the prostate classified as T1N0M0 under TNM staging; • any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter unless there is metastasis; • any non-melanoma skin cancer unless there is metastasis; or • any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: • any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; • any papillary tumor of the bladder classified as Ta under TNM staging; • any tumor of the prostate classified as T1aN0M0 under TNM staging;

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• any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one centimeter or less in diameter;

• any non-melanoma skin cancer; or • any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: • performed outside the United States; • involving organs received from non-human donors; • involving implantation of mechanical devices or mechanical organs; • involving stem cell generated transplants; or • involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: • cerebral symptoms due to migraine; • cerebral injury resulting from trauma or hypoxia; or • vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: • a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); • a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or • a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: • participating in a felony, riot or insurrection; • intentionally causing a self-inflicted injury; • committing or attempting to commit suicide while sane or insane; • voluntarily taking or using any drug, medication or sedative unless it is:

• taken or used as prescribed by a physician; • an “over the counter” drug, medication or sedative taken according to package directions;

• engaging in an illegal occupation; or • serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

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• medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts; or

• symptoms, or any medical or physical conditions existed that would cause an ordinarily prudent person to seek diagnosis, care or treatment.

We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. However, a Preexisting Condition does not include any sickness or injury for which there is no evidence that the sickness or injury actually existed before the Covered Person was insured under the Group Policy.The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.


9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 You; • the date You cease to be in an eligible class; or • the date Your employment ends for any reason.

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Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends except as described below. Continued Insurance is not available if: • Your Group Billed insurance ends due to Your failure to make a required premium payment; or • Your insurance ends because the Group Policy ends and, within 30 days of the day that the Group


11) PREMIUMS


NOTICE REGARDING INSURANCE DESCRIBED

IN THIS OUTLINE OF COVERAGE

This is a supplement to health insurance. It is not a substitute for

essential health benefits or minimum essential coverage as defined in

federal law.

CA Disclosure

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This is a supplement to health insurance. It is not a substitute for hospital or medical expense insurance, a health maintenance organization (HMO) contract, or major medical expense insurance.











3) THE GROUP POLICY DOES NOT PROVIDE ANY TYPE OF MEDICAL COVERAGE AND IS NOT ASUBSTITUTE FOR MEDICAL COVERAGE OR DISABILITY INSURANCE. YOU SHOULD HAVECOMPREHENSIVE MEDICAL INSURANCE IN PLACE WHEN YOU ENROLL FOR THIS COVERAGE.


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5) BENEFITS


The Benefit Amount that determines the amount we will pay for a first occurrence of a Covered Condition is shown on Your enrollment form. (Note that Major Organ Transplant has its own benefit amount). The Total Benefit Amount is the maximum aggregate amount that we will pay for any and all Covered Conditions combined, per Covered Person. The Total Benefit Amount does not include Supplemental Benefits.



Alzheimer’s Disease 100% of Benefit Amount Coronary Artery Bypass Graft 100% of Benefit Amount Full Benefit Cancer 100% of Benefit Amount Partial Benefit Cancer 25% of Benefit Amount Heart Attack 100% of Benefit Amount

NONE 50% of Benefit Amount50% of Benefit Amount12.5% of Benefit Amount 50% of Benefit Amount

Kidney Failure 100% of Benefit Amount Stroke 100% of Benefit Amount Listed Conditions 25% of Benefit Amount Major Organ Transplant 100% of Major Organ

NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:




Mammogram Benefit:

If a covered person undergoes a Covered Mammogram while such covered person is insured under the group policy, proof of the Covered Mammogram must be sent to us. When we receive such proof, we will review the claim and if we approve it, will pay $200 for such Covered Mammogram.




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6) DEFINITIONS

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person.Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue or the presence of one or more malignant tumors.

Listed Conditions means any of the following diseases:Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease);cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’sdisease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis);muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sicklecell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis(scleroderma); tetanus; and tuberculosis.

Partial Benefit Cancer means one of the following conditions that meets the TNM staging classificationand other qualifications specified below: carcinoma in situ which is a tumor that fulfills all pathologic criteria for malignancy except that it has

not invaded the supporting structure of the organ on which it arose (for example, some cancers of thebreast are carcinoma in situ) provided that the carcinoma in situ is classified as TisN0M0and thatSurgery, radiotherapy or chemotherapy has been determined to be medically necessary by aphysician who practices in the medical specialty that is appropriate for the type of carcinoma in situinvolved;

malignant melanomas classified as T1N0M0, for which a pathology report shows maximum thicknessless than or equal to 0.75 millimeters using the Breslow method of determining tumor thickness; and

tumors of the prostate classified as T1bN0M0, or T1cN0M0.

7) EXCLUSIONS

Exclusions Related to Covered Conditions:

We will not pay benefits for a diagnosis of Alzheimer’s Disease for: other central nervous system conditions that may cause deficits in memory and cognition (e.g.,




breastbone, is divided down the middle from top to bottom).

We will not pay benefits for a diagnosis of Full Benefit Cancer for: any condition that is Partial Benefit Cancer; any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1N0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter unless there is metastasis; any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging.

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We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter; any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging.

We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving organs received from non-human donors; involving implantation of mechanical devices or mechanical organs; involving stem cell generated transplants; or involving islet cell transplants.

We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions.

Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition.

General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; or serving in the armed forces or any auxiliary unit of the armed forces of any country.

We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared.

We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States.

Exclusion for Intoxicants and Controlled Substances: We shall not be liable for any loss sustained or contracted in consequence of the Covered Person’s being intoxicated or under the influence of any controlled substance unless administered on the advice of a physician.

Exclusion for Illegal Occupation or Commission of a Felony: We shall not be liable for any loss to which a contributing cause was the commission of or attempt to commit a felony by the Covered Person whose injury or sickness is the basis of claim, or to which a contributing cause was such Covered Person’s being engaged in an illegal occupation.

Preexisting Condition Exclusion:

GOOC14-CI 5 CA

A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical treatment or care was recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.






11) PREMIUMS

GOOC14-CI 6 CA


GOOC14-CI 1 CO
















GOOC14-CI 2 CO

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount12.5% of Benefit Amount 50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:







6) DEFINITIONS

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person.

Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician who is board certified in the medical specialty that is appropriate for the type of cancerinvolved has determined that:

GOOC14-CI 3 CO


and will not benefit from, or has exhausted, curative therapy.

Listed Conditions means any of the following diseases: Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis.

Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below: carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has


malignant tumors classified as T1N0M0 or greater which are treated by endoscopic proceduresalone;


tumors of the prostate classified as T1bN0M0, or T1cN0M0, provided that they are treated with aradical prostatectomy or external beam radiotherapy.

7) EXCLUSIONS









We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging;

GOOC14-CI 4 CO

any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is onecentimeter or less in diameter;

any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging.





General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:


engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country.



Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident.

Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened.

Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

GOOC14-CI 5 CO

medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts; or

symptoms, or any medical or physical conditions existed that would cause an ordinarily prudent person to seek diagnosis, care or treatment.

We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 CO




11) PREMIUMS


GOOC14-CI 1 DE
















GOOC14-CI 2 DE

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount12.5% of Benefit Amount50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:


• we will not pay a Recurrence Benefit for a Covered Condition that recurs during a Benefit SuspensionPeriod; and

• we will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancerunless the Covered Person has not, for a period of 180 days, had symptoms of or been treated forthe Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit.


Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay a health benefit depending on the plan you select.


