HCIWe operate a 24,000 sq. ft. full-service pharmacy that i s licensed and regulated by the Florida...

BETTER FUTURE.�� Build a Better Healthcare Future.

smHCI

Non

-Insu

ranc

e Se

rvic

es in

clud

e:Fr

ee V

itam

ins,

MeM

D (T

eleh

ealth

24/

7), &

Mai

lMyP

resc

riptio

ns.c

omRe

tail

Pres

crip

tion

Disc

ount

Car

d &

Pet R

X Di

scou

nt C

ard

��

��

�

��

�

��

��

��

��

��

��

��

��

��

��

Hos

pita

l Adm

issi

on In

dem

nity

, In-

Hos

pita

l Ind

emni

ty,

Surg

ical

Inde

mni

ty (I

n-ho

spita

l & O

utpa

tient

sur

gica

l pro

cedu

res)

��

� ��

��

��

��

��

��

��!

��

��

"#

��$

� ��

��

��

��an

d Em

erge

ncy

Room

Inde

mni

ty

GAP

HC

I PLA

N1 I

NC

LUDE

S

NON-INSURANCE SERVICES

EMERGENCY ROOM INDEMNITY

HOSPITAL ADMISSION & IN-HOSPITAL

INDEMNITY

SURGICALINDEMNITY

INTENSIVE CARE UNIT INDEMNITY

PHYSICIAN OFFICE VISIT INDEMNITY

UBAGapHCI_MemberGuide_v0419 [9908-17-48 | MB040219-AP]

United Business Association409 W Vickery Blvd, Fort Worth, TX 76104 | 866.438.4274 | ubamembers.com

1 �� !��"��#��$�� %

UBA Healthymericaa

Federal Insurance Company, a member insurer of the Chubb Group of Companies

TO HELP OFFSET

DEDUCTIBLES

COINSURANCE

OUT-OF-NETWORK PROVIDER COSTS

DUE TO ACCIDENTS & SICKNESS

TELEHEALTH

FREE VITAMINS

RX DISCOUNTS

WHOLESALE PHARMACY COSTS AND

ASSOCIATION GROUP COVERAGE

MEMBER NON-INSURANCE ASSOCIATION SERVICESPROVIDED BY:

MEMBER INSURANCE BENEFITS ARE UNDERWITTEN BY:

BILLING, FULFILLMENT, & CUSTOMER SERVICEPROVIDED BY:

INSIDE THE UBA MEMBER GAP HCI PLAN

PGS 04-13…Member Non-Insurance Services

PGS 16-27…Member Insurance Benefits

PG 06 ……Wholesale Pharmacy through MailMyPresricriptions.com®PG 07 ……$0.00 Cost* Telehealth 24/7 with MeMD™ for Urgent Visits & Behavioral HealthPG 08-09…Free One-a-Day Multi-VitaminsPG 10-11…Retail Prescription Discount CardPG 12-13…Pet RX Prescription Discount Card

PG 16-17 …Accident & Sickness Hospital Cash Insurance BenefitsPG 18 ……Hospital Admission IndemnityPG 19 ……In-Hospital Admission IndemnityPG 20 ……Surgical IndemnityPG 22 ……Intensive Care Unit IndemnityPG 23 ……Physician Office Visit IndemnityPG 24 ……Emergency Room IndemnityPG 25 ……Exclusions and LimitationsPG 26-27…How to File a Claim

PGS 14-15…UBA Membership

PG 14 ……About United Business Association (UBA)PG 15 ……List of All UBA Membership Benefits

NON-INSURANCESERVICES

4

5

PG 6 Wholesale Pharmacy through MailMyPrescriptions.com®

PG 7 Telehealth 24/7 through MeMD® Includes Urgent Visits & Behavioral Health

PGS 8-9 Free One-a-Day Mutli-Vitamins

PGS 10-11 Prescription Discount Card For Retail Pharmacy Discounts

PGS 12-13 Pet Prescription Discount Card

PGS 14-15 About United Business Association (UBA) Membership

Note: Federal Insurance Company is not affliated with, nor are the Accident & Sickness Hospital Cash Insurance Benefits dependent on, use of the non-insurance benefits and services, discount programs or benefits and services as provided as part of membership in the United Business Association.

