|TOA’S OA & CL TERMS & CONDITIONS||VERSION 11/06/2017|
TERMS & CONDITIONS
OCCUPATIONAL ACCIDENT & CONTINGENT LIABILITY BENEFITS-PACKAGE PROGRAM
Carefully read all of these Terms & Conditions. If you agree with these Terms & Conditions, indicate your assent below.
THE BENEFITS ARE DESCRIBED IN THESE TERMS & CONDITIONS
The benefits of the Group Coverage of this Truck Owners Association (“TOA”) Program are described in these Terms & Conditions. When you apply to enroll in this Program, you are applying for Occupational Accident Benefits, plus TOA’s Discount Benefit and Prescription Drug Benefit. If you chose the optional Contingent Liability Benefits option, you are applying for those benefits as well. You also may choose the ID Protection option. These are the Terms & Conditions when You are insured under the Group Coverage of this TOA Program.
WHY IT IS IMPORTANT TO READ ALL OF THESE TERMS & CONDITIONS
Read the entire Terms & Conditions carefully because You are entitled to benefits only as described in these Terms & Conditions, so it is very important to read them.
TOA BENEFITS-PACKAGE PROGRAMS IN GENERAL
- To Whom The TOA Benefits-Package Programs Are Available. TOA’s Benefits-Package Programs and the benefits they provide are available and applicable only to active TOA Members and/or their Sponsors. Active TOA membership is required to be eligible for any benefit under TOA Programs.
- Contract Between You And TOA.When you submit a Quote/Application as a Sponsor requesting to enroll your specified Independent Contractor drivers as TOA members and as Occupational Accident coverage Subscribers, the Quote/Application is your offer to enter into a contract with TOA to enroll those drivers as TOA members and as Occupational Accident coverage Subscribers. If you also have requested the optional Contingent Liability Benefits option, you are further offering to enter into a contract with TOA to enroll you as a Named Insured eligible for Contingent Liability coverage. A term of the offer is that TOA can accept the offer only by issuing a TOA Certificate. As your part of the bargain, you promise to be bound by these Terms & Conditions, the terms in the Quote/Application, the terms of the Group Policy and the terms inthe Certificate, if in exchange TOA issues a Certificate and enrolls your drivers for Occupational Accident Benefits, and if you requested the Contingent Liability option, enrolls you for Contingent Liability Benefits. As TOA’s part of the bargain, in exchange for your promise to be bound and your down payment, TOA promises that if you and your drivers are eligible, TOA will enroll you and your drivers, issue a Certificate and provide the benefits of the TOA Benefits-Package Program in accordance with these Terms & Conditions, the terms in the Quote/Application, the terms in the Group Policy and the terms in the Certificate.
When TOA manifests its assent and accepts your offer by issuing the Certificate, at that moment the Application, the Terms & Conditions, the Group Policy and the Certificate become the binding Contract between you and TOA (“the Contract”). TOA’s issuance of the Certificate and enrolment of your drivers for Occupational Accident Benefits, and if you requested the Contingent Liability option, enrolment of you for Contingent Liability Benefits, is TOA’s consideration for your promise to be bound. Your down payment and promise to be bound is consideration for TOA’s promise that if you and your drivers are eligible, TOA will enroll you and your drivers, issue a Certificate and provide the benefits of the TOA Benefits-Package Program. No Contract is created until TOA accepts your offer by issuing a Certificate.
TOA’s decision whether to accept your offer will be based on whether the drivers are acceptable drivers with acceptable loss histories. Motor vehicle reports (MVRs) showing each driver’s driving and license history will be required to bind any benefit under the Programs. TOA may ask you to withdraw this offer and submit a new Application with different pricing based on new information received on the autos and/or drivers quoted.
- You May Cancel The Contract If You Later Decide You No Longer Like The Terms & Conditions. If you later decide that you no longer like the Terms & Conditions, or that you want to cancel coverage for any reason or even no reason, you can cancel the Contract at any time. However, because premiums are fully earned on the 1st day of each month, if you do not cancel by the end of the last day of the month, then on the 1st day of the new month the new month’s premium will be fully earned on due.
- Cancellation Of The Contract By TOA Or Insurer.TOA or the Insurer may cancel the Occupational Accident and/or Contingent Liability coverage benefits for any of the following reasons:
- Nonpayment of premium;
- The coverage was obtained through a material misrepresentation;
- You or your Subscriber violated or failed to comply with any of these Terms and Conditions or those of the Policy;
- The risk originally accepted has measurably increased;
- Statutory reasons.If coverage was obtained through a material misrepresentation, the Contract and coverage will be considered cancelled on the inception date.
- Effect Of Cancellation Of The Contract On Premiums. Upon cancellation by either you or TOA or the Insurer, the premiums paid are fully earned and no return premium will be due or payable. lf you owe premiums for a period prior to the cancellation date, such premiums will be payable at the time of cancellation.
- Adding Subscribers; Deposits; When Premiums Are Due; When Premiums Become Fully-Earned; Removing Subscribers; Cancellation For Non-Payment Of Premiums.A deposit of one month’s premium will be held for each Subscriber. If you add a Subscriber after the 20th day of the month, no premium is due for that Subscriber for that month.Premiums are payable monthly. For the upcoming month, a premium payment in cleared funds must be received by TOA or its designee before the 1st day of the upcoming month. TOA or its designee will take payment of the premium up to five (5) days before the 1st day of the upcoming month.
Even if you fail to pay the premium in cleared funds before the 1st day of the upcoming month, if you fail to notify TOA or its designee before the 1st day of the new month that you are removing the Subscriber, then coverage for that Subscriber rolls over on a short-term basis into the new month.
Premiums are fully earned on the 1st day of each month. Therefore, if a Subscriber is covered on the 1st day of the new month because the premium was paid, or because you failed to notify TOA or its designee that you are removing the Subscriber, the new month’s premium is fully earned on the 1st day of the new month for that Subscriber.
Once a premium is fully earned, if still unpaid then the entire month’s premium is owed and must be paid to TOA, and if already paid then no refund or return premium will be due or payable from TOA, with one exception. The exception is that you may remove the Subscriber up to and including the 10th day of the month and not owe any premium for that month if:
- you notify TOA or its designee in writing by that 10th day of the month that you have removed the Subscriber and are requesting that TOA cancel the Subscriber’s coverage retroactively as of the end of the last day of the preceding month, so that no coverage existed by the 1st of the month;
- the Subscriber was not involved in an occupational accident on or after the 1st of the month; and
- you provide written proof to TOA or its designee that you notified your Subscriber in writing that you terminated their coverage on the last day of the preceding month.
If you already paid the premium, the premium will be refunded and the deposit will also be returned
If the premium for a Subscriber was NOT paid in cleared funds before the the 1st day of the upcoming month, and neither you nor the Subscriber canceled coverage before the 1st day of the new month, then TOA or its designee will notify you and/or the Subscriber that coverage will no longer be in effect as of
the 10th calendar day after the notification date, which 10th day will be the cancellation effective date. At 12:01 a.m. of that date, coverage will no longer be in effect. The notice will further advise you of the aforementioned procedure for removing the Subscriber up to and including the 10th day of the month without owing any premium for that month.
If you forgo or are ineligible for the aforementioned procedure, TOA will apply your deposit toward the fully earned premium and coverage will continue until the cancellation effective date.
If the premium payment in cleared funds is received before the cancellation effective date, that payment will rescind the cancellation notice and TOA will notify you that your cancellation notice has been rescinded. In that event, TOA will reverse the application of your deposit toward the fully earned premium and convert it back to a deposit.
If your cancellation goes into effect, TOA will notify you that your coverage was cancelled as of the cancellation effective date.
Once coverage is cancelled, you have up to 30 calendar days from the cancellation effective date to request reinstatement of coverage, pay all premiums, pay a reinstatement fee, and submit a signed TOA-approved “No Loss Letter.” If TOA approves your request, the coverage will be reinstated retroactively as though the coverage had not lapsed. However, these payments and all future payments must be made in legal tender or cleared funds directly to TOA. Payment to an agent is not acceptable as payment to TOA once a cancellation occurs.
If more than 30 calendar days elapse from the cancellation effective date, a completely new Application/offer must be submitted. If TOA approves the reinstatement request, coverage will be re-written. Once you pay all premiums, pay a reinstatement fee, and pay any other fees or monies due, TOA will issue a new Certificate of Insurance with a new effective date. These and all future payments must be made in legal tender or cleared funds.
If less than 60 calendar days elapsed from the cancellation effective date, TOA may at its sole discretion re-write coverage using the most current information that TOA has on file as to drivers and risks. If 60 or more days elapsed, new information must be submitted.
Cancellation of coverage does not waive your responsibility to immediately pay all premiums, fees, dues or other debts that you owe. Debts not paid in a timely manner will be transferred to a collection agency.
- Premiums May Rise Due To Inaccurate Or Incomplete Information. TOA will determine your premium amount once you have completed your Quote/Application for the specified TOA Benefits-Package Program and benefits. In order to provide you with an accurate premium, TOA relies on you to provide accurate and complete information. TOA will, to the extent allowed by law, verify the information you have provided through third-party providers. If TOA learns the information was inaccurate or incomplete, the premium amount may increase. You or TOA may also cancel the Contract.
- The Insurer May Increase Premium Rates For Occupational Accident Coverage. The Insurer will not increase premium rates for Occupational Accident coverage during the initial 12 months of coverage and not more than once in any 6-month period following the initial 12-month period, except for increases due to a change in age or geographic location of a covered Subscriber or an increase in the Policy benefit level. TOA will notify the Sponsor or Subscriber of any change at least 30 days before the premium due date on which the new rates are to be effective and at least 45 days before an increase of 20% or more is effective.
- The Insurer May Increase Premium Rates For Contingent Liability Coverage. The Insurer has the right to change the rates at which future premiums will be calculated on the 1st day of any month. TOA will notify you of any change at least 30 days before the premium due date on which the new rates are to be effective. The Insurer may only make one rate change during the Coverage Period shown in the Certificate.
- Waiver Of Premium When Total Disability Applies. The Insurer will waive premium for a Subscriber on the 1st of the month following the date the Insurer receives due written proof of the Subscriber’s Total Disability. This provision is subject to all of the provisions of these Terms & Conditions, except as to the payment of premium. If a Subscriber’s Total Disability ends and the Subscriber is still eligible for insurance under these Terms & Conditions, the Certificate and the Policy, coverage will continue provided that premium is paid beginning with the 1st of the month following the Subscriber’s return to active work.
- Changes to Terms & Conditions and Policy. These Terms & Conditions, and those of the Policy, may be changed at any time by the Insurer or TOA. It is not necessary to have the consent of the Sponsors or Subscribers/beneficiaries to make such changes. Such changes are made by an amendment, rider or endorsement, signed by an officer of the Insurer or TOA. No agent may make such change in any way, shape or form. The Insurer and TOA are not bound by any promise or statement made by any individual or agent which is contrary to the TOA Certificate, or to these Terms & Conditions or those of the Policy, and which is not approved in writing by the Insurer and/or TOA. Any unwritten agreements, statements, representations and/or promises are invalid, null and void.If a change requires a premium adjustment, the premium will be adjusted as of the effective date of change. The change becomes effective as of the amendment’s, rider’s or endorsement’s effective date.
You have the right to reject any change. If you want to reject a change, you must notify TOA in writing within 30 calendar days of being notified of the change. If you reject a change, TOA will cancel your Contract. You will still be responsible for any payments that are owed.
You also have the right to cancel the Contract. If you cancel the Contract, you will still be responsible for any payments that are owed.
- If TOA Switches Insurers. The Occupational Accident and Contingent Liability Benefits-Package Program is based on an underlying Group Policy issued by an Insurer. If TOA switches to a different
Insurer, TOA will notify you and give you the option to cancel the Contract between you and TOA.