6) DEFINITIONS



GOOC14-CI 3 DE

• surgery, radiotherapy, or chemotherapy is medically necessary; • there is metastasis; or • the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis

and will not benefit from, or has exhausted, curative therapy. Listed Conditions means any of the following diseases: Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis. Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below: • carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has


• malignant tumors classified as T1N0M0 or greater which are treated by endoscopic procedures alone;

• malignant melanomas classified as T1N0M0, for which a pathology report shows maximum thickness less than or equal to 0.75 millimeters using the Breslow method of determining tumor thickness; and

• tumors of the prostate classified as T1bN0M0, or T1cN0M0, provided that they are treated with a radical prostatectomy or external beam radiotherapy.

7) EXCLUSIONS

Exclusions Related to Covered Conditions: We will not pay benefits for a diagnosis of Alzheimer’s Disease for: • other central nervous system conditions that may cause deficits in memory and cognition (e.g.,

cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus); • systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid

deficiency, niacin deficiency, hypercalcemia, neurosyphilis); • substance-induced conditions; or • any form of dementia that is not diagnosed as Alzheimer’s Disease.

We will not pay benefits for Coronary Artery Bypass Graft: • performed outside the United States; or • that does not involve median sternotomy (a surgical incision in which the sternum, also known as the

breastbone, is divided down the middle from top to bottom). We will not pay benefits for a diagnosis of Full Benefit Cancer for: • any condition that is Partial Benefit Cancer; • any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; • any papillary tumor of the bladder classified as Ta under TNM staging; • any tumor of the prostate classified as T1N0M0 under TNM staging; • any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter unless there is metastasis; • any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known


• any non-melanoma skin cancer unless there is metastasis; or • any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for:

GOOC14-CI 4 DE

• any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; • any papillary tumor of the bladder classified as Ta under TNM staging; • any tumor of the prostate classified as T1aN0M0 under TNM staging; • any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter; • any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known


• any non-melanoma skin cancer; or • any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: • performed outside the United States; • involving organs received from non-human donors; • involving implantation of mechanical devices or mechanical organs; • involving stem cell generated transplants; or • involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: • cerebral symptoms due to migraine; • cerebral injury resulting from trauma or hypoxia; or • vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: • a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); • a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or • a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: • participating in a felony, riot or insurrection; • intentionally causing a self-inflicted injury; • committing or attempting to commit suicide while sane or insane; • voluntarily taking or using any drug, medication or sedative unless it is:

• taken or used as prescribed by a physician; • an “over the counter” drug, medication or sedative taken according to package directions;

• engaging in an illegal occupation; or • serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident.

GOOC14-CI 5 DE

Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.


9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 You; • the date You cease to be in an eligible class; or • the date Your employment ends for any reason.

GOOC14-CI 6 DE


Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends except as described below. Continued Insurance is not available if: • Your Group Billed insurance ends due to Your failure to make a required premium payment; or • Your insurance ends because the Group Policy ends and, within 30 days of the day that the Group


11) PREMIUMS


GOOC14-CI 1 ID


NEW YORK, NEW YORK



OUTLINE OF COVERAGE








10 Day Right to Examine Certificate. You may return the Certificate to Us within 10 days from the date You receive it. If You return it within the 10 day period, the Certificate will be considered never to have been issued. We will refund any premium paid for insurance under this Certificate. NOTE: The terms “You” and “Your” refer to the employee who becomes insured for the group insurance coverage described in this outline. The term “Covered Person” refers to a person for whom insurance is in effect under the Certificate.







GOOC14-CI 2 ID

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount 12.5% of Benefit Amount 50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:





Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay a health screen benefit depending on the plan you select.


6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by the

GOOC14-CI 3 ID

uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis






7) EXCLUSIONS








any non-melanoma skin cancer unless there is metastasis; or

GOOC14-CI 4 ID

any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one



any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving stem cell generated transplants; or involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened.

GOOC14-CI 5 ID

Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.






GOOC14-CI 6 ID

11) PREMIUMS Premium rates are based on your age on the effective date of coverage and are shown in the enclosed materials. Premium rates are subject to change as stated in the Group Policy.

GOOC14-CI 1 KY
















GOOC14-CI 2 KY

5) BENEFITS






NONE 50% of Benefit Amount 50% of Benefit Amount 12.5% of Benefit Amount 50% of Benefit Amount




Recurrence Benefit:





Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay you a health screen benefit depending on the plan you select.


6) DEFINITIONS



GOOC14-CI 3 KY







7) EXCLUSIONS






centimeter or less in diameter unless there is metastasis; any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging;

GOOC14-CI 4 KY

any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one centimeter or less in diameter;


systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any narcotic, hallucinogen, medication or sedative unless it is:

taken or used as prescribed by a physician; an “over the counter” , narcotic, hallucinogen, medication or sedative taken according to package

directions; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion:

GOOC14-CI 5 KY

A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 KY


Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends except as described below. Continued Insurance is not available if Your Group Billed insurance ends due to Your failure to make a required premium payment.

11) PREMIUMS


GOOC14-CI 1 IL
















GOOC14-CI 2 IL

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 IL









7) EXCLUSIONS









increased risk due to the presence of Acquired Immune Deficiency Syndrome (AIDS) or the presenceof HIV;

any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging.

We will not pay benefits for a diagnosis of Partial Benefit Cancer for:

GOOC14-CI 4 IL









General Exclusions: We will not pay benefits for Covered Conditions caused by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:





Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident.

GOOC14-CI 5 IL


8) LIMITATIONS

Reduction of Benefits On Account of Prior Claims PaidWe will reduce what we pay for a claim so that the amount we pay, when combined with amounts for allclaims we have previously paid for the same Covered Person, does not exceed the Total Benefit Amountthat was in effect for that Covered Person on the date of the most recent Covered Condition. Thisprovision does not apply to claim payments for Supplemental Benefits.

Benefit Reduction Due to Age The Benefit Amount and the Total Benefit Amount will each be reduced by: 25% when the Covered Person reaches age 65; and, by 50% when the Covered Person reaches age 70. If the Total Benefit Amount, when reduced under the Benefit Reduction Due to Age, is less than or equal to the sum of all benefits previously paid under the Certificate, insurance under the Certificate will end on the date of such reduction.

9) WHEN INSURANCE ENDS

Date Your Insurance Ends:Your insurance 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 You; the date You cease to be in an eligible class; or the date Your employment ends for any reason.

Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts.

We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate.

The preexisting condition exclusion applies to benefit increases.

The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.

GOOC14-CI 6 IL


Insurance provided under the Certificate may be continued with premium payment in certain situations, asdescribed below. This is referred to as “Continued Insurance”. Insurance in effect under the GroupPolicy for which the group policyholder remits premium is referred to as “Group Billed Insurance”.

You may obtain Continued Insurance for You and for Your dependents by making a request inaccordance with requirements for such a request if Your Group Billed Insurance ends except asdescribed below.Continued Insurance is not available if: Your Group Billed insurance ends due to Your failure to make a required premium payment; or Your insurance ends because the Group Policy ends and, within 30 days of the day that the Group

Policy ends, You become eligible for insurance under another group policy of critical illness orspecified disease insurance issued to or provided through the group policyholder.

11) PREMIUMS

Premium rates are based on your age on the effective date of coverage and are shown in the enclosedmaterials. Premium rates are subject to change as stated in the Group Policy.