Member Driven Value.

MAIL ORDER PRESCRIPTIONS - Good for Maintenance Meds

Pharmacist Help Desk:

1.800.964.9654

NON-INSURANCE SERVICES PROVIDED WITH MEMBERSHIP

6

mailmyprescriptions.com® is a US mail-order pharmacy headquartered in Boca Raton, FL. Our mission? Make your prescriptions affordable.

How do we do this? We charge you the same amount of money our pharmacy acquires the drug for, making us the most transparent and

lowest cash-priced pharmacy service in Amercia, guaranteed. If you find a lower cash pay price on a generic prescription, we will match

it*. Our prices may be cheaper than your copay, deductible, or out-of-pocket price! You can look, browse your drug prices online, or give

our pharmacy staff a call for any questions. Only a valid prescription from a U.S. licensed Physician and major credit, debit FSA, or HSA is

required for payment!

Disclosures:

mailmyprescriptions.com® is America’s first wholesale pharmacy service. We operate a 24,000 sq. ft. full-service pharmacy that is licensed and regulated

by the Florida Board of Pharmacy, Drug Enforcement Agency, and other State Boards of Pharmacy. We are also LegitScript verified as a safe pharmacy

website. mailmyprescriptions.com® also successfully completed the VIPPS accreditation process through the NABP®. All pricing is available online and

guaranteed. Pricing is subject to change. The Program is NOT an insurance plan, a discount medical plan (“DMPO”), a Medicare / Medicaid prescription

drug plan or a health insurance policy. The Program does NOT accept any type of insurance. You shall be solely responsible for any and all applicable

charges and taxes related to purchases made by you through the Program. You understand and agree that the Program is NOT a health insurance plan

and is NOT intended as a substitute for insurance.

This Program is subject to the Terms of Service set for at https://www.mailmyprescriptions.com/terms-of-services.

Please review the HIPAA Notice (https:/www.mailmyprescriptions.com/hipaa-notice) and

Privacy Notice (https://www.mailmyprescriptions.com/privacy-policy).

*Generic Price Match Guarantee subject to Terms and Conditions found at https://www.mailmyprescriptions.com/generic-price-match-guarantee/

**FREE Shipping Policy subject to Terms and Conditions found at https://www.mailmyprescriptions.com/shipping-policy

Get free price quotes and clinical care by calling 1.800.964.9654

Use the Customer Code In Your Guide

when you create your account online or when ordering by phone.

All of your orders ship FREE! We also guarantee** a 5-day delivery

MeMD® makes it easy to receive medical care or therapy from the comfort and privacy of your own home or office. Speak with one of MeMD’s board-certified medical providers online, over the phone or by mobile app available 24 hours a day, 365 days a year.

MeMD® treats many common health issues, like...+ ALLERGIES+ BITES & STINGS+ BRONCHITIS+ DIARRHEA

+ FLU SYMPTOMS+ MEDICATION REFILLS+ SINUS SYMPTOMS

+ SKIN INFECTIONS+ SORE THROATS+ UTIs+ And more

MeMD’s therapists provide care and counseling for:+ ABUSE+ ADDICTION+ ADHD / ADD+ ANXIETY & STRESS

+ BIPOLAR DISORDER+ DEPRESSION+ EATING DISORDERS+ GRIEF & LOSS

+ PARENTING ISSUES+ RELATIONSHIPS+ TRAUMA & PTSD+ And more

STEP 1: SIGN IN TO MeMD®Access your MeMD® account by downloading the app and entering your plan code when prompted.

Visit www.memd.me/app-storePlan Code: Use Code in Guide

or visit your MeMD® website:Use Link in Guide

STEP 2: REQUEST A VISITFor medical & behavioral health issues, you can request & schedule a visit using your smartphone, tablet, or computer.

STEP 3: SPEAK WITH A PROVIDER

Consult with your medical provider or therapist in real-time by video or phone. For medical visits prescriptions can be sent to your pharmacy when medically necessary. $0.00 for cost of visits.^

^With your Membership Plan, the cost of all urgent care or behavioral health visits are paid by Healthy America and not you.

