THIRTY AMERICAN INCOME LIFE INSURANCE COMPANY THIRTY
UNITS Indianapolis, Indiana UNITS
OUTLINE OF COVERAGE
For Policy Form Number CNM (R82)
LIMITED BENEFIT POLICY – PROVIDES BENEFITS FOR CANCER ONLY
This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible for Medicare, review the Medicare Supplement Buyer’s Guide available from the company. This is a limited policy.
Retain this for your records. This is not the policy. It is an outline which briefly describes the basic provisions of the policy. When you receive the policy, please refer to it for further provisions.
The policy is intended to supplement your basic health coverage to help meet the expenses of cancer treatment. By itself, it will not ordinarily cover the major cost. If you are eligible for the policy and it is issued, we cannot cancel it as long as you pay the premium. We can change premium rates only by plan, class, and state.
EXCLUSIONS AND LIMITATIONS
You are not eligible for this policy if you have ever had cancer diagnosed. Any family member who has had cancer diagnosed is not eligible. The policy has a 60-day waiting period. If you or any family member has cancer diagnosed within 60 days of the Policy Date, there is no coverage for that person, and we will refund any premium paid on that person.
This policy covers only cancer and its spread or recurrence. It does not cover other sicknesses even if they are caused by cancer or worsened by cancer. Pathological diagnosis (as defined on Page 6) is required to establish a claim. The only exception is when medical judgment prohibits such procedure and other conclusive evidence is given.
Benefits are not payable for treatment received more than 30 days before the required diagnosis is made. However, if cancer is first diagnosed by autopsy, benefits will be payable for treatment received up to 45 days before the date of death.
Diagnostic work to check for the recurrence of cancer is not covered unless it is found that cancer is present at that time. Cosmetic repair by plastic surgery is not covered. The policy does not cover prosthetic devices or their installation.
BENEFITS: MAXIMUM LIFETIME BENEFIT
HOSPITAL CONFINEMENT $111,300.00
$300.00 per day for twelve days
$150.00 per day thereafter
SURGICAL (diagnostic procedures are not covered) 15,000.00
$135.00 to $2,250.00 per operation as outlined in schedule of operations
ANESTHESIA 3,000.00
Not to exceed $300.00 per operation
RADIATION THERAPY AND CHEMOTHERAPY BENEFIT 6,000.00
Usual and Customary Charge
PRIVATE NURSING (While hospital confined) 6,000.00
At $120.00 per day when required, for RN or LVN
ATTENDING PHYSICIAN (While hospital confined) 3,000.00
$60.00 per day for physician other than surgeon
BLOOD AND PLASMA 3,000.00
Usual and Customary Charge
AMBULANCE 1,500.00
Not to exceed $150.00 for each confinement
TRANSPORTATION (Common Carrier) 1,500.00
Usual and Customary Charge, when required, to hospital
EXTENDED BENEFITS (In lieu of hospital benefits) No Limit
This benefit is payable only when you are hospital confined for 91 straight days or more. The daily hospital confinement benefit is not payable when this benefit is in effect.
$18,000 per month toward charges made by hospital beginning 91st day of continuous hospital confinement (benefits will be prorated for periods of less than 30 days)
GOVERNMENT HOSPITAL CONFINEMENT (In lieu of all other benefits) 55,650.00
This is the only benefit payable for confinement in a government hospital and the treatment
received there.
$150.00 per day for the first twelve days of confinement
$75.00 per day thereafter
AG-1691 E 30 Units