GOOC14-CI 1 IN
















GOOC14-CI 2 IN

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount 12.5% of Benefit Amount 50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 IN







7) EXCLUSIONS









GOOC14-CI 4 IN








GOOC14-CI 5 IN

Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 IN




11) PREMIUMS


GOOC14-CI 1 MA
















GOOC14-CI 2 MA

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 MA







7) EXCLUSIONS









GOOC14-CI 4 MA








GOOC14-CI 5 MA





9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 You; the date You cease to be in an eligible class; or the date 31 days after the date Your employment ends for any reason other than a Plant Closing, a

Partial Plant Closing or Your retirement unless during such 31 day period, You become entitled to benefits under another policy that are similar to the benefits provided under this Certificate; or

the date 90 days after the date Your employment ends due to a Plan Closing or a Partial Plant Closing unless, during such 90 day period, You become entitled to benefits under another policy that are similar to the benefits provided under this Certificate.

Plant Closing and Partial Plant Closing have the meaning set forth in Massachusetts Annotated Law, Chapter 151A, Section 71A

GOOC14-CI 6 MA




11) PREMIUMS


GOOC14-CI 1 MD
















GOOC14-CI 2 MD

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or

GOOC14-CI 3 MD

the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis and will not benefit from, or has exhausted, curative therapy.

Listed Conditions means any of the following diseases: Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis. Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below: carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has

been determined to be medically necessary by a physician; malignant tumors classified as T1N0M0 or greater which are treated by endoscopic procedures

alone; malignant melanomas classified as T1N0M0, for which a pathology report shows maximum thickness

less than or equal to 0.75 millimeters using the Breslow method of determining tumor thickness; and tumors of the prostate classified as T1bN0M0, or T1cN0M0, provided that they are treated with a

radical prostatectomy or external beam radiotherapy.

7) EXCLUSIONS Exclusions Related to Covered Conditions: We will not pay benefits for a diagnosis of Alzheimer’s Disease for: other central nervous system conditions that may cause deficits in memory and cognition (e.g.,





centimeter or less in diameter unless there is metastasis; any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter;

GOOC14-CI 4 MD

any non-melanoma skin cancer (if the non-melanoma skin cancer metastasizes while You are covered under this Certificate it will be considered Full Benefit Cancer); or

any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving organs received from non-human donors; involving implantation of mechanical devices or mechanical organs; involving stem cell generated transplants; or involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a diagnosis of a Listed Condition that is not a definitive Diagnosis. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. A Preexisting Condition does not include a condition revealed on an Enrollment form. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.

GOOC14-CI 5 MD


9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 grace period following the period for which the last full premium has been paid for You; the date You cease to be in an eligible class; or the date Your employment ends for any reason.

GOOC14-CI 6 MD




11) PREMIUMS


12) HEALTH COVERAGE OPTIONS FOR CHILDREN TURNING AGE 26 This Notice provides you with information about how a child may remain covered under your health coverage after the child reaches age 26. Your child may remain covered under your current policy as a dependent beyond age 26, under the following rules: Options to Remain Covered Under Parent's Coverage— If your child, at the time of reaching the limiting age in the policy, is incapable of self-support due to a mental or physical incapacity, the child may remain covered under your policy or contract as long as the child remains: Unmarried; Chiefly dependent on you for support; and Incapable of self-support due to the mental or physical incapacity; and If the child is your grandchild or an individual for whom guardianship is granted by court or

testamentary appointment, in your custody. Information Available from the Maryland Insurance Administration The Maryland Insurance Administration has information available regarding health coverage that you might find helpful. The information includes a Consumer Guide for Health Insurance, as well as a list of all the carriers who sell individual health insurance or individual HMO coverage in Maryland, including contact information. The Maryland Insurance Administration's website is www.mdinsurance.state.md.us. Their telephone number is 1-800-492-611

GOOC14-CI 1 ME



SPECIFIED DISEASE INSURANCE OUTLINE OF COVERAGE

THE CERTIFICATE PROVIDES LIMITED BENEFITS: THE CERTIFICATE ONLY PROVIDES SPECIFIED DISEASE COVERAGE IN THE EVENT THAT A COVERED PERSON IS DIAGNOSED WITH CERTAIN SPECIFIED DISEASES OR HAS CERTAIN

SURGICAL PROCEDURES PERFORMED. BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER MEDICAL

EXPENSES, PERSONS COVERED UNDER MEDICAID SHOULD NOT PURCHASE COVERAGE UNDER THE CERTIFICATE.



HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM METLIFE. READ THE BUYER’S GUIDE TO CANCER INSURANCE TO REVIEW THE POSSIBLE LIMITS ON

BENEFITS UNDER THIS TYPE OF COVERAGE.



2) SPECIFIED DISEASE INSURANCE COVERAGE. Policies of this category are designed to provide alump sum payment if the Covered Person is diagnosed with certain specified diseases for the first timeafter insurance takes effect under the Group Policy, or has certain specified surgeries for the first timeafter insurance takes effect under the Group Policy.



GOOC14-CI 2 ME

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which

the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person.

Full Benefit Cancer means the presence of one or more malignant tumors characterized by the

GOOC14-CI 3 ME

uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis






7) EXCLUSIONS









GOOC14-CI 4 ME

any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one






engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication:

GOOC14-CI 5 ME

We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.


9) WHEN INSURANCE ENDS RENEWABILITY OF THE GROUP POLICY. Once the Group Policy is in effect, it will remain in force until ended by either MetLife or the Group Policyholder. Date Your Insurance Ends: Your insurance 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 You; the date You cease to be in an eligible class; or the date Your employment ends for any reason.

GOOC14-CI 6 ME




11) PREMIUMS


GOOC14-CI 1 MN


NEW YORK, NEW YORK



OUTLINE OF COVERAGE















GOOC14-CI 2 MN

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 MN







7) EXCLUSIONS









GOOC14-CI 4 MN





systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; voluntarily taking or using any narcotic unless it is:

taken or used as prescribed by a physician; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is later confirmed in the United States. If this happens the Covered Condition will be deemed to have occurred on the date the diagnosis outside the United States was made. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts.

GOOC14-CI 5 MN


8) Limitations Reduction of Benefits On Account of Prior Claims Paid We will reduce what we pay for a claim so that the amount we pay, when combined with amounts for all claims we have previously paid for the same Covered Person, does not exceed the Total Benefit Amount that was in effect for that Covered Person on the date of the most recent Covered Condition. This provision does not apply to claim payments for Supplemental Benefits. Benefit Reduction Due to Age The Benefit Amount and the Total Benefit Amount will each be reduced by: 25% when the Covered Person reaches age 65; and, by 50% when the Covered Person reaches age 70. If the Total Benefit Amount, when reduced under the Benefit Reduction Due to Age, is less than or equal to the sum of all benefits previously paid under the Certificate, insurance under the Certificate will end on the date of such reduction.


GOOC14-CI 6 MN




11) PREMIUMS


GOOC14-CI 1 NC



CANCER AND SPECIFIED DISEASE INSURANCE OUTLINE OF COVERAGE








IMPORTANT CANCELLATION INFORMATION: Please read Section 9 of this Outline of Coverage titled “When Insurance Ends” found on page 5.

Cancer and Specified Diseases Insurance coverage is provided under a Group Policy that has been issued to the POLICYHOLDER. One certificate is issued to each employee who is covered under the Group Policy. The Group Policy is a LIMITED POLICY. An employee applying for coverage under the Group Policy is referred to herein as “you” or “your”.

THE CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CERTIFICATE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is available from MetLife. The certificate provides cancer and specified diseases coverage only.



GOOC14-CI 2 NC

2) CANCER AND SPECIFIED DISEASESINSURANCE COVERAGE. Policies of this category aredesigned to provide a lump sum payment if the Covered Person is diagnosed with certain specifieddiseases for the first time after insurance takes effect under the Group Policy, or has certain specifiedsurgeries for the first time after insurance takes effect under the Group Policy.