Upon enrollment in this Program and TOA membership, your Independent Contractor drivers receive the following benefits of TOA membership:
- Accidental Death & Dismemberment (“ADD”) Benefit. Enrolled drivers receive ADD coverage up to $50,000. For a low additional cost, you have the option of providing ADD coverages up to $200,000 to your drivers. You and your drivers are bound by the Terms & Conditions of the underlying Death & Dismemberment Insurance Policy, which is available upon request.
- Discount Benefit. Enrolled drivers receive discounts on lodging and vehicle rentals.
- Prescription Drug Benefit. Enrolled drivers receive discounts on prescription drugs.
- Identity Theft Protection Benefit. For a low additional cost, you have the option of providing identity theft protection to your enrolled drivers.
OCCUPATIONAL ACCIDENT BENEFITS ONLY(Italicized words in the Occupational Accident Benefits part of these Terms & Conditions means that those terms are defined in Section 7 – Definitions.)
Section Important Notice Schedule TABLE OF CONTENTSSection 1 When Coverage Starts Section 2 When Coverage Stops Section 3 Benefit Provision
Section 4 Limitations and Exclusions Section 5 Claim Provisions
Section 6 Definitions
Section 7 General Provisions Covered Activity Rider
All States except Texas: IMPORTANT NOTICE: THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE AND DOES NOT RELIEVE AN EMPLOYER OF WORKERS’ COMPENSATION COVERAGE OBLIGATIONS.
Texas: IMPORTANT NOTICE: THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BV PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS THAT 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.
This Schedule is a very brief summary of the Occupational Accident Benefits. Please read the entire Terms & Conditions for a more complete description of the benefits outlined in this Schedule.
TOA and the Insurer certify that a Group Policy providing Occupational Accident coverage has been issued to TOA, bearing the Policy number shown in Item # 2 of this Schedule.
Item 1. Master Policyholder: Truck Owners AssociationItem 2. Policy Number: R170017, underwritten by Certain Underwriting Members of Lloyd’s of London.Item 3: Named Insured Number: Item 4: Named Insured: Item 5: Named Policyholder Effective Date: 1st February 2017 12:01 AM, Standard Time atthe the address of the Policyholder.
Named Policyholder Expiration Date: 1st February 2018 12:01 AM Standard Time atthe address of the Policyholder.
Item 6. Covered Subscriber: As named and reported on the monthly census by the
Policyholder and stated in the Certificate.
Item 7. Subscribers Enrollment Date: As on file and stated in the Certificate.Item 8. Eligible Classes: As shown below and defined in the Covered Activity Rider.Item 9. Covered Activities – Refer to Covered Activity Rider – Trucking Operation.Item 10. Coverage Basis: Insurance for Subscribers is limited to Occupational-Related Injuries only.Item 11. Amounts of Insurance: Occupational Accident Benefits
Accidental Death Benefit
Principal Sum: USD 25,000
Commencement Period: 365 days
(Commencement Period means the period between the date of the covered Accident that caused the Injury and the date on which the covered loss must occur for benefits to be payable. Thus, the Injury to the Subscriber must result in death within 365 days of the date of the covered Accident for the Accidental Death Benefit to be payable.)
Survivors BenefitsPrincipal Sum: USD 75,000
Monthly Benefit: 1% per month
Accidental Dismemberment Benefit
Principal Sum: USD 100,000
Commencement Period: 365 days
Paralysis BenefitPrincipal Sum: USD 100,000
Commencement Period: 365 days
Temporary Total Disability BenefitCommencement Period: 90 days
Waiting Period: 7 days
Benefit percentage: 75% of Average Weekly Compensation
Minimum Weekly Benefit: USD 125
Maximum Weekly Benefit: USD 250
Maximum Benefit Period: 52 weeks
(The Disability must begin within 90 days from the date of the covered Accident.)
Continuing Total Disablement BenefitWaiting Period: 52 weeks
Benefit percentage: 75% of Average Weekly Compensation
Minimum Weekly Benefit: USD 50
Maximum Weekly Benefit: USD 250
Maximum Benefit: USD 100,000
Maximum Benefit Period: to age 65
Accident Medical Expense Benefit
Commencement Period: 90 days
Maximum Benefit Period: 104 weeks
Dental Maximum: USD 2,500 per covered Accident
Maximum Benefit per covered Accident: USD 50,000 Lifetime Maximum Benefit: USD 50,000
(For this benefit to be payable, the First Expense for Injury caused by a covered Accident must be Incurred and reported within 90 days from the date of the covered Accident, and any further Expenses for Injury caused by the covered Accident must be Incurred within 104 weeks from the date of the covered accident.)
Limits on Accident Medical Expense Benefits
Services provided by a Chiropractor or Acupuncturist, not including Physical Therapy, Occupational Therapy, Work Hardening Therapy
USD 1,000 per Injury
One round trip to & from the Hospital but not more than than USD 1,000 for any one covered Accident
One round trip to & from the Hospital but not more than than USD 7,000 for any one covered Accident
Mental and Nervous – Outpatient
USD 25 per visit
Maximum 20 visits for any one covered
Mental and Nervous – Inpatient
Maximum 20 days Maximum USD covered Accident
Limits of LiabilityCombined Single Limit: USD 100,000 per Insured
Occurrence Limit: USD 200,000 per Occurrence
*The Accidental Dismemberment Benefit and the Paralysis Benefit will be paid as a Monthly Benefit at 1% of the applicable Principal Sum. The payment of this Monthly Benefit will cease upon the earliest of the following: (1) the date the total of the applicable Principal Sum has been paid; or (2)
the date the Subscriber dies. The most the Insurer will pay for these benefits, as well as the Accidental Death Benefit, in total is the Subscriber’s Principal Sum, if the Subscriber can recover benefits under more than one benefits as a result of the same covered accident.
At age 65, the Subscriber’s Principal Sum will be based on the following schedule:
Age at Date of Benefit Payment
% of Principal Sum
70 and over
**lf the Subscriber sustains a Covered Injury at or after age sixty five (65), the Maximum Benefit Period will be one (1) Year.
***lf the Subscriber sustains a Covered Injury after the Subscriber’s normal Social Security retirement age, as determined by federal law, the Subscriber cannot qualify for Continuous Total Disablement.
Schedule of Accidental Death & Dismemberment Benefit for Loss of:
Both Hands or Both Feet
Sight of Both Eyes
One Hand and One Foot
One Hand and the Sight of One Eye
One Foot and the Sight of One Eye
Speech and Hearing in Both Ears
One Hand or One Foot
The Sight of One Eye
Hearing in One Ear
Thumb and Index Finger of Same Hand
Functional Loss of Use: lf Injury to the Subscriber results within 365 days of the date of the the covered Accident that caused the Injury in any one of the losses specified below, the Insurer will pay the percentage of the Principal Sum shown below for that Loss:
Functional Loss of Use:
Use of 4 Limbs
Use of 3 Limbs
Use of 2 Limbs
Use of 1 Limb
Item 12. Additional Conditions and Limitations:
- Premium Payment Mode: Monthly
- Premium Calculation Mode: 15th of the Month
- Age Limit (see Uniform Provisions for more details) Age 65
Item 13. In the event of a claim please notify the following: As per CertificateItem 14. Forms, endorsements and riders attached to and made a part of this Coverage at issuance:
Covered Activity Endorsement (Trucking Operation)
SECTION 1 – WHEN COVERAGE STARTSWhen a Sponsor’s Coverage Commences
A Sponsor’s coverage will begin on the Sponsor’s Effective Date.
Eligibility and When a Subscriber’s Coverage Commences
The Eligibility is identified by the Eligible Class descriptions as shown on the Schedule and defined in the Covered Activity Rider.
A Subscriber’s coverage commences on the date stated in the Certificate issued by TOA, with one exception: If the Subscriber is away from work because the Subscriber is disabled, coverage will not start until the Subscriber is no longer disabled and returns to active work, but only if he/she returns to active work before the expiration date stated in the Certificate.
SECTION 2 – WHEN COVERAGE STOPSWhen a Sponsor’s Coverage StopsA Sponsor’s coverage under the group policy shall terminate when:
- The Insurer gives advance written notice of termination of the group policy for any reason; or
- TOA requests in writing to the Insurer that the group policy be terminated; or
- The Sponsor fails to pay the required premium or portion thereof when due (subject to any Grace Period); or
- TOA receives a written request from the Sponsor to terminate the Sponsor’s participation in the
When a Subscriber’s Coverage StopsA Subscriber may request that the Subscriber’s coverage be terminated by completing the necessary written notice and forwarding it to the Sponsor. The effective date of termination will be the earliest of the following:
- the date the Sponsor receives a written request for termination from the Subscriber; or
- when the Subscriber is no longer in an Eligible Class; or
- when the Subscriber stops making payments for the coverage (subject to any Grace Period); or
- when the group policy terminates; or
- when the Sponsor stops participating in this insurance; or
- when any applicable age limit is attained.SECTION 3 – BENEFIT PROVISIONBenefits hereunder are only payable for loss sustained by a covered accident. NO BENEFITS ARE PAYABLE IN CONJUNCTION WITH AN ILLNESS OR SICKNESS, AS DEFINED HEREIN.Coverage A, B, C, or D are provided as indicated on the Schedule.
Coverage A. – ACCIDENTAL DEATH BENEFIT
If a Subscriber suffers death within 365 days after a covered Accident, Accidental Death Benefits will be paid to the Subscriber’s eligible beneficiary(ies). The benefit payable will be in accordance with the terms, conditions, limitations and exclusions of these Terms & Conditions and any Maximum Benefit as shown in the Schedule. The death must result directly and solely from such covered Accident and be independent of illness, disease or bodily infirmity.
The initial Death Benefit is shown in the Schedule. The remaining balance will be payable as a Survivor’s Benefit in monthly installments of 1% per month for a period of 100 months after the initial payment has been made, or until the satisfaction of the Survivor’s Benefit, whichever occurs first. The Subscriber’s beneficiary may not elect payment in one sum.
If a Subscriber dies within 365 days after a covered Accident and before attaining the Age Limit and is survived by an eligible beneficiary, the Survivor’s Benefit will be payable. This benefit will be paid in accordance with the terms, conditions, limitations and exclusions of these Terms & Conditions, and subject to the following:
- If a Subscriber is survived by a spouse, the spouse will receive a monthly benefit until he/she dies, remarries, enters into a common-law or civil partnership, or until the Maximum Benefit is paid, whichever occurs first;
If the spouse is no longer eligible to receive this benefit, then any eligible Dependent Child(ren) will receive this benefit until no longer eligible, or until the Maximum Benefit has been paid, whichever occurs first. Benefits to any Dependent Child(ren) ceases upon the child’s attainment of age 19, or age 23 if enrolled as a full-time student in an accredited secondary school, vocational school, college or university;
- If there are no eligible beneficiaries, no Survivor’s Benefit will be paid.
A person becomes a beneficiary only if a Subscriber has named them as a beneficiary on an approved beneficiary form. Beneficiary designations may be changed by filling out a Change of Beneficiary form. If no beneficiary is named, the applicable Accidental Death Benefit will be paid to the Subscriber’s estate.
Coverage B. – ACCIDENTAL DISMEMBERMENT BENEFIT
The benefits payable will be in accordance with all of the terms, conditions, limitations and exclusions of these Terms & Conditions including the attached Schedule. The loss must result directly and solely from such covered Accident and be independent of disease or bodily infirmity.
The Principal Sums for Dismemberment and/or Functional Loss of Use are shown in the Schedule.
The term “Dismemberment” means a complete separation of a limb from the body. “Hearing or Speech Loss” means the total and irrecoverable loss of hearing or speech. “Loss of Hand” means removal at or above the wrist joint. “Loss of Foot” means removal at or above the ankle joint. “Loss of an Eye” means the total and irrecoverable loss of sight. “Loss of Thumb and Index Finger of the Same Hand” means the actual, permanent and complete severance through or above the metacarpophalangeal joints. “Functional Loss of Use” means complete paralysis of the entire limb which cannot be recovered.
If more than one Dismemberment, Loss of Life or Functional Loss of Use results from any one covered Accident, the benefit payable is the total percentage of the Principal Sums indicated in the Schedule. However, the most the Insurer will pay for all loss resulting from one covered Accident is 100% of the Principal Sum.
