LONDEN INSURANCE GROUP, INC.
AMENDMENT NO. 1
Effective September 1, 2002 the The Londen Insurance Group, Inc. Benefit Plan shall be amended as follows:
The following shall be deleted and replaced with the following on page 56:
Any reference to Non Public Personal Information (NPI) will now read Protective Health Information (PHI).
This Amendment shall be attached to and form a part of The Londen Insurance Group, Inc. Health Benefit Plan, and shall not be held to alter or affect any of the terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized office on this ______day of ______2002.
______
SIGNATURETITLE
LONDEN INSURANCE GROUP, INC.
AMENDMENT NO. 2
Effective October 1, 2002 the The Londen Insurance Group, Inc. Benefit Plan shall be amended as follows:
The following shall be added to the Plan Document:
Long Term Care
The Plan will pay 100% of the UCR after a $10,000 deductible for care at home or in a facility for Alzheimer’s, Parkinson’s disease, irreversible dementia, senility and all other forms of organic dementia for the following services:
1.Daily care for Skilled, Intermediate or Custodial Facility Services.
2.Professional care from a Physician, Registered Nurse, Licensed Practical Nurse, Vocational Nurse, Social Worker, Registered Dietitian, Physicians Assistant or an Exercise Physiologist.
3.Licensed or Registered Physical, Respiratory, Speech or Occupational Therapist.
4.Personal care from a Nurse Aide, Home Health Aide, or may include Homemaker or Companion Services or care.
5.Durable Medical Equipment, IV therapy, Medicines, Oxygen, Bandages, Adult Briefs and Hosiery for the prevention of Embolisms.
6.Capitol Improvements to the home so the patient can remain at home.
7.Home Health Care
8.Adult Day Care
9.Respite Care
Eligibility Requirements for the Employee or Dependent benefits
1.Employee or Dependent must be 65 years or older and;
2.Employee must have had 30 years of Service with the Londen Insurance Group and;
3.Employee must have been a current full-time Employee and filed with the IRS as a W-2 wager earner at the time benefits commenced.
Exclusions and Limitations
1.Services provided to a patient who is under 65 years of age.
2.Care received outside the United States, its possessions or Canada.
3.Care provided free of charge in a Veteran’s Administration or government facility.
4.Care resulting from Alcoholism, Drug Addiction, or Chemical dependency.
5.Care for which a charge would be normally covered under another provision of this Plan.
6.Duplicating benefits paid by Medicare or other government programs.
7.No benefits will apply to the Reinsurance Carrier aggregate or specific benefits.
December 30, 2002
Londen Insurance Group, Inc.
Amendment #2
Page 2
This Amendment shall be attached to and form a part of The Londen Insurance Group, Inc. Health Benefit Plan, and shall not be held to alter or affect any of the terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized office on this ______day of ______2002.
______
SIGNATURETITLE
WESTERN HERITAGE HEALTH BENEFIT PLAN
AMENDMENT NO. 3
Effective January 1, 2004 The Western Heritage Health Benefit Plan shall be amended as follows:
The SUBSECTION entitled “Eligibility Requirements/Effective Date - Agents”, under the SECTION entitled “ELIGIBILITY AND EFFECTIVE DATES”, shall be deleted and replaced with the following:
Eligibility Requirements/Effective Date - Agents
Agents and Managers will be eligible for coverage the first of the month following any production period of at least one (1), and up to three (3) consecutive months where the written business with the company meets the following production requirements:
Agents must write, within a period of one (1), but not more than three (3) consecutive months, $18,000 in discounted annualized premium. Managers are eligible subject to minimum quarterly production of $90,000. If there is a partnership, the second partner will qualify with a total production (within 1-3 consecutive months) of $157,500.
Qualification is based on annual, semi-annual and checking bank draft modes of written discounted annualized premium only. To determine discounted annualized premium, production will be credited on the following basis:
- Whole Life and Multiple Pay Life with payment period
of 10 years or longer:100% of Annualized Premium
- Multiple Pay Life with payment period of less than 10
Years: 50% of Annualized Premium
3.Single Premium Life: 10% of Premium
4.Stand Alone Accident Plan:100% of Annualized Premium
5.Medicare Supplement: 25% of Annualized Premium
Annuity premium does not count; nor does premium written on monthly or quarterly direct bill modes or savings bank draft mode. Zero-CWA production will count only after it is placed in force as of the 7th calendar day after the initial withdrawal.