5) BENEFITS








Recurrence Benefit:





Health Screening Benefit

GOOC14-CI 3 NC

If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay a health sscreening benefit depending on the plan you select.


6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis








7) EXCLUSIONS







GOOC14-CI 4 NC


centimeter or less in diameter unless there is metastasis; any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one

centimeter or less in diameter; any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving organs received from non-human donors; involving implantation of mechanical devices or mechanical organs; involving stem cell generated transplants; or involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: actively participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:


engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared.

GOOC14-CI 5 NC

We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, diagnosis, care or treatment was recommended by, or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 NC




11) PREMIUMS


GOOC14-CI 1 ND
















GOOC14-CI 2 ND

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 ND









7) EXCLUSIONS










GOOC14-CI 4 ND





engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered

GOOC14-CI 5 ND

Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 ND




11) PREMIUMS


GOOC14-CI 1 NE
















GOOC14-CI 2 NE

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 NE







7) EXCLUSIONS









GOOC14-CI 4 NE





systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: committing a felony or attempting to commit a felony, participating in a riot or insurrection ; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:



GOOC14-CI 5 NE


prescribed by or received from a physician or other practitioner of the healing arts; or any medical or physical conditions existed that would cause an ordinarily prudent person to seek

diagnosis, care or treatment. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 NE




11) PREMIUMS


GOOC14-CI 1 NJ




THE CERTIFICATE IS A GROUP CERTIFICATE. IT PROVIDES LIMITED BENEFITS: THE CERTIFICATE ONLY PROVIDES CRITICAL ILLNESS COVERAGE IN THE EVENT THAT A

COVERED PERSON IS DIAGNOSED WITH CERTAIN SPECIFIED DISEASES. IT DOES NOT PROVIDE COMPREHENSIVE MEDICAL OR HOSPITAL INSURANCE, MEDICARE SUPPLEMENT INSURANCE,

LONG-TERM CARE INSURANCE, NURSING HOME INSURANCE ONLY, HOME HEALTH CARE INSURANCE ONLY, OR NURSING HOME AND HOME CARE INSURANCE. YOU MAY CONTACT YOUR LOCAL SOCIAL SECURITY OFFICE OR METLIFE AND OBTAIN A COPY OF THE GUIDE TO HEALTH

INSURANCE FOR PEOPLE WITH MEDICARE. RECEIPT OF BENEFITS UNDER THE CERTIFICATE MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL BENEFITS AND ENTITLEMENTS.







3) THE GROUP POLICY DOES NOT PROVIDE ANY TYPE OF MEDICAL COVERAGE AND IS NOT ASUBSTITUTE FOR MEDICAL COVERAGE OR DISABILITY INSURANCE. YOU MUST HAVEMEDICAL INSURANCE IN PLACE WHEN YOU ENROLL FOR THIS COVERAGE.


GOOC14-CI 2 NJ

5) BENEFITS





Alzheimer’s Disease 100% of Benefit Amount Coronary Artery Disease 100% of Benefit Amount Full Benefit Cancer 100% of Benefit Amount Partial Benefit Cancer 25% of Benefit Amount Heart Attack 100% of Benefit Amount Kidney Failure 100% of Benefit Amount Stroke 100% of Benefit Amount Listed Conditions 25% of Benefit Amount Major Organ Transplant 100% of Major Organ



Recurrence Benefit:







6) DEFINITIONS


Coronary Artery Disease means the blockage or narrowing of one or more coronary arteries due toatherosclerotic heart disease for which a Physician has determined coronary artery bypass graft to bemedically necessary.

GOOC14-CI 3 NJ

Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis








7) EXCLUSIONS





We will not pay benefits for Coronary Disease: for Coronary Artery Bypass Graft performed outside the United States unless coronary artery bypass

graft is performed in the United States.




GOOC14-CI 4 NJ


centimeter or less in diameter; any non-melanoma skin cancer; or any melanoma in situ classified as TisN0M0 under TNM staging. We will not pay benefits for a Major Organ Transplant: performed outside the United States; involving organs received from non-human donors; involving implantation of mechanical devices or mechanical organs; involving stem cell generated transplants; or involving islet cell transplants. We will not pay benefits for a diagnosis of Stroke for: cerebral symptoms due to migraine; cerebral injury resulting from trauma or hypoxia; or vascular disease affecting the eye or optic nerve or vestibular functions. Exclusions Related to Listed Conditions: We will not pay benefits for: a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS); a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as

systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: committing or attempting to commit a felony; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s being intoxicated or being under the influence of any narcotic unless administered or consumed on the advice of a physician . Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered

GOOC14-CI 5 NJ

Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. If no benefits are paid for a Covered Condition because it is caused by or results from a Preexisting Condition, We will treat the Covered Person’s next Occurrence (if any) of such Covered Condition as the First Occurrence of such Covered Condition provided that: the next Occurrence of the Covered Condition occurs after the first 3 months that the Covered Person

is insured under this Certificate; or with respect to a Benefit Increase, the Covered Condition occurs more than 3 months after such

increase in the Total Benefit Amount. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.

8) LIMITATIONS Reduction of Benefits On Account of Prior Claims Paid We will reduce what we pay for a claim so that the amount we pay, when combined with amounts for all claims we have previously paid for the same Covered Person, does not exceed the Total Benefit Amount that was in effect for that Covered Person on the date of the most recent Covered Condition. This provision does not apply to claim payments for Supplemental Benefits.


GOOC14-CI 6 NJ




11) PREMIUMS

Premium rates are based on your age on the effective date of coverage and are shown in the enclosed materials. Premium rates are subject to change as stated in the Group Policy. The applicable premium for you is shown in the rate sheet.

12) DISCLOSURE This outline of coverage is only a very brief summary of your certificate.

The certificate itself sets forth the rights and obligations of both you and the insurance company. It is therefore imperative that you READ YOUR CERTIFICATE carefully. The anticipated loss ratio for this certificate is 75%. This ratio is the portion of future premiums which MetLife expects to return as benefits, when averaged over all people with this certificate.

GOOC14-CI 1 NV
















GOOC14-CI 2 NV

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 NV







7) EXCLUSIONS









GOOC14-CI 4 NV





systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts.

GOOC14-CI 5 NV




GOOC14-CI 6 NV




11) PREMIUMS


GOOC14-CI 1 OK
















GOOC14-CI 2 OK

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that: surgery, radiotherapy, or chemotherapy is medically necessary;

GOOC14-CI 3 OK

there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis






7) EXCLUSIONS Exclusions Related to Covered Conditions: We will not pay benefits for a diagnosis of Alzheimer’s Disease for: other central nervous system conditions that may cause deficits in memory and cognition (e.g.,







any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging;

GOOC14-CI 4 OK

any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one






engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion:

GOOC14-CI 5 OK

A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage: medical advice, treatment or care was sought by such Covered Person, or recommended by,





GOOC14-CI 6 OK




11) PREMIUMS


GOOC14-CI 1 OR
















GOOC14-CI 2 OR

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 OR







7) EXCLUSIONS









GOOC14-CI 4 OR







engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

GOOC14-CI 5 OR






GOOC14-CI 6 OR




11) PREMIUMS


GOOC14-CI 1 PA
















GOOC14-CI 2 PA

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 PA









7) EXCLUSIONS












GOOC14-CI 4 PA








GOOC14-CI 5 PA

Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 90 days before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 PA




11) PREMIUMS


GOOC14-CI 1 RI
















GOOC14-CI 2 RI

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 RI









7) EXCLUSIONS












GOOC14-CI 4 RI








GOOC14-CI 5 RI




GOOC14-CI 6 RI




11) PREMIUMS


GOOC14-CI 1 SD
















GOOC14-CI 2 SD

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician who is board certified in the medical specialty that is appropriate for the type of cancerinvolved has determined that: surgery, radiotherapy, or chemotherapy is medically necessary;

GOOC14-CI 3 SD

there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis






7) EXCLUSIONS








any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth;

GOOC14-CI 4 SD

any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one




systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage: medical advice, treatment or care was sought by such Covered Person, or recommended by,


person to seek diagnosis, care or treatment.