Coverage C. – ACCIDENTAL DISABILITY BENEFIT
The Insurer will pay an Accidental Disability Benefit for each week of a Subscriber’s disability as stated in the Schedule. Payment will not be made during the Waiting Period indicated on the Schedule. Once the applicable Waiting Period is satisfied, benefits will be payable as shown in the Schedule.
In order to be considered under this Benefit provision, disability must (1) result from a covered Accidental Injury, (2) begin within the Disability Reporting Period shown in the Schedule, (3) require the ongoing care of a legally qualified Physician, and (4) prevent a Subscriber from engaging in work for compensation, wage or profit.
The definition of Total Disability is further limited in scope as follows:
Temporary Total Disability, a benefit, up to the Maximum Weekly Benefit shown in the Schedule, will be payable for a Subscriber’s inability to perform all of the substantial and material duties of the Subscriber’s regular occupation as defined in the Subscriber’s Covered Contract for up to the Maximum Payment Period shown in the Schedule; or
Permanent Total Disability, if the Subscriber is still disabled after the Maximum Payment Period for Temporary Total Disability, a benefit will be payable, up to the Maximum Payment Period for Permanent Total Disability as shown in the Schedule, if the Subscriber:
- Cannot engage in any work for pay or profit, and is unable to perform all of the substantial and material duties of ANY occupation or employment which the Subscriber might qualify for by reason of education, training or experience; and
- Is granted a Total Disability Award status and starts receiving disability payments by the Social Security Administration for such Total Disability. If the Subscriber is ruled ineligible based on the status or the Subscriber is ineligible for Social Security Administration disability payments for any reason, the Subscriber will also be deemed ineligible for payments under this Permanent Total Disability benefit.For Temporary Total Disability, the Accidental Disability Benefit will be payable for the duration of the Disability after satisfying any applicable Waiting Period. For any Total Disability of less than one Week, one-seventh of the Weekly Benefit will be payable per full day of Disability. For Permanent Total Disability, the monthly benefit will be equal to 4.3 times the Weekly benefit.
Separate periods of Disability resulting from the same or related causes will be considered one period of Disability unless separated by the Subscriber’s return to active work or until the Subscriber can perform the daily functions of a person of like age in good health for at least six (6) consecutive months.
Separate periods of Disability resulting from unrelated causes will be considered one period of Disability unless separated by the Subscriber’s return to active work or until the Subscriber can perform the daily functions of a person of like age in good health for at least one full day.
The Maximum Weekly Benefit payable will be a percentage of the Subscriber’s Average Weekly Compensation. At the Insurer’s discretion, benefits may be paid on a monthly or bi-monthly basis, instead of weekly. From time to time, the Subscriber’s status will be reviewed and may require an accounting of earnings and/or proof of continued disability. The Subscriber’s failure to furnish any such required information within 30 days of written notice may result in termination of coverage and/or benefits.
Reduction in Disability Income Benefits
The amount of Total Disability Income Benefits will be reduced by the amount of any Social Security benefits payable on account of such disability. This amount shall include any benefits payable to dependents. Cost-of-living increases in Social Security payments effective after the correct Social Security benefit has been determined will be used to reduce the Insurer’s Disability Income Benefit.
Coverage D. – ACCIDENT MEDICAL EXPENSE BENEFITS
If the Subscriber suffers Bodily Injury in a covered Accident that requires medical attention, the Insurer will pay for medically necessary services or supplies as provided for herein. There is no coverage under this benefit for the Subscriber’s sickness, illness or ordinary disease of life (by whatever named called). However, if the Subscriber develops an illness or disease that is the result of and directly related to Bodily Injury which first occurred from a covered Accident, benefits will be payable as provided for herein. In any case, medical benefits payable are limited to expenses Incurred within the time frame specified under the Medical Incurral Period (as shown in the Schedule) or until any Maximum Benefit (as shown in the Schedule) has been paid, whichever occurs first.Subject to Utilization Management, payment for medically necessary and appropriate treatment will be made in accordance with these Terms & Conditions. These expense must be Incurred during the Medical Incurral Period shown in the Schedule up to the Maximum Benefit. This benefit is payable regardless of where the expenses are Incurred, whether in or out of the hospital, subject to Utilization Management as defined herein.
Charges: Payments for covered expenses are made based upon usual, customary and reasonable criteria that is procedure or service specific and calculated by geographic location. Benefits are payable only up to usual, customary and reasonable levels; amounts in excess of this amount will not be covered.
Subject to the Accident Medical provisions set forth herein, this benefit covers the Subscriber’s stay in facilities including a general hospital, up to the stated limits shown in the Schedule. For stays in an Extended Care Facility or Rehabilitation Facility, this benefit covers the average room and board costs and miscellaneous services. The confinement must begin within 14 days of discharge from a hospital confinement of at least 3 days for the same or related conditions, provided a legally qualified Physician is supervising such care and certifies in writing that the patient continues to need skilled nursing care or supportive therapeutic services as part of a regimen of medical care.
SURGICAL PROCEDURES EXPENSE
Subject to the Accident Medical provisions set forth herein, this benefit covers the cost of surgical procedures undergone by the Subscriber as a result of a covered Accidental Injury, up to the amount customarily charged for the procedure in the geographical locality where it is performed.
DENTAL PROCEDURES AND ORAL SURGERY
Dental procedures are not covered, except for the prompt, necessary repair to a sound natural tooth which results from a covered Accidental Injury. Such injuries must occur while covered under the Certificate. Subject to the Accident Medical provisions set forth herein, certain oral surgical procedures are covered. Covered procedures are limited to the following:
- excision of unerupted, partly erupted or impacted teeth;
- repair of a fractured or dislocated jaw;
- osseous surgery;
- maxillofacial surgery.
Subject to the Accident Medical provisions set forth herein, this benefit covers the costs of a legally qualified Physician (who is not the attending surgeon or assistant surgeon) who performed anesthetic procedures in connection with a surgical procedure for which benefits are payable due to a covered Accident. This benefit also covers the cost of the anesthetic itself. These charges are paid on a usual, customary and reasonable basis.
PHYSICIAN SERVICES EXPENSE
Subject to the Accident Medical provisions set forth herein, visits by a Physician for treatment of a covered Accidental Injury while the Subscriber is a registered bed patient in a hospital, will be paid on a usual, customary and reasonable basis. Physician care and treatment, including consultations, will be paid on a usual, customary and reasonable basis.
DIAGNOSTIC PROCEDURES EXPENSE
Subject to the Accident Medical provisions set forth herein, this benefit covers radiological or laboratory procedures recommended by a Physician or surgeon for diagnosis in connection with a covered Accidental Injury. Radiological and laboratory procedures must be rendered, where possible, at centers other than a hospital. Venipuncture is not covered. This benefit covers up to the usual, customary and reasonable charge.
PRESCRIPTION DRUG EXPENSE
Coverage for expenses Incurred by the Subscriber for prescription drugs shall be considered payable if necessary for the care and treatment of a covered Accidental Injury and only when prescribed by a Physician when:
- confined as an inpatient in a hospital; or
- administered as part of a Physician’s office visit.
Incurred expenses are payable subject to the applicable Deductible, if any. No prescription drug expense benefits shall be paid for expenses related to:
- therapeutic devices or appliances (unless the Insurer authorizes coverage under Alternative Treatment Expense);
- any prescription which the Subscriber is entitled to receive without charge from any municipal, state or federal program;
- any prescription refilled in excess of or dispensed after one (1) year from the Physician’s original order;
- immunization agents;
HOME HEALTH CARE EXPENSE
Subject to the Accident Medical provisions set forth herein, this benefit covers certain services or supplies furnished to a Subscriber in their home in connection with a covered Accidental Injury. The services and supplies must be furnished under a program approved in writing by the attending Physician, as an alternative to continued hospital care, and must be provided by a certified Home Health Care Agency and pre-approved by the Insurer.
The services and supplies to which this benefit applies are:
- Part-time or intermittent nursing care by a Registered Nurse, or by a Licensed Practical Nurse under the supervision of a Registered Nurse if the services of a Registered Nurse are not available;
- Part-time or intermittent home health aide services which consist primarily of patient care of a medical therapeutic nature by other than a Registered or Licensed Practical Nurse;
- Physical therapy, occupational therapy, and speech therapy provided by the Home Health Care Agency;
- Medical supplies, drugs and medications prescribed by a Physician, and laboratory services by or on behalf of a hospital to the extent such items would have been covered under the Hospital Benefit if the Subscriber had remained in the hospital.For determining the limit of benefits with respect to above services, each visit by a member of a home health care team shall be considered as one home health care visit and four hours of home health aide service shall be considered as one home health care visit.
No payments will be made for:
- Services or supplies of a Home Health Care Agency furnished to anyone eligible for Medicare; or
- Services or supplies not included in a home health care plan; or
- Services of a person who ordinarily resides in the home, or is a member of the family; or
- Transportation services, and services and supplies provided to an individual primarily to assist him/her in the activities of daily living; or
- Any period during which the Subscriber is not under the continuing care of a Physician; or
- Expenses for services and supplies not related to medical care or treatment.EMERGENCY ROOM EXPENSESubject to the Accident Medical provision set forth herein, emergency room costs for the treatment
of an Injury arising from a covered Accident that requires Emergency Core as defined by these Terms & Conditions, are covered on usual, customary and reasonable basis.
COVERED MEDICAL EXPENSESubject to the Accident Medical provisions as set forth herein, the following are Eligible Expenses
under the Certificate. All of the following medical expenses will be covered on a usual, customary and reasonable basis:
Hospital charges for:
- the actual Room and Board expenses Incurred subject to usual, customary and reasonable charges;
- the actual expense Incurred for confinement in an Intensive Care Unit, Cardiac Care Unit or Burn Unit;
- miscellaneous hospital services and supplies during hospital confinement.
- Charges Incurred for confinement in a Rehabilitation Facility or in a Convalescent or Skilled nursing facility. However, such expenses are limited as follows:
- Charges will be considered only if confinement begins within 14 days after a hospitalconfinement of at least three (3) consecutive days; and
- The Attending Physician certifies that confinement is medically necessary; and
- Only charges Incurred in connection with care related to the covered Accidental Injury
for which a Subscriber was confined will be eligible.
- Charges Incurred for Surgical procedures, as follows:
- For medically necessary Surgical Procedures.
- When two or more Surgical Procedures occur during the same operation, the Eligible Expense for all charges are as follows:
- Charges for multiple surgical procedures performed during the same operative session which do not require separate incisions are handled as follows: the covered Eligible Expense for the greater procedure will be considered in full; the covered eligible expense for the next lesser procedure will be considered at 50%; and the covered eligible expense for any additional procedures will be considered at 25%.
- When an incidental procedure is required because of a covered Accident and performed through the same incision, the Eligible Expense is the usual, customary and reasonable fee for the major surgical procedure only.
- When an assistant surgeon is required to render technical assistance at an operation, the Eligible Expense for such services shall be limited to 20% of the usual, customary and reasonable charge of the surgical procedure.
Usual, customary and reasonable charges for the following oral surgery procedures:
- Open or closed reduction of a fracture or dislocation of the jaw;
- Osseous surgery;
- Maxillofacial surgery;
Accidental Injury to a sound, natural tooth.
Usual, customary and reasonable charges for reconstructive surgery, but only in the following situation: Treatment within six (6) months of a covered Accidental Bodily Injury sustained and treated while a Subscriber.