MeMD® provides access to online medical consultations with physicians, nurse practitioners, and physician assistants who can write prescriptions when medically necessary and permitted by state law. MeMD® also provides access to online counseling or talk therapy with behavioral health providers; however, therapists cannot write prescriptions. MeMD® is not an online pharmacy, and medications cannot be purchased or dispensed from MeMD® directly. MeMD® is not a replacement for your primary care physician or annual doctor’s office visit. Subject to state regulations, MeMD® is available nationwide with providers licensed to practice in your state who use video and/or audio technology.

When medically necessary, MeMD’s providers (except therapists) can submit a prescription electronically for purchase and pick-up at your local participating pharmacy; however, MeMD® providers cannot prescribe elective medications, narcotic pain relievers, or controlled substances. MeMD’s providers are each licensed by the appropriate licensing board for the state in which they are providing services and all have prescriptive authority for each of the states in which they are licensed. 7

8

STAY HEALTHY

9

FREE^

ONE-A-DAYMULTI-VITAMINS

A strong immune system helps fight many of the illnesses that occur, and can delay the aging process. Study after study shows that proper supplementation with nutrients, vitamins, and herbal remedies can help prevent many “inevitable” ailments.

We will supply, free of charge, the highest quality multi-vitamins for your entire family. The vitamins will be shipped directly to

your home at no cost to you.

This private-label program provides the same quality vitamins as are currently found on the shelves of pharmacies, supermarkets, and other retail outlets. These one-a-day formulas are complete from A-Z. The multi-vitamins your family will receive are one of the leading brands sold by healthcare professionals.

SCAN FOR VITAMIN

ORDER FORM

To Order, Scan the code above or go to:

https://form.jotformpro.com/71306387418964

^Free Vitamins are paid by Healthy America

10

UBA Prescription Retail Discount ProgramRETAIL PRESCRIPTIONS - Good for Acute Meds (Antibiotics, traveling, etc)

Your nationally recognized United Business Association Prescription Discount Plan provides discounts on ALL FDA approved prescription drugs. There are no limited drug lists, no waiting periods or deductibles and your Discount Drug Card—which you will receive in the mail—is active the moment you present it to the pharmacy.


1.800.481.0605

RX Member Services:

1.800.974.3454

��

On average, you’ll save 15% off the cash price for Brand drugs and 40% off Generic drugs. In the event a pharmacy’s price is lower than our discounted price you will always receive the lowest price available.

This plan applies to your entire family. Everyone deserves to save. All family members are eligible for this benefit. Please present your card every time you need to fill a prescription for instant savings. There are absolutely no restrictions.

��

Your Discount Drug Card is widely accepted at over 54,000 participating pharmacies across the United States, including all national and regional chains, pharmacy associations, as well as many of your local community pharmacies. If your community pharmacy is not enrolled, ask them to contact member services at 1-800-974-3454; we always welcome new participation.

Web Tools

http://www.paramountrx.com/client/uba/home.aspx

��

��

��

11

Participating Pharmacies

Your card is accepted at over 54,000 pharmacies nationwide. If your local pharmacy is not participating please have them contact member services to obtain the proper enrollment materials. The list below shows just some of the most recognized pharmacies in the network.

AlbertsonsEPICLongsSav-OnWalmartA&PGiant Eagle

MarcsSupervaluWegmansBi-LoHEBMeijerTarget

Winn DixieCostcoHY-VeeOscoTopsCVSKmart

Rite AidUnitedDuane ReadeKrogerSafewayWalgreens

This is not insurance—discount only. Process all claims electronically.

12

��

�� ! ��

�� !��!�� !��

�� "�� #�$�� %&��

1.800.866.0514 for assistance on utilizing the program.

��

�� (��

��)��*+,�� !��

pharmacy.

��

�� -��/��/��

�� 0�1++�122�+*03��!��!�� "�

medications.

4�� 4��5��

�� "��

�� !��!��

UBA Pet Prescription Discount Program


1.800.481.0605

RX Member Services:

1.800.66.0514

Web Tools

http://www.paramountrx.com/client/ubapetmed/home.aspx

��

��

��!��

��

13

This is not insurance—discount only. Process all claims electronically.

Participating Pharmacies

Your card is accepted at over 54,000 pharmacies nationwide. If your local pharmacy is not participating please have them contact member services to obtain the proper enrollment materials. The list below shows just some of the most recognized pharmacies in the network.