GOOC14-CI 5 SD

We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the claim for such Covered Condition is incurred during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 SD




11) PREMIUMS


GOOC14-CI 1 TX


NEW YORK, NEW YORK



OUTLINE OF COVERAGE









1) THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. READ YOUR CERTIFICATE CAREFULLY. This outline of coverage provides a very brief description of the important features of the group insurance coverage provided by the Group Policy and Certificate. This is not the insurance contract and only the actual provisions of the Group Policy and Certificate under which You have coverage will control. The Certificate sets forth in detail the rights and obligations of both You and MetLife with respect to the coverage. It is, therefore, important that You READ YOUR CERTIFICATE CAREFULLY!




GOOC14-CI 2 TX


5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS

GOOC14-CI 3 TX

Benefit Suspension Period means the 365 day period following the date a Covered Condition, for which the Certificate pays a benefit, “Occurs”, as defined in the Certificate, with respect to a Covered Person. Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis








7) EXCLUSIONS








centimeter or less in diameter unless there is metastasis;

GOOC14-CI 4 TX

any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a knownincreased risk due to the presence of Acquired Immune Deficiency Syndrome (AIDS) or the presenceof HIV;


We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one












GOOC14-CI 5 TX

We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 TX




11) PREMIUMS


GOOC14-CI 1 VA
















GOOC14-CI 2 VA

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount12.5% of Benefit Amount50% of Benefit Amount NONE 50% of Benefit Amount NONE NONE


Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 VA







7) EXCLUSIONS









GOOC14-CI 4 VA








GOOC14-CI 5 VA




GOOC14-CI 6 VA




11) PREMIUMS


GDISC14-CI-WA 1 WA


IMPORTANT INFORMATION ABOUT THE COVERAGE YOU ARE BEING OFFERED


Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about fixed payment benefits. Critical Illness Insurance coverage is provided under a Group Policy that has been issued to Policyholder. One certificate is issued to each employee who is covered under the Group Policy. The Group Policy is a LIMITED POLICY. An employee applying for coverage under the Group Policy is referred to herein as “you” or “your”.

THE CERTIFICATE ONLY PROVIDES CRITICAL ILLNESS COVERAGE IN THE EVENT THAT A COVERED PERSON IS DIAGNOSED WITH CERTAIN SPECIFIED DISEASES OR HAS CERTAIN









CRITICAL ILLNESS INSURANCE COVERAGE. Policies of this category are designed to provide a lumpsum payment if the Covered Person is diagnosed with certain specified diseases for the first time afterinsurance takes effect under the Group Policy, or has certain specified surgeries for the first time afterinsurance takes effect under the Group Policy.

This coverage is not comprehensive health care insurance and will not cover the cost of most hospital

and other medical services.

GDISC14-CI-WA 2 WA

This disclosure provides a very brief description of the important features of the coverage being considered. It is not an insurance contract and only the actual policy provisions will control. The policy itself will include in detail the rights and obligations of both the master policyholder and Metropolitan Life Insurance Company (“MetLife”).

This coverage is designed to pay you a fixed dollar amount regardless of the amount that the provider charges. Payments are not based on a percentage of the provider’s charge and are paid in addition to any other health plan coverage you may have.

The benefits under this policy are summarized below:

Type of Coverage: Critical Illness Insurance Coverage. Policies of this category are designed to provide a fixed payment if the covered person is diagnosed with certain specified diseases or has certain surgeries performed for the first time after the coverage effective date. Alzheimer’s Disease, Heart Attack, Kidney Failure, Listed Conditions, Major Organ Transplant, Stroke, Full Benefit Cancer, Partial Benefit Cancer and Coronary Artery Bypass Graft (the “covered conditions”) are the only diseases or surgeries for which a covered person may receive benefits under the certificate.

2) BENEFITS










Recurrence Benefit:


CAUTION: If you are also covered under a High Deductible Health Plan (HDHP) and are contributing to a Health Savings Account (HSA), you should check with your tax advisor or benefit advisor prior to purchasing this coverage to be sure that you will continue to be eligible to contribute to the HSA if this coverage is purchased.

GDISC14-CI-WA 3 WA






3) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that: surgery, radiotherapy, or chemotherapy is medically necessary; there is metastasis; or the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis








4) EXCLUSIONS



cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus);

GDISC14-CI-WA 4 WA

systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis);

substance-induced conditions; or any form of dementia that is not diagnosed as Alzheimer’s Disease.





any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging; any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one





GDISC14-CI-WA 5 WA

General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage: medical advice, treatment or care was sought by such Covered Person, or recommended by,





GDISC14-CI-WA 6 WA




8) PREMIUMS


GOOC14-CI 1 WI
















GOOC14-CI 2 WI

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 WI









7) EXCLUSIONS










GOOC14-CI 4 WI



systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection for which the Covered Person was convicted; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; voluntarily taking or using any drug, medication or sedative unless it is:


engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

GOOC14-CI 5 WI





9) WHEN INSURANCE ENDS Date Your Insurance Ends: Your insurance 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 last day of the 31 day grace period following the date the last full premium was paid for

You; the date You cease to be in an eligible class; or the date Your employment ends for any reason.

GOOC14-CI 6 WI




11) PREMIUMS


GOOC14-CI 1 WY
















GOOC14-CI 2 WY

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 WY









7) EXCLUSIONS












GOOC14-CI 4 WY















GOOC14-CI 5 WY


Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person

becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts.




8) LIMITATIONS





GOOC14-CI 6 WY




11) PREMIUMS


GOOC14-CI 1 WV
















GOOC14-CI 2 WV

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 WV







7) EXCLUSIONS









GOOC14-CI 4 WV








GOOC14-CI 5 WV




GOOC14-CI 6 WV




11) PREMIUMS


GOOC14-CI 1 MO
















GOOC14-CI 2 MO

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 MO







7) EXCLUSIONS









GOOC14-CI 4 MO





systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane; voluntarily taking or using any drug, medication or sedative unless it is:



GOOC14-CI 5 MO




GOOC14-CI 6 MO




11) PREMIUMS


This product is not approved for policies to be issued in this state. Please verify the correct POLICY ISSUANCE state. Furthermore, if you are a RESIDENT of this state you are not eligible to enroll for this product.

This product is not approved for policies to be issued in this state. Please verify the correct POLICY ISSUANCE state.

GOOC14-CI 1 UT
















GOOC14-CI 2 UT

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount12.5% of Benefit Amount50% of Benefit Amount


NONE 50% of Benefit AmountNONE NONE


Recurrence Benefit:


we will not pay a Recurrence Benefit for a Covered Condition that recurs less than 365 days after another Occurrence of a Coverage condition for which we paid a benefit; and we will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancer unless the Covered Person has not, for a period of 180 days, had symptoms of or been treated for the Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit.


Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate,we will pay a health screening benefit depending on the plan you select.