Usual, customary and reasonable Charges, as follows:
- for the services of a legally qualified Physician for medical care and/or surgical treatment including office, home visits, hospital inpatient care, hospital outpatient visit/exams, clinic care, and surgical opinion consultations;
- of registered nurses (RNs) or licensed practical nurses (LPNs) for private duty nursing;
- for the treatment or services rendered by a licensed Physician or Occupational Therapist under direct supervision of a Physician in a home setting or at a facility or institution whose primary purpose is to provide medical care for a covered Accidental Injury;
- of a legally qualified Physician or qualified Speech Therapist under direct supervision of a Physician for restorative speech therapy for speech loss or impairment due to a covered Accidental Injury, or due to surgery performed on account of a covered Accidental Injury other than a functional nervous disorder;
- for professional ambulance service to the hospital in an emergency situation when a Subscriber is subsequently admitted as an inpatient; and transport between medical facilities when medically necessary;
- for drugs requiring the written prescription of a licensed Physician; such drugs must be necessary for the treatment of a covered Accidental Injury;
- for radiological services, microscopic tests and laboratory tests;
- for the processing and administration of blood components, but not for the cost of the actual blood or blood components if replaced;
- for physical and manipulative therapy when such therapy is part of a Physician-approved Home Health Care Plan;
- for oxygen and other gases and their administration;
- for electrocardiogram, electroencephalograms, pneumoencephalogram, basal metabolism tests, or similar well established diagnostics generally approved by Physicians throughout the United States;
- for the cost and administration of an anesthetic;
- for dressings, sutures, casts, splints, trusses, crutches, braces, and other necessary medical supplies;
- for rental of a wheelchair, hospital bed, ventilator, or other durable medical equipment required for therapeutic use, or the purchase of this equipment if economically justified, whichever is less;
- for non-dental prostheses and appliances includíng artificial limbs, eyes, or larynx, to replace limbs or eyes lost while covered under the Certificate, but not the replacement thereof unless the replacement is necessary because of physiological changes;
- for services of an ambulatory or outpatient surgical center;
- for Dental Services rendered by a Physician for treatment of an Injury to a sound, natural tooth if:
- The Injury is caused by a covered Accident sustained while a Subscriber;
- All treatment is rendered within six (6) months of the covered Accident; and
- All treatment is rendered while a Subscriber;
- for hyperalimentation or Total Parenteral Nutrition (TPN) for persons recovering from or preparing for surgery;
- for the services of a qualified physiotherapist;
Usual, customary and reasonable Charges made by a Home Health Care Agency for care in accordance with a Home Health Care Plan.
Such expenses include:
- Part-time or intermittent nursing care by a registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed vocational nurse (L.V.N.), or public health nurse who is under the direct supervision of a registered nurse;
- Home health aides; and
- Medical supplies, drugs and medicines prescribed by a Physician, and durable medical equipment prescribed by a Physician.Specifically excluded from coverage under the Home Health Care benefit are the following:
- Services and supplies not included in the Home Health Care Plan;
- Services of a person who ordinarily resides in the Subscriber’s home, or is a close relative of the Subscriber;
- Transportation services;
Custodial Care and housekeeping.
Home Health Care Visit means a visit by a member of a Home Health Care team. Each such visit that lasts for a period of four (4) hours or less is treated as one Home Health Care Visit. lf the visit exceeds four (4) hours, each period of four (4) hours is treated as one visit and any part of a four (4) hour period that remains is treated as one Home Health Care Visit.
SECTION 4 – LIMITATIONS AND EXCLUSIONS
Limitations and Exclusions Applicable to all Benefits
Coverage hereunder shall not apply to any person who is acknowledged as a statutory employee of the Sponsor or any Subscriber prior to a claim being filed under the Certificate, or to any claim brought by employees of the Subscriber who are not considered to be independent contractors.
No payment of benefits will be made:
- for, or in connection with, an Occupational Disease or Cumulative Trauma arising out of, or in the course of, any employment for wage or profit;
- for, or in connection with, an Illness or an Injury if the Subscriber is deemed to be an employee and covered under any Workers’ Compensation or similar state or federal law;
- for treatment, services or supplies received in a hospital owned or operated by the United States Government;
- for charges which the Subscriber is not legally required to pay or for which no charge or payment would have been required if coverage was not in force;
- for charges which are in excess of usual, customary and reasonable charges; or which are determined to be inappropriate or not medically necessary;
- for, or in connection with, custodial care, education or training;
- for, or in connection with, reconstructive surgery or treatment, except as otherwise specifically provided;
- for eyeglasses, contact lenses and hearing aids, and examinations for their prescriptions and fitting including charges for surgical procedures for the correction of visual refractive problems (radial keratotomy), except for the replacement of eyeglasses, contact lenses or hearing aids which are damaged in a covered Accident;
- for nursing, medical or surgical care or treatment rendered by a family member, including, but not limited to, a spouse, child, mother, father, brother, sister, parent of spouse, aunt, uncle, or son-in-law/daughter-in-law;
- for, or in connection with, dental services or supplies, except as provided for herein;
- to the extent that the Subscriber is reimbursed, entitled to reimbursement, or in any way indemnified for those expenses by or through any government sponsored program, including, but not limited to, Medicare or Social Security;
- for any loss directly resulting from the commission of or attempt to commit a felony or directly resulting from being engaged in an illegal act or occupation;
- as a direct or indirect result of war (whether declared or not), invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolution, terrorism, insurrection, military or usurped power or confiscation or nationalization;
- for nuclear reaction, nuclear radiation or radioactive contamination;
- for devices, equipment and supplies that are not durable medical equipment or prostheses, except as otherwise specifically provided;
- for services paid, payable or required to be provided as Basic Reparations Benefits under any No-Fault Automobile Insurance Law except as provided herein. An uninsured or underinsured motorist will be considered self-insured for bodily injury expenses. The Insurer will not be required to extend benefits which are required under any No-Fault Automobile Insurance Law;
- for, or in connection with, experimental procedures or treatment methods not approved by the American Medical Association, the American Dental Association or the appropriate medical or dental specialty society;
- for experimental drugs or substances not approved by the Food & Drug Administration, or for drugs labeled: “Caution: Limited by Federal Law to Investigational Use”;
- for non-medical hospital expenses such as newspapers, guest trays, beauty shop services, cots, guest accommodations, admission kit, rental of telephones, radios, televisions or any other items solely for personal use or comfort;
- for care, treatment, services, supplies, materials, and/or equipment that is not medically necessary or that is inappropriate for the diagnosis and related care/treatment of a covered Accidental Injury;
- by any provider of medical services for the time spent traveling in the course of rendering medical care;
- for the services of nutritionists, acupuncturists, massage therapists, herbalists, whether or not they are licensed or certified. For the services of any other allied or alternative health professionals that are unlicensed;
- for suicide, attempted suicide or self-inflicted Bodily Injury while sane or insane;
- for failure to attend or remain at scheduled visits and charges for copying or completion of any claim form, operative report or medical records;
- for a Bodily Injury while the Subscriber is:
- Intoxicated (a Subscriber will be conclusively presumed to be intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the locale in which the covered Accident occurred, to be under the influence of alcohol or intoxicating liquid if operating a motor vehicle, regardless of whether he or she is in fact operating a motor vehicle when the Bodily Injury is sustained); or
- Under the influence of a narcotic or controlled substance, unless prescribed by a
Physician and taken in accordance with the prescribed dosage;
- for medical care or treatment received while incarcerated in a local, state or federal facility (benefits as shown on the Schedule will be terminated as of the first day of incarceration);
- for sickness, disease or bacterial or infections;
- for purposely self-inflicted Injury or any Injury resulting from a provoked attack;
- for any Bodily Injury incurred while riding or driving in any kind of organized race for profit;
- for any Bodily Injury incurred during travel or flight in any vehicle or device for aerial navigation, including boarding or alighting therefrom,
- while being used for any test or experimental purpose; or
- while a Subscriber is operating, learning to operate or serving as a member of the crew thereof; or
- while being operated by or for or under the direction of any military authority, other than transport type aircraft;
- when skydiving, parasailing, bungee-jumping, or doing any similar activity: or
- for prostatitis or hemorrhoids not directly related to a covered Accident; or
- for any amount of a covered claim that exceeds the Combined Single Limit. The Combined Single Limit is shown in the Schedule; or
- for Pre-existing Conditions. The term Pre-existing Condition means an illness or injury for which a covered Subscriber:
- Incurred charges,
- Received medical treatment,
- Consulted a physician, or
- Took prescribed drugs
within 12 months before he or she became insured under a given benefit section of the policy.
SECTION 5 – CLAIMS PROVISIONS
Utilization Management is a proven strategy for containing health care costs. The goal of utilization management is to reduce the incidence of medically unnecessary and inappropriate Physician care, surgical procedures, or hospital admissions through a pre-certification process.
These Terms and Conditions provide for the utilization of Physicians and health care professionals to determine the medical necessity and appropriateness of procedures and review claims submitted for reimbursement. All Physicians and hospitals will be informed of this process as applicable. If questions arise regarding Utilization Management requirements, please call the utilization review provider. Questions will be answered professionally and confidentially by specially trained staff.
TOA will designate a Claims Administrator to: (a) complete a Call-In sheet logging the Subscriber’s answers to the Call-In sheet’s questions; (b) send to the Subscriber the initial claim forms and an Injury Letter explaining the Subscriber’s obligations; and (c) assist the Subscriber in submitting the initial claim forms. The Insurer will designate a Claims Administrator who shall be responsible for the remainder of the claims processing. Claim forms are to be submitted directly to the Insurer’s Claims Administrator.
Currently, TOA has designated All United Risk Managers LLC (“All United”) as its Claims Administrator and the Insurer has designated Gallagher Bassett Services Inc (“Gallagher Bassett”) as its Claims Administrator. Completed claim forms are to be submitted directly to the Gallagher Bassett.
If a Physician or other provider is submitting a claim where benefits have been assigned, he or she may use any standard or generally accepted claim form. The claim form must be completed and accompanied by an itemized bill that shows specific services, dates of service, and other information in detail.
If there is any question with regard to Subscriber eligibility, continuance of coverage, payment of a claim, or if there is a dispute with the denial of a claim or the amount paid, contact should first be made with the Insurer’s Claims Administrator and then with TOA. The Subscriber is allowed at least 60 days to request a review of the claim. The Subscriber has the right to review pertinent documents affecting the acceptability of a claim and to submit comments in writing. The review of the claim is normally made within 30 days after receipt of a request for review. An additional 30 days will be allowed if special circumstances require more time. A notice in writing will be sent before the expiration of the initial 30-day period if an extension is needed. The decision on a review will be sent in writing. It will include specific reasons for the decision and will refer to pertinent Certificate provision, Terms & Conditions or legal provisions on which the decision was based.
Filing a false or misleading claim for benefits is a FELONY and is punishable by a fine and/or imprisonment. TOA and the Insurer have the right, but not the duty, to prosecute any person or organization who they believe may have filed for and/or received benefits as a result of filing a false or misleading claim for benefits. TOA and the Insurer may also prosecute, at their sole discretion, any individual who they believe may have aided or assisted in the filing of a false or misleading claim. If a claimant is later found to be guilty of filing a false or misleading claim, the Insurer shall be relieved of any unpaid benefits otherwise due under the Certificate and shall pursue repayment from the Subscriber or to any other parties for amounts already paid as may be permissible by law.
Upon receipt of a notice of claim, TOA’s Claims Administrator will furnish to the Subscriber the required claim forms. The Subscriber shall complete the forms and submit them directly to the Insurer’s Claims Administrator who shall be responsible for the remainder of the claims processing. It is the Subscriber’s responsibility to advise TOA and TOA’s Claims Administrator if the claim forms are not received within five (5) calendar days..
NOTICE OF CLAIM
Written notice of claim must be given to Gallagher Bassett within ninety (90) days after the occurrence or commencement of any loss covered by the Certificate or as soon after the loss as is reasonably possible.
TIME LIMIT ON CERTAIN DEFENSES
After two (2) years from the date of issue of the Certificate, no misstatement made by any Subscriber in the application for this insurance shall be used to void the Certificate or to deny a claim for loss Incurred, as defined herein, commencing after the expiration of such two (2) year period.