AlbertsonsEPICLongsSav-OnWalmartA&PGiant Eagle

MarcsSupervaluWegmansBi-LoHEBMeijerTarget

Winn DixieCostcoHY-VeeOscoTopsCVSKmart

Rite AidUnitedDuane ReadeKrogerSafewayWalgreens

WHO IS UBA

United Business AssociationThe United Business Association (UBA) is a nationwide membership of small business owners and employees. UBA leverages our purchasing power to secure benefits and discounts that may not be otherwise available on an individual basis. With association group insurance programs, shared business knowledge, business and lifestyle benefits and services and opportunities to network, We are Better Togethersm. Your membership in the United Business Association allows you to access and enroll in association group insurance programs and to apply for association short term medical insurance. Various insurance companies have issued group insurance policies to the United Business Association as the group master policyholder. Product features, additional plans and availability may vary by state.

The Gap HCI Plan is only available to United Business Association members. You can view the Member Guide for UBA Membership at:

http://www.ubamembers.com/ubamembershipsampleguide19.pdf.

You can also download a quick reference chart that has all the codes needed to access your membership benefits. Download it to your phone, print a copy or save it to your computer.

Download UBA Membership Reference Sheet at: Use the link located in your membership guide.

If you are not completely satisfied with your UBA Plan, please call your Personal Member Concierge at

866.438.4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisfied with your UBA benefits and services.

Note: This membership is separate from any other insurance or supplemental plan you have purchased. Please contact your agent for any plans other than a UBA Membership Plan. If you are canceling, please make sure to cancel using our cancellation phone number at 866.438.4274 or our cancellation form located at http://www.ubamembers.com/billing.html. Please do not cancel through your agent. Cancel directly with your Personal Member Concierge to make sure your cancellation request is handled promptly and correctly.

UBA REFUND / CANCELLATION POLICY

UBA MEMBERSHIP & GAP HCI

14

Note: Please be aware that premium and dues can’t be refunded in a month in which a claim was filed.

• 24-Hr Nurse Helpline• Lab Discounts• Discount Hearing Service• Gateway Medicard• Health Savings Account - HSA Bank®• Travel Assistance Plan• LensCrafters Vision Club• GymAmerica.com• 24-Hr Roadside Assistance• TrueCar Buying Network• Graduate Scholarship Program• HopTheShops.com• LegalConnect®• TravelerBonus.com

• Child ID Card Services• Car Rental Discounts• ADP Payroll Processing• 1800Flowers.com Discounts• Office Supplies & Furniture• Hewlett (HP) Computers & Equipment• UPS Express Delivery Service• UBA Savings Perks Program• National Theme Park Discounts• Business Owners Policy• Data Breach / Cyber Liability• Tickets at Work• Choice Hotels

MEMBERSHIP BENEFIT & SERVICES HIGHLIGHTS

15

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITA

L C

AS

H IN

SU

RA

NC

E UBAACCIDENT & SICKNESS HOSPITAL CASH INSURANCEBENEFITS

Group Policy No: 9909-17-48 issued to the United Business Association. Coverage becomes effective on the date provided in your membership material following the receipt of the Application and the payment of the first month’s dues to the United Business Association.

Federal Insurance Company, a member insurer of the Chubb Group of Insurance Companies, is the underwriter of the Group Accident and Sickness Limited Benefit Cash Insurance. Chubb Accident & Health, 202 Halls Mill Road, Whitehouse Station, NJ 08889.

"��#��

��$��%��

��%��'��$��%��

��%��(��'��$��%��)

100%

100%

50%

WE PAY:

WE PAY:

WE PAY:

*�'+��,��#��

16

*Please make sure to read the full terms, definitions, limitations, and exclusions in the Certificate of Insurance and on page 25 of this guide.

65 Years Old on the date of loss

50% of the Benefit Amount*�'+��,��#��'��,��

70 Years Old on the date of loss

25% of the Benefit Amount*�'+��,��#��'��,��

��'+��,��'��+��#��.If a Covered Person is age 65 years old or older on the date of loss covered under this Policy, the benefit otherwise payable will be reduced according to the schedule below.