6) DEFINITIONS

Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that:

surgery, radiotherapy, or chemotherapy is medically necessary;

there is metastasis; or

the patient has terminal cancer, is expected to die within 24 months or less from the date of diagnosis and will not benefit from, or has exhausted, curative therapy.

GOOC14-CI 3 UT


Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below:

carcinoma in situ classified as TisN0M0, provided that surgery, radiotherapy or chemotherapy has been determined to be medically necessary by a physician;




7) EXCLUSIONS


We will not pay benefits for a diagnosis of Alzheimer’s Disease for:

other central nervous system conditions that may cause deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus);

systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis);

substance-induced conditions; or

any form of dementia that is not diagnosed as Alzheimer’s Disease.

We will not pay benefits for Coronary Artery Bypass Graft:

performed outside the United States; or

that does not involve median sternotomy (a surgical incision in which the sternum, also known as the breastbone, is divided down the middle from top to bottom).

We will not pay benefits for a diagnosis of Full Benefit Cancer for:

any condition that is Partial Benefit Cancer;

any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth;

any papillary tumor of the bladder classified as Ta under TNM staging;

any tumor of the prostate classified as T1N0M0 under TNM staging;

any papillary tumor of the thyroid that is classified as T1N0M0 or less under TNM staging and is one centimeter or less in diameter unless there is metastasis;

any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known increased risk due to the presence of Acquired Immune Deficiency Syndrome (AIDS) or the presence of HIV;


any malignant tumor classified as less than T1N0M0 under TNM staging.



any papillary tumor of the bladder classified as Ta under TNM staging;

any tumor of the prostate classified as T1aN0M0 under TNM staging;


GOOC14-CI 4 UT

any cancer in the presence of human immuno-deficiency virus (HIV) for which there is a known increased risk due to the presence of Acquired Immune Deficiency Syndrome (AIDS) or the presence of HIV;

any non-melanoma skin cancer; or

any melanoma in situ classified as TisN0M0 under TNM staging.

We will not pay benefits for a Major Organ Transplant:

performed outside the United States;

involving organs received from non-human donors;

involving implantation of mechanical devices or mechanical organs;

involving stem cell generated transplants; or

involving islet cell transplants.

We will not pay benefits for a diagnosis of Stroke for:

cerebral symptoms due to migraine;

cerebral injury resulting from trauma or hypoxia; or

vascular disease affecting the eye or optic nerve or vestibular functions.

Exclusions Related to Listed Conditions: We will not pay benefits for:

a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS);

a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not diagnosed as systemic lupus erythematosus (SLE); or

a suspected or probable diagnosis of a Listed Condition.

General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person:

voluntarily participating in a felony, riot or insurrection;

intentionally and voluntarily causing a self-inflicted injury;

committing or attempting to commit suicide while sane or insane;

voluntarily taking or using any drug, medication or sedative unless it is:

taken or used as prescribed by a physician;

an “over the counter” drug, medication or sedative taken according to package directions;

engaging in an illegal occupation; or

serving in the armed forces or any auxiliary unit of the armed forces of any country.





GOOC14-CI 5 UT

Preexisting Condition Exclusion:

A preexisting condition is a sickness or injury which first manifests itself in the 6 months before a Covered Person becomes insured under this Certificate, or before any Benefit Increase with respect to such Covered Person; or was diagnosed by a Physician at any time prior to the effective date of coverage.




8) LIMITATIONS




Date Your Insurance Ends:Your insurance 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 You;

the date You cease to be in an eligible class; or

the date Your employment ends for any reason.

GOOC14-CI 6 UT


Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends except as described below. Continued Insurance is not available if:

Your Group Billed insurance ends due to Your failure to make a required premium payment; or

Your insurance ends because the Group Policy ends and, within 30 days of the day that the Group Policy ends, You become eligible for insurance under another group policy of critical illness or specified disease insurance issued to or provided through the group policyholder.

11) PREMIUMS


GOOC14-CI 1 CT
















GOOC14-CI 2 CT

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 CT







7) EXCLUSIONS









GOOC14-CI 4 CT





systemic lupus erythematosus (SLE); or a suspected or probable diagnosis of a Listed Condition. General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. Riot means all forms of public violence, disorder, or disturbance of the peace by three or more persons. It does not matter whether: there was common intent; or there was intent to damage any person or property, or to break the law. We will not pay benefits for any Covered Conditions caused by the voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless as prescribed by the Covered Person’s Physician. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared.

GOOC14-CI 5 CT

We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts. We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under the Certificate. The preexisting condition exclusion applies to benefit increases. The preexisting condition exclusion does not apply to benefits for Heart Attack and Stroke.



GOOC14-CI 6 CT


Insurance provided under the Certificate may be continued with premium payment in certain situations, as described below. This is referred to as “Continued Insurance”. Insurance in effect under the Group Policy for which the group policyholder remits premium is referred to as “Group Billed Insurance”. You may obtain Continued Insurance for You and for Your dependents by making a request in accordance with requirements for such a request if Your Group Billed Insurance ends for any reason other than Your failure to make a required contribution.

11) PREMIUMS


GOOC14-CI 1 MT


POLICYHOLDER: Your Employer Group Policy Form No: GPNP14-CI (Referred to as the “Group Policy”)

Certificate Form No: GCERT14-CI-MT1 (Referred to as the “Certificate”)



SURGICAL PROCEDURES PERFORMED. THE CERTIFICATE DOES NOT PROVIDE COVERAGE FOR MENTAL ILLNESS OR CHEMICAL DEPENDENCY. RECEIPT OF BENEFITS UNDER THE CERTIFICATE

MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL BENEFITS AND ENTITLEMENTS. ACCORDINGLY, PERSONS WHO WISH TO MAINTAIN ELIGIBILITY FOR SUCH BENEFITS SHOULD NOT PURCHASE THE COVERAGE MADE AVAILABLE UNDER THE GROUP

POLICY WITHOUT CONSULTING A LEGAL ADVISOR. BENEFIT AMOUNTS ARE NOT BASED ON ANY MEDICAL

EXPENSES INCURRED.








GOOC14-CI 2 MT

5) BENEFITS










Recurrence Benefit:







Mammogram Benefit For women who are 35 years of age or older, a mammogram that is performed will be covered each year for $70.

GOOC14-CI 3 MT





been determined to be medically necessary;




7) EXCLUSIONS







6) DEFINITIONS


Full Benefit Cancer means the presence of one or more malignant tumors characterized by theuncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue providedthat a physician has determined that:

GOOC14-CI 4 MT














GOOC14-CI 5 MT


Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 6 months before a Covered Person becomes insured for this coverage, medical advice, treatment or care was recommended by, prescribed by or received from a physician or other practitioner of the healing arts.






Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is voluntarily intoxicated at the time of the incident and is the operator of a vehicle involved in the incident.




GOOC14-CI 6 MT







8) LIMITATIONS



11) PREMIUMS


Please complete the following estimated annual premium information once you have made your coverage selections using the premium rate sheets supplied by us.

Estimated annual premium (to be completed by applicant): $_______________

At this time there is no trend information regarding premium increases and decreases to disclose.