TIME OF PAYMENT OF CLAIMS
All benefits payable under the Certificate will be payable immediately upon receipt of due written proof of such loss. Should the Insurer fail to pay the benefits payable under the Certificate upon receipt of due written proof of loss, the Insurer shall have thirty (30) days thereafter within which to mail a letter or notice which states the reasons the Insurer may have for failing to pay the claim, either in whole or in part, and which also gives a written itemization of any documents or other information needed to process the claim or any portions thereof which are not being paid. When all of the listed documents or other information needed to process the claim have been received, the Insurer shall then have thirty (30) days within which to process and either pay the claim or deny it, in whole or in part, stating the reasons the Insurer may have for denying such claim or any portion thereof. The Insurer shall pay interest as required by law on the benefits due under the terms of the Certificate and these Terms & Conditions for failure on the Insurer’s part to comply with the requirements of this provision.
To the extent that benefits are paid under the Policy, the Insurer shall be subrogated to all rights of recovery which any Subscriber may acquire against any other party for the recovery of the amount paid under the Policy, however the Insurer’s right of subrogation is secondary to the right of the Subscriber to be fully compensated for his or her damages. The Subscriber must deliver all necessary documents or papers, execute and deliver all necessary instruments, furnish information and assistance, and take any action the Insurer may require to facilitate enforcement of the Insurer’s right of subrogation. The Insurer agrees to pay the Insurer’s portion of the Subscriber’s attorneys’ fee or other costs associated with a claim or lawsuit to the extent that the Insurer recovers any portion of the benefits paid under the Policy pursuant to the Insurer’s right of subrogation.
RIGHT OF REIMBURSEMENT
To the extent that benefits are provided or paid under the Policy, if a Subscriber fully recovers his damages from a third party, then he will reimburse the Insurer the portion of the damages recovered for the expenses incurred by the Subscriber that were provided or paid by the Insurer. The Insurer agrees to pay the Insurer’s portion of the Subscriber’s attorneys’ fee or other costs associated with a claim or lawsuit to the extent that the Insurer recovers any portion of the benefits paid under the Policy pursuant to the Insurer’s right of reimbursement.
COORDINATION OF BENEFITS
The Coordination of Benefits provision is intended to prevent the duplication or overpayment of benefits for eligible expenses Incurred. It applies when a Subscriber is also covered by any other certificates or policies. When more than one coverage exists, one coverage normally pays its benefits in full and the other coverage pays a reduced benefit. The Insurer will always pay either benefits in full or a reduced amount which when added to the benefits payable by the other certificates or policies, will not exceed 100% of Allowable Expenses. Only the amount paid by the Insurer will be charged against the Subscriber’s maximums indicated in the Schedule.
Allowable Expense: Allowable expenses as used herein means the usual, customary and reasonable expenses for medical and/or dental care or treatment. Part of the expenses must be covered under at least one of the policies.
As Used in this Section, “policy” or “plan” shall mean:
- coverage under a statutory workers’ compensation policy;
- the Certificate or the Group Policy to which it applies;
- any group, blanket or franchise insurance policy or contract;
- a group contractual prepayment or indemnity policy;
- a group Health Maintenance Organization (HMO) contract, whether group practice or individual practice association;
- medical benefits coverage in automobile policies, to the extent permitted by law;
- any individual medical policy or coverage.If an arrangement has two parts and the Coordination of Benefits rules apply only to one of the two, each of the parts is considered a separate plan.
Primary Plan: When the Insurer’s Plan is primary, the Insurer’s benefits are determined before those of the other policy. The benefits of the other policy are not considered.
Secondary Plan: When the Insurer’s Plan is secondary, the Insurer’s benefits are determined after those of the other policy. The Insurer’s benefits benefits may be reduced because of the other policy’s benefits.
The following “Order of Benefit Determination” establishes when the Insurer’s Plan is the Primary Plan or Secondary Plan in relation to any other plans covering the Subscriber. When there are more than two Plans covering the Subscriber, the Insurer’s Plan may be either a Primary Plan as to one or more other Plans and may be a Secondary Plan as to a different Plan(s).
ORDER OF BENEFIT DETERMINATION:
The Subscriber’s coverage under the Certificate will be the Primary Plan in all cases except for the following:
- when any coverage is available under the federal Social Security Act or similar law; or
- when Medicare is primary; or
- when the Subscriber qualifies for Workers’ Compensation or any other similar statutory program.
Right to Receive and Release Needed Information – The Insurer may, at its sole discretion, give or receive any information that the Insurer needs to underwrite, investigate and/or settle claims under this insurance. Any person having any information as to a diagnosis, the treatment, or prognosis of any physical or mental conditions or nonmedical information about the Subscriber’s family or the Subscriber is authorized to release such information to the Insurer or its designee. This includes information related to substance use or abuse. Any medical practitioner, medical facility, pharmacy, the Medical Information Bureau (MlB), employer or insurance company that may have such information is authorized to release
such information to the Insurer or its designee. The Insurer or its Claíms Administrator may also release this information about the Subscriber’s family or the Subscriber to the MIB or any insurer to which the Subscriber has applied for coverage or to anyone else the Insurer or its Claíms Administrator deems necessary to investigate and/or settle a claim under this insurance.
SECTION 6 – DEFINITIONS
Accident or Accidental Injury: The term Accident or Accidental Injury means an unforeseen event, or series of events, which results in Bodily Injury.
This event must meet all of the following:
- It must happen while the Subscriber is covered under this Plan;
- It must be an Occupational Accident;
- The bodily injury must result directly from the covered Accident and must be independent of an
Occupational Disease, ordinary disease of life or bodily infirmity;
- It must be an event which was unforeseen, unplanned and unexpected;
- It must have occurred at a specifically identifiable time and place;
- It must have occurred by sudden and abrupt cause or by chance;
- It must have resulted in physical Injury to a Subscriber;
- It must have arisen out of and in the course of a Subscriber’s duties under a Covered Contract; and
- It must have occurred during the Coverage Period.Accident or Accidental Injury does not include any of the following:
- Aggression in a fight; or
- Suicide or attempted suicide; or
- An illness or sickness; or
Cumulative trauma; or
Occupational disease; or
- Hernia of any type.Ambulatory Care Facility: The term ambulatory care facility means a facility equipped to handle surgical procedures that require hospital-type facilities, but do not require hospital confinement. In order to qualify, an ambulatory care facility must:
- be established, equipped and operated for the performance of surgical procedures by Physicianswho are part of an organized medical staff; and
- have equipment and supplies not usually available to a Physician outside a hospital including operating rooms, recovery room, diagnostic facilities, emergency equipment and full-time Nurses; and
- have a written agreement with a nearby hospital to accept patients who develop complications and require hospital confinement.Ambulatory Surgical Center: The term ambulatory surgical center means an institution or facility, either free-standing or as part of a hospital with permanent facilities, equipped and operated for the primary purpose of performing surgical procedures and to which a patient is admitted and from which he or she is discharged within a twenty-four (24) hour period. An office maintained by a Physician for the practice of medicine or dentistry, or for the primary purpose of performing terminations of pregnancy, is not an ambulatory surgical center.
Average Weekly Compensation: The term average weekly compensation means either of the following:
- The Subscriber’s net earnings as reported to the Internal Revenue Service on Form Schedule C for the twelve (12) calendar months immediately preceding the date of the covered Accident, divided by 52. If the period of time worked is less than one year, the Insurer will take the average of the total consecutive weeks worked as an Independent Contractor.
- 75% of the gross settlements earned by the Subscriber and reported on Form 1099 for the twelve(12) calendar months immediately preceding the date of the covered Accident, divided by 52 weeks. If the period of time worked is less than one full year, then the average of the total consecutive weeks worked as an Independent Contractor will be used to establish the gross settlement amount and then adjusted by the 75% factor for offsetting expenses and operating costs incurred by the Independent Contractor.
This average weekly compensation amount will then be used to calculate the benefit amount payable as defined in the Schedule section of this policy.
Bodily Injury: The term Bodily Injury means an Occupational Accident resulting in physical injury to a Subscriber which occurs during the Coverage Period and while the Subscriber is under contract and arises solely out of and in the course of his/her occupation and duties as defined in the Covered Contract as an Independent Contractor.
Certificate: The term Certificate means the Certificate of Insurance issued by TOA.
Convalescent or Skilled Nursing Facility: The term convalescent or skilled nursing facility means an institution or distinct part thereof, operated pursuant to law and meets all of the following conditions:
- It is licensed to provide, and is engaged in providing on an inpatient basis, for persons convalescing from injury, nursing services rendered by a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), or a licensed vocational Nurse (L.V.N.) under the direction of a Registered Nurse and physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential activities of daily living; and
- Its services are provided for compensation from its patients and under the full-time supervision of a Physician or Registered Nurse; and
- It provides 24-hours per day nursing services by licensed nurses, under the direction of a full-time Registered Nurse; and
- It has a Medical Director and/or has a Physician who visits the facility and its patients on a regular basis; and
- It maintains a complete medical record on each patient; and
- It is not, other than incidentally, a place for rest, custodial or educational care, the care of mental disorders, the care and treatment of substance abuse, or a home for the aged; and
- It is approved and certified by Medicare.This term shall also apply to expenses Incurred in an institution referring to itself as an Extended Care Facility, Convalescent Care Facility, Nursing Home or any such other similar nomenclature.
Convalescent Period: The term convalescent period means a period of time commencing with the date of confinement to a Convalescent or Skilled Nursing Facility. Such confinement must meet all of the following conditions:
- Such confinement must commence within fourteen (14) days of being discharged from a hospital; and
- Said hospital confinement must have been for a period of not less than three (3) consecutive days; and
- Both the hospital and convalescent confinements must have been for the care and treatment of the same covered injury.The convalescent period will terminate when free of confinement in any and all institutions providing hospital or nursing care for a period of ninety (90) consecutive days. A new convalescent period shall not commence until the previous convalescent period has terminated.
Cosmetic Procedure: The term cosmetic procedure means a procedure performed solely for the improvement of a Subscriber’s appearance and not for the improvement or restoration of a bodily function.
Coverage Period: The term coverage period means a continuous period of time that begins on the Subscriber’s Enrollment Date and continues until coverage terminates as per the Certificate and these Terms & Conditions. Such benefit period will terminate on the earliest of the following dates:
- the day any Maximum Benefit applicable to a Subscriber is paid; or
- the day a Subscriber ceases to be covered under the Certificate and these Terms & Conditions.
Covered Contract: The term covered contract means a legal, written work agreement that meets state
Independent Contractor requirements and definitions as further defined in the Covered Activity Rider.
Cumulative Trauma: The term cumulative trauma means an injury diagnosed by a Physician as occurring without Accidental Bodily Injury being the direct cause of loss. Cumulative trauma includes injury caused by continual stress and strain. Such injury may be causally related to a person’s job. Such injury may be due to repetitive traumatic acts. Hernia is not considered to be cumulative trauma.
Custodial Care: The term custodial care means that type of care or service, wherever furnished and by whatever name called, which is designed primarily to assist a Subscriber, whether or not totally disabled, in the activities of daily living. Such activities include, but are not limited to: bathing, dressing, feeding, preparation of special diets, assistance in walking or in getting in and out of bed, and supervision of medication which can normally be self-administered.
Durable Medical Equipment: The term durable medical equipment means equipment which is:
- able to withstand repeated use;
- primarily and customarily used to serve a medical purpose; and
- not generally useful to another individual or an otherwise healthy individual.Examples of durable medical equipment include, but are not limited to: wheelchairs, ventilators, hospital type beds, etc. Examples of equipment which do not meet the definition of durable medical equipment include, but are not limited to: humidifiers, safety bars or other similar apparatus that assist in the activities of daily living, exercise bikes or equipment, orthopedic shoes or lifts, saunas, spas, hot tubs, etc.
Emergency Care: The term emergency care means those procedures or services due to Accidental Injury
or an illness that results from a covered Accidental Injury that requires immediate medical attention.
Experimental: The term experimental means services and supplies which are experimental or investigational in nature, meaning any treatment, procedure, facility, equipment, drugs, drug usage, devices, or supplies not generally recognized as accepted medical practice and includes any such services or supplies requiring Committee approval not granted at the time of service.