*Spouse and Dependents are eligible if listed on the Membership Enrollment Application or later added, recorded, and acknowledged by the Association and meet the age requirements listed in the Policy Certificate.

17

Based on 2017 AHA Annual Survey, there were a little over

35 million total admissions

to Registered Hospitals in the United States.1

1 American Hospital Association (AHA) Hospital Statistics is published annual by Health Forum, an affiliate of the American Hospital Association. Fast Facts on US Hospitals 2019. - https://www.aha.org/statistics/fast-facts-us-hospitals

Gap HCI Plan is available in the following states:

Plan 1:AL, AZ, AR, DE, DC, FL, GA, IL, IN, IA, KY, MI, MS, NC, NE, ND, NM, OH, OK, PA, RI, SC, TN, TX, VA, WI & WY.

Plan 2:CA & NV

GROUP ACCIDENT & SICKNESS HOSPITAL CASH INSURANCE BENEFITS ARE PROVIDED THROUGH A LIMITED FIXED INDEMNITY INSURANCE POLICY. THIS IS NOT COMPREHENSIVE MAJOR MEDICAL INSURANCE. This Policy provides limited benefits on a fixed indemnity basis. It does not constitute comprehensive health insurance

coverage (often referred to as “major medical coverage”) and does not satisfy a person’s individual obligation to secure

the requirement of minimum essential coverage under the Affordable Care Act (ACA). For more information about the

ACA, please refer to http://www.HealthCare.gov.

Read the brochure and the group insurance certificates carefully. This is a brief description of the important features of this insurance plan. It is not an insurance contract. Insurance benefits are underwritten by Federal Insurance Company. Coverage may not be available in all states or certain terms may be different where required by state law. Chubb NA is the U.S. -based operating division of the Chubb Group of Companies, headed by Chubb, Ltd. (NYSE: CB). Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself.

Hospital,��"��+��

+��,��,��

$750.00

We will pay a Hospital Admission Benefit if a Covered Person is admitted to a hospital and confined due to a sickness or as the result of an accident. The Covered Person must become confined within 6 months after the covered accident. We will not pay more than the maximum number of admissions as shown below.

18

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITA

L C

AS

H IN

SU

RA

NC

E

Maximum of 1 admission

per sickness or accident per plan year

No Hospital ��%��%��'��.

• Emergency Room Treatment

• Outpatient Treatment

• Stay of less than 20 hours in an Observation Unit

*Please make sure to read the full terms, definitions, limitations, and exclusions in the Certificate of Insurance. See exclusions on page 25 of this guide.

19

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITAL C

AS

H IN

SU

RA

NC

E

In-Hospital"��+��

(��+��,�� $1,000.00

We will pay the daily In-Hospital Benefit amount shown for each day a Covered Person is in-hospital due to a sickness or accident. The first day of a hospital stay must occur within thirty (30) days of the accident, causing the injury. A confinement for a sickness shall not be combined with another confinement for an accident in determining a Period of Confinement. We will not pay more than the maximum benefit amount shown below.

Maximum of 30 days per Period of Confinement

The In-Hospital +��,��%��the earliest of the ��.

• Covered Person dies;

• Covered Person is no longer in-hospital or;

• Maximum number of days per Period of Confinement listed in the In-Hospital Indemnity Benefit has elapsed or;

• Maximum Benefit amount has been paid.

$�0��%��amount per sickness ��%��1

$30,000.00

��%��1

If a Covered Person is discharged from the hospital and a different sickness or accident causes such Covered Person to be in-hospital again after 1 day of non-confinement, then We will consider it a new Period of Confinement. If a Covered Person is discharged from the Hospital and readmitted for the same sickness or accident as the prior Period of Confinement within 180 days of the prior Period of Confinement’s discharge, it will be considered the same Period of Confinement.


Surgical"��+��

We will pay the Surgical Indemnity Benefit if a Covered Person has a Major or Minor Surgical Procedure performed while in-hospital or on an outpatient basis in an Outpatient Unit. The benefit amounts are shown below.

If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. A surgical procedure due to an accident must occur within thirty (30) days of the accident, causing the injury. We will not pay more than the maximum benefit amount shown below.