GOOC14-CI 7 MT

GOOC14-CI 1 VT


POLICYHOLDER: Your Employer Group Policy Form No: GPNP14-CI (Referred to as the “Group Policy”)

Certificate Form No: GCERT14-CI [1] (Referred to as the “Certificate”)

LIMITED BENEFIT INSURANCE OUTLINE OF COVERAGE

THE CERTIFICATE PROVIDES LIMITED BENEFITS: THE CERTIFICATE ONLY PROVIDES LIMITED BENEFIT COVERAGE IN THE EVENT THAT A

COVERED PERSON IS DIAGNOSED WITH CERTAIN SPECIFIED DISEASES OR HAS CERTAIN SURGICAL PROCEDURES PERFORMED. THE CERTIFICATE DOES NOT PROVIDE COVERAGE FOR

MENTAL ILLNESS OR CHEMICAL DEPENDENCY. RECEIPT OF BENEFITS UNDER THE CERTIFICATE MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL BENEFITS AND

ENTITLEMENTS. ACCORDINGLY, PERSONS WHO WISH TO MAINTAIN ELIGIBILITY FOR SUCH BENEFITS SHOULD NOT PURCHASE THE COVERAGE MADE AVAILABLE UNDER THE GROUP

POLICY WITHOUT CONSULTING A LEGAL ADVISOR. BENEFIT AMOUNTS ARE NOT BASED ON ANY MEDICAL

EXPENSES INCURRED.





2) LIMITED BENEFIT INSURANCE COVERAGE. Policies of this category are designed to provide a lumpsum payment if the Covered Person is diagnosed with certain specified diseases for the first time afterinsurance takes effect under the Group Policy, or has certain specified surgeries for the first time afterinsurance takes effect under the Group Policy.



GOOC14-CI 2 VT

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount 12.5% of Benefit Amount 50% of Benefit Amount




Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 VT









7) EXCLUSIONS












GOOC14-CI 4 VT









General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane; engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country.



GOOC14-CI 5 VT

Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage: medical advice, treatment or care was sought by such Covered Person, or recommended by,


person to seek diagnosis, care or treatment.




8) LIMITATIONS


Benefit Reduction Due to AgeThe Benefit Amount and the Total Benefit Amount will each be reduced by: 25% when the CoveredPerson reaches age 65; and, by 50% when the Covered Person reaches age 70. If the Total BenefitAmount, when reduced under the Benefit Reduction Due to Age, is less than or equal to the sum of allbenefits previously paid under the Certificate, insurance under the Certificate will end on the date of suchreduction.



GOOC14-CI 6 VT





11) PREMIUMS


GOOC14-CI 1 DC
















GOOC14-CI 2 DC

5) BENEFITS










Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 DC









7) EXCLUSIONS












GOOC14-CI 4 DC















GOOC14-CI 5 DC


Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage medical advice, treatment or care was sought by such Covered Person, or recommended by, prescribed by or received from a physician or other practitioner of the healing arts.




8) LIMITATIONS





GOOC14-CI 6 DC





11) PREMIUMS


GOOC14-CI 1 FL
















GOOC14-CI 2 FL

5) BENEFITS






NONE 50% of Benefit Amount50% of Benefit Amount 12.5% of Benefit Amount50% of Benefit Amount




Recurrence Benefit:







6) DEFINITIONS



GOOC14-CI 3 FL







7) EXCLUSIONS






centimeter or less in diameter unless there is metastasis; any non-melanoma skin cancer unless there is metastasis; or any malignant tumor classified as less than T1N0M0 under TNM staging. We will not pay benefits for a diagnosis of Partial Benefit Cancer for: any benign tumor, dysplasia, intraepithelial neoplasia or pre-malignant growth; any papillary tumor of the bladder classified as Ta under TNM staging; any tumor of the prostate classified as T1aN0M0 under TNM staging;

GOOC14-CI 4 FL





engaging in an illegal occupation; or serving in the armed forces or any auxiliary unit of the armed forces of any country. We will not pay benefits for Covered Conditions arising from war or any act of war, even if war is not declared. We will not pay benefits for any Covered Condition for which diagnosis is made outside the United States, unless the diagnosis is confirmed in the United States, in which case the Covered Condition will be deemed to occur on the date the diagnosis is made outside the United States. Exclusion for Intoxication: We will not pay benefits for any Covered Condition that is caused by, contributed to by, or results from a Covered Person’s involvement in an incident, where such Covered Person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. Intoxicated means that the Covered Person’s alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident happened. Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

GOOC14-CI 5 FL






GOOC14-CI 6 FL




11) PREMIUMS


GOOC14-CI 1 GA



LIMITED BENEFIT CRITICAL ILLNESS INSURANCE OUTLINE OF COVERAGE










2) LIMITED BENEFIT CRITICAL ILLNESS INSURANCE COVERAGE. Policies of this category aredesigned to provide a lump sum payment if the Covered Person is diagnosed with certain specifieddiseases for the first time after insurance takes effect under the Group Policy, or has certain specifiedsurgeries for the first time after insurance takes effect under the Group Policy.



GOOC14-CI 2 GA

5) BENEFITS










Recurrence Benefit:





Health Screening Benefit If a Covered Person takes one of the screening/prevention measures listed in the Certificate, we will pay you a health screening benefit depending on the plan you select.


6) DEFINITIONS



GOOC14-CI 3 GA









7) EXCLUSIONS












GOOC14-CI 4 GA








GOOC14-CI 5 GA






GOOC14-CI 6 GA




11) PREMIUMS


GOOC14-CI-1 NH


POLICYHOLDER: Your EmployerGroup Policy Form No: GPNP14-CI (Referred to as the “Group Policy”)

Certificate Form No: GCERT14-CI (Referred to as the “Certificate”)

CRITICAL ILLNESS INSURANCE COVERAGE ONLYTHIS CERTIFICATE PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES


SURGICAL PROCEDURES PERFORMED. RECEIPT OF BENEFITS UNDER THE CERTIFICATE MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL ENTITLEMENTS.







1) This coverage is designed only as a supplement to a comprehensive health insurance policy and shouldnot be purchased unless you have this underlying coverage. Persons covered under Medicaid should notpurchase it. Read the Buyer’s Guide to Specified Disease Insurance to review the possible limits onbenefits in this type of coverage.


3) CRITICAL ILLNESS INSURANCE COVERAGE. Policies of this category are designed to provide topersons insured, restricted coverage payment benefits ONLY when certain losses occur as a result ofcritical illness. Coverage is not provided for basic hospital, basic medical-surgical, or major medicalexpense. Policies of this category are designed to provide a lump sum payment if the Covered Person isdiagnosed with certain specified diseases for the first time after insurance takes effect under the Group

OUTLINE OF COVERAGE

GOOC14-CI-1 NH

Policy, or has certain specified surgeries for the first time after insurance takes effect under the Group Policy.



6) BENEFITS


The Benefit Amount that determines the benefits for Covered Conditions is shown on Your enrollment form. There is a separate Benefit Amount that applies to Major Organ Transplant. The Total Benefit Amount is the maximum aggregate amount that we will pay for any and all Covered Conditions except Major Organ Transplant, combined. The Total Benefit Amount does not include Supplemental Benefits or the Major Organ Transplant Benefit Amount.


Covered Condition Initial Benefit Recurrence Benefit For First Occurrence 100% of Benefit Amount 100% of Benefit Amount 100% of Benefit Amount 25% of Benefit Amount $100 100% of Benefit Amount 100% of Benefit Amount 100% of Benefit Amount 25% of Benefit Amount

Alzheimer’s Disease Coronary Artery Bypass Graft Full Benefit Cancer Partial Benefit Cancer All Other Cancer Heart Attack Kidney Failure Severe Stroke Listed Conditions Major Organ Transplant 100% of Major Organ

NONE 50% of Benefit Amount 50% of Benefit Amount 12.5% of Benefit Amount $5050% of Benefit Amount NONE 50% of Benefit Amount NONE** NONE


Recurrence Benefit:



we will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancer or an

All Other Cancer unless the Covered Person has not, for a period of 180 days, had symptoms of orbeen treated for the Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit.