Home Health Care Agency: The term home health care agency means a public or private agency or organization that specializes in providing medical care and treatment in the home. Such a provider must meet all of the following conditions:
- it is primarily engaged in and duly licensed, if such licensing is required, by the appropriate licensing authority to provide skilled nursing and other therapeutic services; and
- it has policies established by a professional clinical group associated with the agency or organization; this group must include at least one Physician and at least one Registered Nurse (RN) to govern the services provided; and
- it must provide for full-time supervision of such services by a Physician or Registered Nurse; and
- it maintains complete medical records; and
- it has a full-time administrator.
Home Health Care Plan: The term home health care plan means a program for care and treatment established and approved by the attending Physician, which provides for coordinated care in the home which is medically necessary.
Hospital: The term hospital means an accredited institution which is approved as a hospital by the Joint Commission of the Accreditation of Health Care Organizations or the American Osteopathic Association, and which meets all of the following criteria;
- It is primarily engaged in providing, for compensation from its patients and on an inpatient basis, diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons by or under the supervision of a staff of Physicians. If primarily a facility for the treatment of mental and/or psychological conditions, or chemical dependency, such facility must have a bona fide arrangement by contract or otherwise with a hospital to perform such surgical procedures as may be required; and
- it continuously provides twenty-four (24) hours per day nursing services by Registered Nursesunder the supervision of Physicians; and
- it is not, other than incidentally, a place for rest, the aged, a nursing home, a hotel or the like.Hospital Confinement: The term hospital confinement means a stay as a registered bed patient in a hospital for twenty-four (24) hours or longer. A registered bed patient is one assigned to a bed in any department of a hospital except the outpatient department, and who is charged for room and board. The stay must be recommended by a Physician for a medically necessary purpose. The patient cannot leave the hospital during the stay.
Illness or Sickness: The terms illness or sickness means a bodily disorder, disease, physical illness or psychiatric disorder. Illness/sickness also includes pregnancy.
Incurred: The term incurred means the date on which care, treatment, services or supplies are rendered or supplied.
Incurred Expenses: The term incurred expenses means the cost of services and supplies rendered or supplied. Such expenses are considered incurred at the time or date the service or supply is actually provided.
Independent Contractor: The term independent contractor means a Subscriber who meets the specific legal definitions and requirements as set forth in the applicable State law for an Independent Contractor. The following criteria represent the minimum requirements for an Independent Contractor:
- performs work under a formal written work agreement or contract defined as a Covered Contract; and
- receives compensation reported under a Form 1099 for compensation and self-employment tax purposes; and
- has responsibility for determining the time, means and method of performing the work required under a Covered Contract; and
- cannot be an employee of the Sponsor or of any scheduled Additional Insured parties covered under the Certificate.
Injury: See Accident, Accidental Injury or Occupational Accident.
Inpatient: The term inpatient means a person who is admitted to a hospital and who is confined to bed for health care.
Insurer: means the Underwriters or Insurance Company identified on the Schedule as the underwriter of this insurance.
Medically Necessary: The term medically necessary means those medical services, supplies or treatment authorized by a Physician to treat the Subscriber’s covered Accidental Injury which are:
- consistent with the symptoms or diagnosis; and
- appropriate and accepted according to good medical practice standards; and
- consistent with the most appropriate supply or level of service which can safely be provided to the patient.Medicare: The term Medicare means all benefits under Part A and/or Part B of Title XVIII of the Social Security Act of 1965 as may be amended from time to time.
Nurse: The term nurse means an individual who has received specialized nursing training and is authorized to use the designation “RN” Registered Nurse, “LPN” Licensed Practical Nurse or “LVN” Licensed Vocational Nurse, and who is duly licensed by the state or regulatory agency responsible for issuing such license in the appropriate jurisdiction.
Occupational Accident: The term occupational accident means a covered Accident resulting in Bodily Injury sustained within the time frame indicated in the Schedule and Certificate and which meets all of the following criteria and stipulations:
- it must happen while the Subscriber is engaged in the duties as defined in the Covered Contractwith the Sponsor; and
- engaged in a covered activity as defined herein; and
- it must happen while the Subscriber is covered under this plan; and
- the Bodily Injury must result directly from the covered accident and be independent of any
Occupational Disease, ordinary disease of life or bodily infirmity.
Occupational Accident does not include any of the following:
- aggression in a fight;
- a sojourn or personal deviation;
- suicide or attempted suicide;
- Hernia of any type.Occupational Disease: The term occupational disease means an illness arising out of a Subscriber’s duties under a Covered Contract which causes damage or harm to the physical structure of the body. Occupational disease does not include ordinary illnesses of life to which the general public is exposed
outside of the Subscriber’s duties defined within a Covered Contract or an illness resulting directly from a covered Accident.
Outpatient: The term outpatient means a person who is not admitted as an inpatient but who receives health care, services or supplies.
Physician: The term Physician means a licensed doctor of medicine (M.D.), doctor of osteopathy (D.O.), chiropractor (D.C.), podiatrist (D.P.M.), dentist (D.D.S. or D.M.D.), optometrist (O.D.), psychologist (Ph.D.), licensed independent clinical social worker (L.I.C.S.W.), registered nurse clinical specialist (R.N.C.S.), any other licensed practitioner including Nurse practitioners, Physician assistants, Nurse midwives, Nurse anesthetist. A Physician must be acting within the scope of their license. This definition does not include someone who ministers to a Subscriber that is related to the Subscriber by blood, marriage or adoption or who is normally a member of the Subscriber’s household.
Policy: The term “Policy”, also referred to as “Group Policy” means the contract between the Insurer and the Policyholder under which Sponsors can provide insurance benefits to Subscribers.
Policyholder: The term Policyholder means TOA, the organization named in Item #1 of the Schedule. TOA is the Policyholder of the master policy issued by the Insurer. The Policyholder may request cancellation of the Group Policy, negotiate terms and conditions, request changes in coverage or amounts of insurance and request termination of all Certificates.
Pre-admission Testing: The term pre-admission testing means the actual charges made by a hospital for services rendered on an outpatient basis which are medically necessary prior to scheduled inpatient confinement at the same facility.
Pre-existing Conditions: The term pre-existing conditions means an illness or injury for which a covered
- incurred charges;
- received medical treatment or advice;
- consulted a Physician; or
- took prescribed drugs,within 12 months before the effective date he or she became insured under a given benefit section of this
Prescription Drug: The term prescription drug means any drug, under applicable state law, that is dispensed only with a written prescription from a Physician and has a label bearing the legend: “Caution: Federal law prohibits the dispensing without a prescription.” It is also any mixed medicine with at least one ingredient bearing the above legend.
Prosthesis (or Appliance): The term prosthesis means a device to replace natural body parts or limbs; appliance means a device or instrument used to assist an infirmed person in ambulating (e.g., walker, cane, crutches) or which is used to remedy a chronic condition.
Rehabilitation Facility: The term rehabilitation facility means a legally operating institution or distinct part of an institution which has a transfer agreement with one or more hospitals, and which is primarily engaged in providing comprehensive multi-disciplinary physical restorative services, post-acute hospital and rehabilitative inpatient care and is duly licensed by the appropriate government agency to provide such services. It does not include institutions which provide only minimal care, custodial care, ambulatory or part-time care services, or an institution which primarily provides treatment of mental disorders, chemical dependency or tuberculosis except if such facility is licensed, certified or approved as a rehabilitation facility for the treatment of medical conditions or drug addiction or alcoholism in the jurisdiction where it is located, or is accredited as such facility by the Joint Commission on the Accreditation of Health Care Organizations or the Joint Commission for the Accreditation of Rehabilitation Facilities or similar group or organization.
Sojourn/Personal Deviation: The terms sojourn or personal deviation means any personal deviation that takes away from, or interferes with the dispatched activities of the Sponsor.
Sound Natural Tooth: The term sound natural tooth means a tooth that has no fillings or cavities, or the fillings or cavities do not undermine the tooth cusps; the pulpal tissues are healthy and intact; and the periodontal tissue shows little or no signs of active or chronic inflammation.
Sponsor: The term Sponsor means a person or organization named in Item #3 of the Schedule that applies for coverage under the Group Policy. A Sponsor must complete an Application Agreement agreeing to these Terms and Conditions and all requirements and terms specified and approved by the Insurer.
Sponsor Effective Date: The term Sponsor effective date means the date/time designated in writing by the
Insurer and/or TOA for the Sponsor’s participation under the Policy to begin.
Subscriber: The term Subscriber means a person who is either: a) a bona fide member of the Sponsor – if the Sponsor is an association, or b) an individual Independent Contractor of a Sponsor who has applied to be a Subscriber under the Group Policy. To be a Subscriber, a person must first:
- meet the eligibility requirements for coverage; and
- be validly enrolled; and
- be contracted with a Sponsor covered under the Group Coverage.A Subscriber’s coverage will not start until the effective date stated in the Certificate issued by TOA. However, if the Subscriber is away from work because the Subscriber is disabled on the date coverage would start, coverage will not start until the Subscriber is no longer disabled and returns to active work, but only if he/she returns to active work before the expiration date stated in the Certificate.
Subscriber’s Enrollment Date: The term Subscriber’s enrollment date means the the effective date on which the Subscriber’s insurance begins as stated in the Certificate issued by TOA. However, if the Subscriber is away from work because the Subscriber is disabled on the date coverage would start,
coverage will not start until the Subscriber is no longer disabled and returns to active work, but only if he/she returns to active work before the expiration date stated in the Certificate.
Usual, Customary And Reasonable: The term usual, customary and reasonable means the lesser of:
- the usual fee – the charge most frequently made for the covered services or supplies by a
Physician or hospital;
- the customary fee – the charge made for covered services or supplies by those of similar professional standing in the same geographic area;
- the reasonable fee – the charge determined by considering the complexity involved, the degree of professional skill required and other pertinent factors, if the first two methods above cannot be easily determined.Valid Enrollment: The term valid enrollment means coverage is validly in force only if the enrollment information supplied to TOA, the Insurer, the Insurer’s Claims Administrator and TOA’s Claims Administrator is correct. The only way coverage can be in force is if information provided regarding the Subscriber is accurate, complete, legible and signed. No one is authorized to waive this requirement without prior written consent from the Insurer or its Administration.
Valid and Collectible Insurance: (Applies when the Insurer’s coverage is subject to the Coordination of Benefits provision.) The term valid and collectible insurance means any plan providing benefits or services for or by reason of medical or dental care or treatment, which benefits or services are provided by any of the following plans covering the Subscriber:
- for individuals in a group whether on an insured, self-insured, or uninsured basis, such as group, blanket or franchise insurance, prepayment plans or any other plan arranged through any school, employer, trustees, association, union or employee benefit association, including individual policíes which are not exclusively health policies; or
- provided under government programs; or
- required or provided by any federal, state or local law, except Medicaid or Medicare; or
- workers’ compensation or similar statutory coverage.Waiting Period: The term waiting period means a period of time a Subscriber must be continuously disabled before benefits are payable.
You, Your and Yours: The terms You, Your or Yours refer to the Sponsor.
SECTION 7 – GENERAL PROVISIONS
- Entire Contract. Upon acceptance by TOA, the Application, these Terms & Conditions, the Policy, the Certificate, and all forms and documents related to the coverages indicated in the Certificate, represent the complete and entire Contract between TOA and the Sponsor. TOA has made no representations or warranties except as expressly set forth therein.
- (a) Request for Insurance. TOA will provide an Application to entities that wish to become Sponsors to enroll Subscribers, along with any other forms TOA or the Insurer requires to start coverage. TOA will also provide to current Sponsors a form for requesting the enrollment of additional Subscribers. The Sponsor or would-be Sponsor must submit these documents and they must be accurate, complete, legible and signed. The only way coverage can be in force is if the Sponsor or would-be Sponsor accurately includes all information asked for in the Application and forms.
- Misstatement of Age. If the wrong age of a Subscriber is given and the coverage or premium is affected by age, the coverage and/or premium will be adjusted accordingly. If age is a factor in determining eligibility or amount of insurance and there has been a misstatement of age, the insurance coverage or amount of benefits, or both, shall be adjusted in accordance with the Subscriber’s true age. Any such misstatements of age will not have an affect on insurance otherwise validly in force.