Maximum of 1 In-Hospital procedure

whether Major or Minor Surgical procedure

$7,500.00

20


IN-HOSPITALSURGICALPROCEDURES

+��Amount per��#��Per Plan Year

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITA

L C

AS

H IN

SU

RA

NC

E

$500.00

Major Surgical

Procedure

Benefit Amount

Minor Surgical

Procedure

Benefit Amount

Maximum of 1 Outpatient procedure

whether Major or Minor Surgical procedure

$3,750.00OUTPATIENTSURGICAL PROCEDURES

+��Amount per��#��Per Plan Year

$500.00

Major Surgical

Procedure

Benefit Amount

Minor Surgical

Procedure

Benefit Amount

"��Care Unit"��+��

We will pay the daily Intensive Care Unit benefit amount shown below for each day of Confinement if an accident or sickness causes a Covered Person to be confined in an Intensive Care Unit. This benefit is paid in addition to the In-Hospital benefit amount. The first day of Confinement in the Intensive Care Unit must occur within thirty (30) days of the accident. We will not pay more than the maximum benefit amount shown below.

Up to a Maximum of 30 days per Period of Confinement

$100.00

22

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITA

L C

AS

H IN

SU

RA

NC

E

(��+��Amount

2��"��3��%��amount will be ��.

• Covered Person dies;

• Covered Person is no longer confined in an Intensive Care Unit; or

• Maximum number of days per Period of Confinement has elapsed

$�0��%��amount per sickness ��%��1

$3,000.00

��%��1

A Confinement for a sickness in an Intensive Care Unit shall not be combined with another Confinement in an Intensive Care Unit for an accident in determining a Period of Confinement. If a Covered Person is discharged from the Hospital and a different sickness or accident causes such Covered Person to be confined in an Intensive Care Unit again after 1 day of non-confinement, then We will consider it a new Period of Confinement. If a Covered Person is discharged from the Hospital and readmitted to an Intensive Care Unit for the same sickness or accident as the prior Period of Confinement within 180 days of the prior Period of Confinement’s discharge, it will be considered the same Period of Confinement. If it is considered the same Period of Confinement then a Covered Person will be subject to the same maximum number of days and any maximum benefit amounts shown above.


23

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITAL C

AS

H IN

SU

RA

NC

E

#��45��6��"��+��

Per Visit+��,��

$100.00

We will pay the Phyician Office Visit Indemnity Benefit amount, as shown below for a Physician Office Visit as a result of an accident or sickness. The visit must be made to the physician’s office or clinic. The visit to a physician’s office must occur within thirty (30) days of the accident, causing an injury. We will not pay more than the maximum benefit amount, shown below.

Maximum of 2 Visits Per Sickness or Accident Per Plan Year

+��%��'��.

• Visits made by a physician while the Covered Person is confined in a hospital

• Routine eye examinations, or fitting of glasses or fitting of hearing aids

• Dental examinations or dental care other than expenses resulting from accidental injury; or

• Annual physicals, school sports physicals, and other types of preventive visits not required due to an accident or sickness


24

GR

OU

P A

CC

IDE

NT

& S

ICK

NE

SS

HO

SP

ITA

L C

AS

H IN

SU

RA

NC

E ��Room "��+��

We will pay the Emergency Room benefit amount, shown below if an accident or sickness causes the Covered Person to require and receive emergency medical care in an emergency room of a hospital. Treatment must be received within 24 hours of the accident. We will not pay more than the maximum benefit amount, shown below.

Up to a Maximum of 2 ER Visits

per Sickness or Accident per Plan Year.

$300.00Per Visit +��,��


Limitations & Exclusions

25

Group Accident and Sickness Hospital Cash Insurance

GROUP ACCIDENT & SICKNESS HOSPITAL CASH INSURANCE BENEFITS ARE PROVIDED THROUGH A LIMITED FIXED INDEMNITY INSURANCE POLICY. THIS IS NOT COMPREHENSIVE MAJOR MEDICAL INSURANCE.%6�7��56�-6%�$4$-��6�-�%64�88��

This insurance does not apply to:

1. Any Accident caused by or resulting from, directly or indirectly, a Covered Person’s participation in scuba diving to depths of more than 130 feet; skydiving; hang-gliding or para-gliding; parascending other than over water; bungee jumping; mountaineering or rock climbing normally requiring the use of guides or ropes; or caving.

2. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person’s commission or attempted commission of a felony or being engaged in an illegal occupation. (Does not apply for Plan 2 - CA & NV residents).

3. Any Accident or Sickness caused by or resulting from, directly or indirectly any occurrence while the Covered Person is incarcerated.

4. Alcoholism or drug or substance abuse. In addition, the insurance does not apply to any confinement in a detoxification facility or drug or alcohol rehabilitation facility that is not also a Hospital or part of a Hospital.

5. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person being under the influence of any narcotic or other controlled substance at the time of the loss. This exclusion does not apply if any narcotic or other controlled substance is taken and used as prescribed by a Physician. (Does not apply for Plan 2 - CA & NV Residents.)

6. Sickness caused by or resulting from a Covered Person’s Pre-Existing Condition if the Sickness occurs during the first 12 months that a Covered Person is insured under this policy. Pre-Existing Condition means an Accident or Sickness for which, in the 6 months before the Covered Person becomes insured under the policy, medical advice, treatment or care was sought by a Covered Person, or was recommended by, prescribed by or received from a Physician.

7. Normal pregnancy. Complications of Pregnancy are covered as any other Sickness.

8. Pregnancy of a Dependent Child, unless required by law.

9. Any Accident caused by or resulting from, directly or indirectly, the Covered Person participating in any professional sporting activity for which the Covered Person received a salary or prize money.

10. Any rest care or custodial care or treatment for any Accident or Sickness.

11. Any Accident caused by or resulting from, directly or indirectly, the Covered Person being engaged in or participating in a motorized vehicular race or speed contest.

12. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person participating in military action while in military service with the armed forces of any country or established international authority.

13. No benefits are payable related to the Covered Person’s suicide, attempted suicide or intentionally self-inflicted injury.

14. Voluntary abortion, except with respect to You or Your covered Spouse or Domestic Partner where such person’s life would be endangered if the fetus were carried to term.

15. Any Accident or Sickness caused by or resulting from, directly or indirectly, war, undeclared war, civil war, insurrection, rebellion, revolution, warlike acts by a military force or personnel, any action taken in hindering or defending against any of these or any consequences of any of these acts regardless of any other direct or indirect cause or event, whether covered or not, contributing in any sequence to the loss or an Insured Person’s active participation in an insurrection, rebellion, or revolution.

16. Routine newborn or well baby care, including routine nursery charges.

17. Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit or which are payable under Occupational Disease Law, Workers Compensation or similar law, whether or not application for such benefits have been made.

This policy does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit the provision of insurance, including but not limited to the payment of claims.

HOW TO FILEA CLAIM

26

27

HOW TO FILE AN ACCIDENT & SICKNESS HOSPITAL CASH INSURANCE CLAIM

United Business Association Claims Unit

Health Special Risk, Inc.HSR Plaza II4100 Medical ParkwayCarrollton, TX 75007Phone Number: 866.523.3452Fax Number: 972.512.5824Email: [email protected] the Policy Number: 9908-17-48For Claim forms, go to: ubamembers.com/claimforms.htmlBenefit payment is subject to the terms, conditions, limitations, exclusions and other provisions within the Certificate. For more information and complete details of terms, conditions, limitations, and exclusions of coverage, please refer to the Certificate. Coverage may vary and may not be available in all states. Written claim notice must be given within twenty (20) days after the occurrence or commencement of any loss covered by this policy or as soon as reasonably possible. Notice must include enough information to identify the Covered Person and the Policyholder. Failure to give claim notice within twenty (20) days will not invalidate or reduce any otherwise valid claim if notice is given as soon as reasonably possible.

WE PROUDLY SUPPORT

®

United Business Association | 409 W Vickery Blvd Fort Worth, TX 76104 | 866.438.4274 | [email protected] | ubamembers.com

smHCI Gap HCI Plan

SampleGuide_v04.19 [9908-17-48]

SIGN UPContact Your Agent Today!

Find out cost of membership for this and other UBA Plans at ubamembers.com

HCIWe operate a 24,000 sq. ft. full-service pharmacy that i s licensed and regulated by the Florida...

Documents

Transcript of HCIWe operate a 24,000 sq. ft. full-service pharmacy that i s licensed and regulated by the Florida...