GOOC14-CI-1 NH

7) DEFINITIONS

All Other Cancer means all cancers that are not Full Benefit Cancer or Partial Benefit Cancer.


Full Benefit Cancer means the presence of one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue provided that a physician who is board certified in the medical specialty that is appropriate for the type of cancer involved has made such a determination.

Listed Conditions means any of the following diseases:

Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia; (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis.

Partial Benefit Cancer means one of the following conditions that meets the TNM staging classification and other qualifications specified below:

carcinoma in situ classified as Stage 0 and as TisN0M0 (cancer cells that still lie in the tissue of thesite or origin and have not spread to neighboring tissue), provided that surgery, radiotherapy orchemotherapy has been determined to be medically necessary by a physician who is board certifiedin the medical specialty that is appropriate for the type of carcinoma in situ involved;

malignant tumors classified as Stage I or greater and as T1-4N0-3M0-1 provided that such tumorsare treated by endoscopic procedures alone. (In other words);

the primary tumor is assigned a “T1”, “T2”, “T3” or “T4”;

the extent of spread to lymph nodes is assigned a “N0”, “N1”, or “N3”; and

the absence or presence of distant metastasis is assigned an “M0” or “M1”; provided thatsuch tumors are treated by endoscopic procedures alone);

malignant melanomas classified as Stage I and T1N0M0 (localized melanoma that has not spread tothe lymph nodes and where there is no distant metastasis), for which a pathology report showsmaximum thickness less than or equal to 0.75 millimeters using the Breslow method of determiningtumor thickness;

tumors of the prostate classified as Stage II and T1bN0M0 (cancer that cannot be detected by digitalrectal examination or seen by imaging, which is incidentally found when prostate tissue is removedfor reasons other than cancer, which occupies more than 5% of the tissue removed, that has notspread to the lymph nodes and where there is no distant metastasis), provided that they are treatedwith a radical prostatectomy or external beam radiotherapy; and

tumors of the prostate classified as Stage II and T1cN0M0 (cancer that cannot be detected by digitalrectal examination or seen by imaging, which is identified by needle biopsy, often because ofelevated PSA levels, that has not spread to the lymph nodes and where there is no distantmetastasis), provided that they are treated with a radical prostatectomy or external beamradiotherapy.

GOOC14-CI-1 NH

8) EXCLUSIONS


We will not pay benefits for a diagnosis of Alzheimer’s Disease for:

other central nervous system conditions that may cause deficits in memory and cognition (e.g.,cerebrovascular disease, Parkinson’s disease, normal-pressure hydrocephalus);

systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic aciddeficiency, niacin deficiency, hypercalcemia, neurosyphilis);

substance-induced conditions; or

any form of dementia that is not diagnosed as Alzheimer’s Disease.

We will not pay benefits for Coronary Artery Bypass Graft:

performed outside the United States; or

that does not involve median sternotomy (a surgical incision in which the sternum, also known as thebreastbone, is divided down the middle from top to bottom).

We will not pay benefits for a diagnosis of Full Benefit Cancer for:

any condition that is Partial Benefit Cancer;


any papillary tumor of the bladder classified under TNM Staging as TaN0M0 (a tumor of the bladderthat has not spread to the lymph nodes and where there is no distant metastasis);

any tumor of the prostate classified under TNM Staging as T1N0M0 (cannot be detected by digitalrectal examination or seen by imaging, which has not spread to the lymph nodes and where there isno distant metastasis);

any papillary tumor of the thyroid that is classified under TNM Staging as Stage I and as T1N0M0 orless (a tumor that is confined to the thyroid gland, which has not spread to the lymph nodes andwhere there is no distant metastasis) provided that such tumor is one centimeter or less in diameterunless there is metastasis;


any malignant tumor classified under TNM Staging as Stage 0, Stage I or Stage II and as less thanT1N0M0.



any papillary tumor of the bladder classified under TNM Staging as Stage 0a and as TaN0M0 (atumor that has not spread to the lymph nodes and where there is no distant metastasis);

any tumor of the prostate classified under TNM Staging as T1aN0M0 (cancer that cannot be detectedby digital rectal examination or seen by imaging, which is incidentally found when prostate tissue isremoved for reasons other than cancer, that is limited to 5% or less of the prostate tissue removed,that has not spread to the lymph nodes and where there is no distant metastasis);

any papillary tumor of the thyroid that is classified under TNM Staging as Stage I and as T1N0M0 orless (a tumor that is confined to the thyroid gland, which has not spread to the lymph nodes andwhere there is no distant metastasis) provided that the tumor is one centimeter or less in diameter;

any non-melanoma skin cancer; or

any melanoma in situ classified under TNM Staging.

We will not pay benefits for a Major Organ Transplant:

performed outside the United States;

involving organs received from non-human donors;

involving implantation of mechanical devices or mechanical organs;

involving stem cell generated transplants; or

involving islet cell transplants.

GOOC14-CI-1 NH

We will not pay benefits for a diagnosis of Severe Stroke for:

cerebral symptoms due to migraine;

cerebral injury resulting from trauma or hypoxia; or

vascular disease affecting the eye or optic nerve or vestibular functions.

We will not pay benefits for a Diagnosis of All Other Cancer for:

a condition that is Full Benefit Cancer; or

a condition that is Partial Benefit Cancer.

Exclusions Related to Listed Conditions: We will not pay benefits for:

a diagnosis of multiple sclerosis for clinically isolated syndrome (CIS);

a diagnosis of systemic lupus erythematosus (SLE) for any form of Lupus that is not Diagnosed assystemic lupus erythematosus (SLE); or

a suspected or probable diagnosis of a Listed Condition.

General Exclusions: We will not pay benefits for Covered Conditions caused or contributed to by, or resulting from a Covered Person:

participating in a felony, riot or insurrection;

intentionally causing a self-inflicted injury;

committing or attempting to commit suicide while sane or insane;

voluntarily taking or using any drug, medication or sedative unless it is:

taken or used as prescribed by a physician;

an “over the counter” drug, medication or sedative taken according to package directions;

engaging in an illegal occupation; or

serving in the armed forces or any auxiliary unit of the armed forces of any country.



Preexisting Condition Exclusion: A preexisting condition is a sickness or injury for which, in the 3 months before a Covered Person becomes insured for this coverage:

medical advice, treatment or care was sought by such Covered Person, or recommended by,prescribed by or received from a physician or other practitioner of the healing arts; or

symptoms, or any medical or physical conditions existed that would cause an ordinarily prudentperson to seek diagnosis, care or treatment.

We will not pay benefits for a Covered Condition that is caused by or results from a preexisting condition if the Covered Condition occurs during the first 6 months that a Covered Person is insured under theCertificate.


The preexisting condition exclusion does not apply to benefits for Heart Attack and Severe Stroke.

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9) LIMITATIONS



Date Your Insurance Ends:Your insurance 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 You;

the date You cease to be in an eligible class; or

the date Your employment ends for any reason.



You may obtain Continued Insurance for You and for Your dependents by making a request inaccordance with requirements for such a request if Your Group Billed Insurance ends except asdescribed below.Continued Insurance is not available if:

Your Group Billed insurance ends due to Your failure to make a required premium payment; or

Your insurance ends because the Group Policy ends and, within 30 days of the day that the GroupPolicy ends, You become eligible for insurance under another group policy of critical illness orspecified disease insurance issued to or provided through the group policyholder.

12) PREMIUMS


READ YOUR OUTLINE OF COVERAGE · the important features of the group insurance coverage provided by...

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