A portion of the premium cost will be paid by the Plan Sponsor, Londen Insurance Group, and a portion will be paid by the agent or manager according to the following schedule:
AGENT LEVEL MONTHLY PREMIUMS
Three (3) Months’ ProductionIndividualOrFamily
$18,000$400$600
24,000 300 500
30,000 200 400
36,000 100 300
MANAGER LEVEL MONTHLY PREMIUMS
Three (3) Months’ ProductionIndividualOrFamily
$90,000$400$600
120,000 300 500
150,000 200 400
180,000 100 300
Once enrolled, an agent’s production is reviewed every three month period from the date the agent’s insurance became effective. This three (3) month period will be referred to as the “agent’s quarter” and does not necessarily fall into a calendar quarter.
Premiums for a given agent’s quarter will be based on the total production from the previous agent’s quarter. EXAMPLE: If an agent produced $26,000 in his last agent’s quarter, his monthly premium for the next quarter will be $300 for individual coverage or $500 if he has family coverage.
If production requirements are not met within the first six (6) months of writing business, enrollment cannot be made until the requirements have been met. If, in the future, production requirements are attained, evidence of good health will be required for the Life and AD&D benefit and the effective date will be on the first of the month following underwriting approval. The medical and dental portion will be effective the first of the month following the date of application.
It is the agent’s responsibility to contact the Company if he believes he has produced enough to qualify after the initial six (6) months of writing business. If the agent fails to contact the Company and enroll within 31 days after production requirements have been met, his coverage can become effective only in accordance with the “Late Enrollment/Re-Enrollment” provision below.
Once enrollment has been made, production will be reviewed every three (3) month agent’s quarter to determine eligibility. If an agent does not meet the minimum requirements for a given agent’s quarter, the agent will have three (3) months to re-qualify. If the minimum production level after the allotted three (3) months is not met, coverage will be terminated unless continuation of coverage (COBRA) is elected.
Agents who have been continuously producing for ten years or more will have an additional three (3) month period to re-qualify for coverage. If the minimum production level is not met after the additional three (3) month period, coverage will then be terminated unless continuation of coverage (COBRA) is elected.
This Amendment shall be attached to and form a part of the Western Heritage Health Benefit Plan, and shall not be held to alter or affect any terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized officer on this ______day of ______, 2003.
______
SIGNATURETITLE
WESTERN HERITAGE TRUST
AMENDMENT NO. 4
Effective January 1, 2004, The Western Heritage Health Benefit Plan shall be amended as follows:
The SECTION entitled “MEDICAL BENEFITS” under the SUBSECTION entitled “Schedule of Benefits”, the following section shall be deleted and replaced with the following:
PPONON-PPO
ELIGIBLE MEDICAL EXPENSESPROVIDERSPROVIDERS
Ambulance (When Medically Necessary)80% After Deductible80% After Deductible
Ambulatory Surgical Facility 80% After Deductible70% After Deductible
Anesthesia, Assistant Surgeon (Inpatient/Outpatient)
InpatientHospital$20 Copay/100%70% After Deductible*
Outpatient Facility$20 Copay/100%70% After Deductible*
Physician’s Office$20 Copay/100%70% After Deductible*
* NOTE: If the Surgeon is a PPO Provider, then the Anesthesia and Assistant Surgeon benefits will be paid at the PPO level of benefits based on the Usual, Customary and Reasonable (UCR) Charge for your area.
Chemotherapy80% After Deductible70% After Deductible
Durable Medical Equipment80% After Deductible70% After Deductible
Emergency Room Services
Physician80% After Deductible70% After Deductible
Facility80% After Deductible70% After Deductible
Home Health Care80% After Deductible70% After Deductible
Hospice Care80% After Deductible70% After Deductible
Hospital Services
Outpatient Services80% After Deductible70% After Deductible
Inpatient Services80% After Deductible70% After Deductible
Maternity
Female Participants andSame as anySame as any
Dependent Spouses Onlyother illnessother illness
Mental Health
Inpatient80% After Deductible70% After Deductible
Outpatient - Group50% After Deductible50% After Deductible
Outpatient - Individual50% After Deductible50% After Deductible
Out-of-PPO Service Area80% After Deductible
Physician ServicesPer Provider
Office Visit$20 Copay/100%70% After Deductible
Consultations$20 Copay/100%70% After Deductible
Hospital Visits$20 Copay/100%70% After Deductible
Routine X-Ray and Lab $20 Copay/100%70% After Deductible
Complex - MRI, CT, Etc. $20 Copay/100%70% After Deductible
Physician Surgical Services (Inpatient/Outpatient)