- Misstatement of Eligibility. TOA and the Insurer reserve the right to refund any premiums reported and paid on any insured who is found to not meet the definitions of a Subscriber in these Terms & Conditions. The inadvertent receipt of any such premiums will not obligate TOA or the Insurer to any potential claims. Upon determination of such receipt, TOA or the Insurer will refund those specific premiums within a reasonable amount of time.
- Time Limit for Reporting Changes in Covered Subscribers. The Sponsor must report changes in covered Subscribers to TOA and the Insurer by the end of each week. The Insurer or TOA, at their sole discretion, may choose to not honor any changes not reported within sixty (60) days of the date of such change.
- Workers’ Compensation. The Certificate and the benefits are not in lieu of, nor shall affect any requirements for coverage under any Workers’ Compensation law or other similar law.
If a Subscriber is not subject to Workers’ Compensation laws or is not eligible for Workers’ Compensation benefits as an Independent Contractor and if coverage for Occupational Injuries is extended to a Subscriber, benefits under this insurance will be payable for any covered accidental injury.
- Benefits and Examination Determination. Binding decisions regarding benefits covered and payable are made by the Insurer. No benefits are payable for services, supplies or treatment that are not medically necessary and appropriate. In the course of Pre-certification and/or Utilization Management, the Insurer may require that a Subscriber be examined by a Physician of the Insurer’s choosing, at the Insurer’s expense. If a Subscriber refuses, the claims in question may be denied.
- Physical Exam and Autopsy. The Insurer shall have the right and opportunity to examine any Subscriber when and as often as the Insurer may reasonably require during the pendency of a claim. The Insurer shall have the right to access an autopsy report in case of death where it is not forbidden by law.
- Inadvertent Error. At Insurer’s sole discretion, the failure of a Sponsor or Subscriber to transmit, report, pay premium or comply with any of the provisions of the Certificate or these Terms & Conditions, when such failure is due to an inadvertent error or clerical mistake, will not prejudice the insurance of a Subscriber.
- Age Limit. Benefits payable under the Certificate shall only apply to covered Subscribers prior to attaining the Age Limit shown in the Schedule. If the Subscriber reaches the Age Limit during a coverage period, AD&D benefits shall be reduced based on the Reduction of Benefits Table outlined next in #14. Benefits for Subscribers Over Age 65.
- Benefits for Subscribers Over Age 65. Benefits provided by the Certificate can be extended to a Subscriber over the age of 65 on a “Named” basis only. The Subscriber must qualify for and be approved by the Insurer’s Administrator before this extension of benefits will apply. The Subscriber must submit a Request for Extended Benefits and supply any required underwriting information including, but not limited to, an attending Physician’s statement, if required. The Administrator will advise the specifically Named Subscriber in writing of any approval or disapproval of any request for extensions of benefits.Extended Benefits. The benefits extended to Subscribers over the age of 65 shall consist of Accidental Death & Dismemberment, Accidental Disability (limited to Temporary Total Disability benefits for a maximum of two years) and Accident Medical benefits. No benefits are provided for Permanent Total Disability. The Subscriber’s premium when 65 or older is based on 100% of the coverage that would be in effect if the Subscriber were under age 65. “AGE” as used above refers to a Subscriber’s age on their most recent birthday, regardless of the actual time of birth.
Reduction of Benefits Table. The amount payable for any AD&D loss will be reduced when a Subscriber is age 65 or older. The AD&D amount payable will be reduced by the applicable percentage shown in the following table:
AGE ON DATE OF ACCIDENT % OF PRINCIPAL SUM
70 and over
- Assignment of Benefits. Payments for Disability may be assigned to a third party as indicated on an Assignment of Benefits Form provided by the Insurer. The form must be completed, signed and approved by the Insurer and the third party before it will take effect. Benefits paid under this Assignment of Benefits Provision will be deducted from the total amount of benefits payable to the eligible Subscriber.
COVERED ACTIVITY ENDORSEMENT TRUCKING OPERATIONThis ENDORSEMENT is to be attached to and forms a part of the Certificate of Insurance shown below issued by Participating Lloyd’s Underwriters to the Policyholder shown below.
Effective Date: 01/02/2017 Policy Number: Named Insured: Truck Owners AssociationInsurance under the Certificate of Insurance is provided to covered Subscribers participating under the Named Insured shown above and while engaged in the Covered Activity as specified hereon.
Coverage is applicable while the Subscriber is performing the regular duties of an Owner/Operator truck driver, scheduled co-driver or scheduled Contract Driver as defined below while under dispatch pursuant to a covered contract.
Owner/Operator is a Person who meets all of the following criteria:
- Is an independent contractor as defined by law; and
- Is responsible for determining the time, means and method of performing the work; and
- Has entered into a covered contract with the Named Insured for the leasing of the Owner/Operator’s truck; and
- Is compensated on a Form 1099 and not a Form W-2; and
- Does not own or control the Sponsor.Contract Driver is a driver who drives a motor vehicle owned or leased by an Owner/Operator or the Named insured. A Contract Driver cannot be an employee of the Named Insured or the Owner/Operator. The Contract Driver must meet all of the following criteria:
- Is an independent contractor as defined by law; and
- Works under a covered contract that provides for possible financial loss or gain by the Contract Driver relative to the operation of the truck being utilized; and
- Is responsible for determining the time, means and method of performing the work; and
- Is compensated on a Form 1099 and not a Form W-2.Under Dispatch is the period of time the Subscriber operates a truck. This includes all of the following:
- In route to pick up a load;
- Picking up a load;
- In route to deliver a load;
- Unloading a load;
- In route to pick up another load;
- The waiting time for a load if the Subscriber is not at home;
- Returning to a terminal or home after delivering a load, whichever occurs first; and
- Performing truck repair.Nothing in this Endorsement shall be held to alter, vary or affect any of the terms, provisions and conditions of said Certificate of Insurance other than as above stated.
CONTINGENT LIABILITY BENEFITS ONLYSection Important Notice ScheduleSection 1 Definitions
TABLE OF CONTENTSSection 2 General Section Section 3 Insuring Agreement Section 4 Limit of Liability
Section 5 Exclusion
Section 6 Claims
Section 7 Conditions
IMPORTANT NOTICEIMPORTANT NOTICE: THIS IS NOT A COVERAGE OF WORKERS’ COMPENSATION INSURANCE AND DOES NOT RELIEVE AN EMPLOYER OF WORKERS’ COMPENSATION OBLIGATIONS.SCHEDULE
This Schedule is a very brief summary of the Contingent Liability Benefits. Please read the entire Terms
& Conditions for a more complete description of the benefits outlined in this Schedule.
TOA and the Insurer certify that a Group Policy providing Contingent Liability coverage has been issued
to TOA, bearing the Policy number shown in Item # 2 of this Schedule.
Item 1. Master Policyholder: Truck Owners AssociationItem 2. Policy Number: R170017, underwritten by Certain UnderwritingMembers of Lloyd’s of London.
Item 3: Named Insured Number: Item 4: Named Insured: Item 5: Named Policyholder Effective Date:1st February 2017 12:01 A.M., Standard
Time at the address of the Policyholder.
Item 6: Named Policyholder Expiration Date:1st February 2018 12:01 A.M., Standard
Time at the address of the Policyholder.
Item 7. Additional Conditions and Limitations:
- Premium Payment Mode: Monthly
- Premium Calculation Mode: 15th of the Month
- Age Limit (see General Provisions for more details) Age 65
Amount of InsuranceItem 8. Contingent Liability Coverage
- Limit of Liability any one Covered Person / Subscriber: $500,000
- Limit of Liability any one Occurrence: $1,000,000
Contingent Liability CoverageTHIS COVERAGE PART CONTAINS BOTH A SUNSET PROVISION FOR REPORTING CLAIMS AND A COMMUTATION PROVISION FOR SETTLING CLAIMS, PLEASE READ CAREFULLY.
In return for the payment of premium, the Insurer agrees to provide this Contingent Liability Coverage to the Named Insured. Coverage is provided during the period listed in the Certificate issued by TOA.
Various provisions in this Coverage part restrict Coverage. This Coverage is contingent on the occurrence of specified events. A covered contingency will occur when the Sponsor receives notice of a claim for Occupational Bodily Injury by a Subscriber who is seeking to be deemed an employee of the Sponsor in order to claim Workers’ Compensation benefits from the Named Insured within the applicable Workers’ Compensation law. This Coverage Part, including any riders, endorsements, and amendments constitute the Coverage granted. The Insurer and you, the Named Insured Sponsor, have agreed to all the terms contained therein.
Read the entire Coverage Part Coverage carefully to determine rights, duties and what is and is not covered.
Section 1 – DefinitionsDefinitionsAccident, in this Coverage Part, means an event which:
- was unforeseen, unplanned and unexpected;
- occurred at a specifically identifiable time and place;
- occurred by sudden and abrupt cause or by chance;
- resulted in physical injury to a Subscriber;
- arose out of and in the course of a Subscriber’s duties under a Covered Contract; and
- occurred during the Coverage Period.Bodily Injury means an occupational accident resulting in physical Injury to a Subscriber which occurs during the coverage period and while the Subscriber is under contract and arises solely out of and in the course of their occupation and duties as defined in the covered contract.Covered Contract means a legal, written work or lease agreement that meets state independent contractor requirements and definitions as further defined in the Covered Activity Rider and has been submitted to and approved by the Insurer.Subscriber means Your owner/operators and contract drivers; provided:
- they have a written Covered Contract with You;
- they are covered under an occupational accident Coverage approved by TOA and the Insurer;
- their name is on file with the Insurer or the Insurer’s administrator; and
- they are not (prior to a claim under this Coverage) a statutory employee of yours or another Subscriber.Legal Expenses means expenses incurred in defending You against claims, proceedings and suits and amounts incurred as:
- premiums for bonds to release attachments and for appeal bonds;
- litigation costs included in a judgment against You; and
- interest on judgments as required by law until the Insurer offers the amount due under this insurance.
Occurrence means an Accident or series of Accidents arising out of one event or incident.State means any State of the United States of America and the District of Columbia.Worker’s Compensation Law(s) means the worker’s compensation law of each State. lt includes any
amendments to that law which are in effect during the Coverage Period. lt does not include nonoccupational disability benefits.
You or Your refer to the Named Insured Sponsor shown in the Certificate issued by TOA.Section 2 – General SectionGeneral Section
- CoverageThis Coverage íncludes, at its effective date, the provisions of this Coverage as stated in the Policy and these Terms & Conditions, the Schedule and all endorsements and schedules listed. lt is a contract of insurance between You and the Insurer. The only agreements relating to this insurance are stated in this Coverage. The terms of this Coverage may not be changed or waived except by rider or endorsement issued by the Insurer to be part of this Coverage.
- The Coverage PeriodThe Coverage Period is shown in the Certificate issued by TOA. lf this Coverage is cancelled, the Coverage Period will end at 12:01 A.M. on the cancellation date.
- Who Is Insuredln addition to the Named Insured Sponsor in the Certificate issued by TOA, each of the following is also a Named Insured:
- lf the Named Insured in the Certificate is an individual, then his spouse, but only with respect to the conduct of a business of which the Named Insured is the sole owner.
- lf the Named Insured in the Certificate is a partnership or joint venture, then the partners and their spouses or members of the joint venture but only with respect to the conduct of the partnership’s or joínt venture’s business.
- lf the Named Insured in the Certificate is a corporation, then the directors, officers and stockholders of the corporation, but only with respect to the conduct of the corporation’s business.
Section 3 – Insuring AgreementsInsuring Agreements Coverage – Contract Liability
The Insurer will reimburse You for the benefit You are required to pay under the Workers’ Compensation laws of any State because of an Accident resulting in Bodily Injury to a Subscriber; provided that:
- It is determined by a court of law or the appropriate State regulatory authority that You are required to pay those benefits within 36 months after the date of the Accident; and
- the Accident must take place during the Coverage Period shown in the Certificate.
The Insurer will defend any claim, proceeding or suit against You for claims payable under this Coverage. The Insurer has the right to investigate and settle these claims, proceedings or suits. The Insurer has no duty to defend or continue defending a claim, proceeding or suit after the Insurer has paid its applicable Limit of Liability under this Coverage.
The Insurer will pay on Your behalf the benefits required of You by the Workers’ Compensation Law of any State up to the Limits of liability shown in Item 8 of the Schedule.
lf the Insurer makes any payments ín excess of the benefits regularly provided by the Workers Compensation Law of any State on Your behalf, You will reimburse the Insurer promptly.
Section 4 – Limit of LiabilityLimit of Liability
The Limits of Liability shown on Item 8. of the Schedule is the most the Insurer will pay.
The Limits of Liability shown in Item 8. of the Schedule is the most the Insurer will pay for all claims involving Bodily Injury covered under this Coverage to any one Subscriber.
Naming more than one Named Insured in the Certificate does not increase the Insurer’s Limit of Liability under this Coverage.
Section 5 – ExclusionsExclusions
This Coverage does not apply to:
- Claims which did not arise from or in connection with an Accident while under dispatch.
- Claims arising out of the promulgation of any statute, regulation, or rule, or the amendment of any existing statute, regulation, or rule, the effect of which is to make an Owner-Operator or Contract Driver Your employee for purposes of the Workers’ Compensation law.
- Claims arising out of all causes of action other than the Workers’ Compensation laws.
- Claims for an intentionally self-inflicted Bodily Injury to a Subscriber while either sane or insane or Bodily Injury intentionally caused or intentionally caused or intentionally aggravated by You.
- Claims resulting from a Subscriber’s participation in:
- a riot or act of civil disturbance;
- a felony;
- a war, declared or undeclared;
- any act of war; or
- the service of the armed forces of any country or any civilian non-combatant unit serving with such forces.
- Claims for Bodily Injury if the Subscriber was legally intoxicated under the law of the State where the Accident occurred.
- Claims resulting from nuclear reaction, nuclear radiation or radioactive contamination.
- Claims for Bodily Injury occurring while the Subscriber was under the influence of any chemical substance not lawfully available or consumed in accordance with the Controlled Substance Act in force at the time and location of the Accident.
- Claims for Bodily Injury occurring outside the United States of America, its territories or possessions and Canada.
- Claims brought by a símilarly situated Subscriber after the issuance of an order by a state administrative or regulatory agency or board or a court of competent jurisdiction which has the effect of making all of Your similarly situated Subscribers employees for the purposes of workers’ compensation insurance.
- Claims arising from Employers’ Liability.
Section 6 – ClaimsClaims
- Duty to DefendThe Insurer will defend You against any claim, proceeding or suit against You for Bodily Injury covered by this insurance. The Insurer has the right to investigate and settle any claim, proceeding or suit at the Insurer’s discretion. The Insurer has a duty to defend a claim if You are not defended by a Workers’ Compensation insurer. The Insurer has no duty to defend or continue defending after the Insurer has paid its applicable Limit of Liability shown in Item 8. of the Schedule. You shall cooperate fully with the Insurer and TOA and assist the Insurer and TOA in the investigation, settlement or defense of any claim, proceeding or suit and shall, upon the Insurer’s or TOA’s request, supply:
- the names and addresses of the injured Subscriber(s) and any witness(es);
- all notices, demands and legal papers related to a Bodily Injury covered under thisinsurance; and
- such other information as the Insurer and TOA may require.
- Claim ReportingYou shall notify the Insurer as soon as practicable in the event of a claim or a situation which may result in a claim. Such notice shall be sent to:Gallagher Bassett
P.O. Box 4L9797, Kansas City,
MO 64141, USA
Attn: Brenda Cullinan Tel: 816 216 5200
You agree not to voluntarily make payments, assume obligations or incur expense on any claim, proceeding or suit against You for Bodily Injury that may be covered by this insurance except at your
- Subrogation – Recover From OthersThe Insurer has Your rights to recover any payments. The Insurer may make recoveries under this insurance from anyone liable for Bodily Injury covered by this insurance. You will do everything necessary to protect those rights for the Insurer and help the Insurer enforce them. You agree to do nothing that would interfere with those rights after any Bodily Injury.
- Sunset ClauseThis Coverage applies in respect of incidents which occur during the Coverage Period stated in the Certificate provided that, and only in so far as, such incidents are reported to the Insurer and TOA within thirty six (36) months of the end of the Coverage Period stated in the Certificate unless extended by a longer period due to the filing of a compensable claim under a State’s Worker’s Compensation law, which claim is not barred by a statute of limitations or similar statute under state’s Workers’ Compensation law.
The Insurer has the right to commute all claims at any point after sixty (60) months from the end of the Coverage Period. All claims which are not finally settled will be eligible for commutation. An Independent actuary or appraiser shall be appointed by mutual agreement between You and the Insurer. The independent actuary or appraiser shall investigate, determine and capitalize the present value of such unsettled claims. The Insurer will share the expenses of the independent actuary or appraiser with You equally. The Insurer will advise You in writing of the Insurer’s intention to commute along with the name of the Insurer’s chosen appraiser and if You fail to respond in writing within 90 days then You will be deemed to have consented to the same.
lf the Insurer and You cannot them mutually agree to an independent actuary or appraíser, both the Insurer and You will appoint their own independent actuary or appraiser who will, in turn, appoint a third independent actuary or appraiser who will establish the present value of each claim(s). The Insurer and You will pay the expenses of their own independent actuary or appraiser and share the expenses of the third independent actuary or appraiser equally.
The Insurer will pay You the present value determined by the independent actuary or appraiser within 30 days from receipt of the independent actuary’s or appraiser’s report. Upon receipt of the Insurer’s payment, You agree to release the Insurer from any further liability under this Coverage for such claim(s). lf for any reason, the Insurer fails to make payment within thirty (30) days of receipt from the independent actuary or appraiser, then the Insurer will pay You interest at the rate of 5% per annum on the present value of such claim(s) from the date payment was due to the date of actual payment.
Section 7 – Conditions
- Agreement Upon TermsYour acceptance of this Coverage means that You agree with the Insurer and TOA that the statements You provided to TOA and the Insurer are Your representations, that this Coverage is issued in reliance upon such representations, and this Coverage as stated in the Policy and these Terms & Conditions embodies all agreements between You and the Insurer, or any of the Insurer’s agents, relating to this insurance, and that Your full compliance with all terms of this Coverage is a condition to the Insurer’s liability hereunder.
- AssignmentYour rights or duties under this Coverage may not be assigned or transferred without the Insurer’s written consent.
- Other Insurancelf any other insurance, indemnity or reimbursement agreement exists protecting You for Bodily Injury to which this insurance applies, this insurance shall be excess of such other insurance, indemnity or reimbursement agreement. But this does not apply to any excess insurance, indemnity or reimbursement agreement specifically purchased by You to apply in excess of our Limit of Liability.
- Several Liability Notice
The subscribing insurers’ obligations under contracts of insurance to which they subscribe are several and not joint and are limited solely to the extent of their individual subscriptions. The subscribing insurers are not responsible for the subscription of any co-subscribing insurer who for any reason does not satisfy all or part of its obligations.
COMMON CONDITIONS(applicable to Occupational Accident and Contingent Liability benefits)
- Sponsor’s and Subscriber’s Additional Obligations. TOA and/or the Insurer have no duty to provide any benefit or payment, and may also cancel coverage, unless there has been full compliance with the following duties:
- It is the Sponsor’s duty and Subscriber’s duty to fully comply with all of the provisions of the Contract, the Certificate, these Terms & Conditions or those of the Policy.
- It is the Sponsor’s duty and Subscriber’s duty to deliver proper documentation in a timely manner as required by TOA, the Insurer, their designees, the Certificate, these Terms & Conditions or those of the Policy.
- It is the Sponsor’s duty to inform any Subscribers/beneficiaries that you sponsored about any suspension or cancellation of benefits or coverage, and any change in Terms & Conditions and Policy provisions.
- TOA will deliver TOA’s correspondence with TOA members and TOA Program participants to the Sponsor’s address or email or fax. It is the Sponsor’s duty to deliver that correspondence to all persons it sponsored for TOA membership and the TOA Programs.
- Coverage Is Subject To Underlying Policy’s Terms, Provisions, Limitations, Exclusions, Conditions And Definitions. The coverage provided by TOA’s Occupational Accident Benefits and Optional Contingent Liability Benefits-Package Program is subject to all of the underlying Policy’s terms, provisions, limits, exclusions, conditions and definitions. If there is no coverage under the Insurer’s policy, then there is no eligibility for any TOA Program benefit that is related to that policy.
C Inspection. The Insurer has the right, but not the duty, to inspect Your or a Subscriber’s operations and work places. Such inspections are not safety inspections. They relate only to the insurability of the work places and the premiums to be charged. The Insurer may give reports to You or a Subscriber on the conditions found upon inspection. The Insurer does not undertake to provide for the health or safety of Your or a Subscriber’s employees, Independent Contractors or the public. The Insurer does not warrant that Your or a Subscriber’s work places are safe or healthful or that they comply with any law, regulation, code or standard.
- Audit. You agree to keep records of information needed to compute premium. You agree to let the Insurer or its representative examine and audit all payroll, business records, and documents including ledgers, journals, registers, vouchers, contracts, dispatch logs, tax reports, disbursement records and programs for storage or retrieving data. The Insurer has the right to conduct audits during regular business hours while the Certificate and coverage is in force and within three (3) years after the final settlement of all claims under the Certificate and coverage.
- Bankruptcy or Insolvency. Your or a Subscriber’s bankruptcy, insolvency or other financial deficiencies will not relieve the Insurer from liability under the Certificate and coverage. However, theInsurer’s reimbursement obligations and/or liability will be the same as they would have been had your bankruptcy, insolvency or other financial deficiencies not occurred.
- Actions of Law and Limitation Period.Since only the Insurer can approve or deny the payment Occupational Accident and Contingent Liability benefits, any legal action for payment of such benefits or to recover under the Certificate must be brought against the Insurer, and may not be brought against TOA.Furthermore: (1) no one may bring a legal action against TOA for any reason pertaining to this Contract and Program until there has been full compliance with the Contract provisions and these Terms and Conditions and all of the terms of the Policy; and (2) no legal action can be brought against TOA unless the action is started within 12 months after the event or occurrence which gave rise to the action.
With respect to Occupational Accident benefits, no legal action may be brought against the Insurer to recover under the Certificate prior to sixty (60) days after filing proof of loss. No such action may be brought against the Insurer after three (3) years from the time written proof of loss is required to be given.
- Conformity with State Statutes. If any provision of this Contract, the Certificate, these Terms & Conditions or the Policy is in conflict with the statutes of the State in which the Certificate is delivered or issued for delivery, the provision is automatically amended to meet minimum requirements of the statute.
- Severability. If any provision of this Contract, the Certificate, these Terms & Conditions or the Policy is found by any court or administrative body of competent jurisdiction to be invalid or unenforceable, such invalidity or unenforceability will not affect the other provisions which will remain in full force and effect.
ACCEPTANCE AND ELECTRONIC DELIVERY
By clicking “I Agree”:
You acknowledge that you have reviewed the Terms & Conditions, understand them and agree to them.
You acknowledge that you know you can print a paper copy of the Terms & Conditions, review them at your leisure, and cancel the Contract at any time if you decide you no longer like the Terms & Conditions.
You acknowledge that the Terms & Conditions will be a part of and govern our Contract.
You certify that you are duly authorized to bind the company or business indicated in the Application.
You consent to conduct all transactions with TOA and our agents by electronic means, which consent you may withdraw by notifying us via email.
You are asking us to electronically deliver documents, and are foregoing your option to receive paper documents by regular mail.
You confirm that you are able to open, view, save and print PDF documents, that you have provided your email address, and that you can receive paperless documents through email, our website and PDF.
You agree that you will notify us if your email address changes.