InpatientHospital$20 Copay/100%70% After Deductible
Outpatient Facility$20 Copay/100%70% After Deductible
Physician’s Office$20 Copay/100%70% After Deductible
Pre-Admission Testing80% After Deductible70% After Deductible
Prescription Drugs
Prescription Drug CardGeneric$10.00CopayNot Covered
Brand Name$25.00 CopayNot Covered
Mail Order (90 Day Supply)Generic$10.00 CopayNot Covered
Brand Name$25.00 CopayNot Covered
Prosthetic and Orthotic Devices80% After Deductible70% After Deductible
Preventive CarePer Provider
Physical Examination$20 Copay/100%70% After Deductible
Gynecological Examination$20 Copay/100%70% After Deductible
Pap Smears$20 Copay/100%70% After Deductible
Mammography$20 Copay/100%70% After Deductible
Prostate Exam Blood Test$20 Copay/100%70% After Deductible
Well Child Care and Immunizations$20 Copay/100%70% After Deductible
X-ray & Lab$20 Copay/100%70% After Deductible
Second Surgical Opinion 100%70% After Deductible
(When required by CCN)
Short Term Rehabilitation Services (Physical Therapy)
Outpatient$20 Copay/100%70% After Deductible
Skilled Nursing Facility
First 60 Days50% After Deductible50% After Deductible
Next 30 Days25% After Deductible25% After Deductible
Substance Abuse Care
Inpatient80% After Deductible70% After Deductible
Outpatient - Individual50% After Deductible50% After Deductible
Urgent Care Facilities$20 Copay/100%70% After Deductible
All Other Eligible Medical Expenses80% After Deductible70% After Deductible
This Amendment shall be attached to and form a part of The Western Heritage Health Benefit Plan, and shall not be held to alter or affect any of the terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized officer on this______day of______, 2003.
______
SIGNATURETITLE
WESTERN HERITAGE TRUST
AMENDMENT NO. 5
Effective January 1, 2004, The Western Heritage Health Benefit Plan shall be amended as follows:
Under the SECTION entitled “Medical Provisions”, the SUB-SECTION entitled “Deductibles” shall be deleted and replaced with the following:
A Deductible is an amount which a Covered Person must contribute toward payment of eligible medical expenses.
Individual Deductible per Calendar Year$500
Maximum Family Deductible per Calendar Year$700
If a total of $700 in eligible medical expenses is incurred collectively by two (2) or more covered members of a family during a Calendar Year, and is applied toward the Calendar Year Deductibles, the Deductible is satisfied for the family. For these purposes a “family” will include a covered Participant and his covered Dependents.
This Amendment shall be attached to and form a part of The Western Heritage Health Benefit Plan, and shall not be held to alter or affect any of the terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized officer on this______day of______, 2003.
______
SIGNATURETITLE
WESTERN HERITAGE TRUST
AMENDMENT NO. 6
Effective January 1, 2004, The Western Heritage Health Benefit Plan shall be amended as follows:
Under the SECTION entitled “Schedule of Benefits”, the SUB-SECTION entitled “Out-of-Pocket Maximum” shall be deleted in its entirety and replaced with the following:
Except as noted, a Covered Person will not be required to pay more than $2,000 for PPO Providers, $3,000 for Non-PPO Providers, and $2,000 for Out-of-Area Providers in any Calendar Year towards the percentage of Eligible Expenses which are not paid by the Plan. Once they have incurred these amounts, Eligible Expenses for the balance of the Calendar Year will be paid at 100%.
NOTE: The following will not apply to the out-of-pocket maximums:
Deductibles, Copays, Penalty for not Pre-Certifying, Substance Abuse Care and any charge excluded in the limitations.
This Amendment shall be attached to and form a part of The Western Heritage Health Benefit Plan, and shall not be held to alter or affect any of the terms of such Plan other than specifically stated.
Londen Insurance Group, Inc. has caused this Amendment to be executed by its duly authorized officer on this______day of______, 2003.
______
SIGNATURETITLE
PLAN SPONSOR ACCEPTANCE OF RESPONSIBILITY
PLEASE SIGN BELOW TO ACKNOWLEDGE YOUR ACCEPTANCE OF RESPONSIBILITY FOR THE CONTENTS OF THIS DOCUMENT AND RETURN THIS SIGNED FORM TO:
Dan R. Wagnon & Associates
3825 N. 24th St.
Phoenix, Arizona 85016
We, the Plan Sponsor, recognize that we have full responsibility for the contents of the Plan Document and that, while the Contract Administrator (its employees and/or subcontractors) may have assisted in the preparation of the document, we are responsible for the final text and meaning. We further certify that the document has been fully read, understood, and describes our intent with regard to our employee welfare plan.
Plan Sponsor/Plan Administrator:Londen Insurance Group, Inc.
______
Signed (authorized representative of Plan Sponsor) Date
* * * * * *
YOU SHOULD ALSO BE AWARE OF THE FOLLOWING REQUIREMENTS WHICH MAY APPLY TO YOUR PLAN...
*A copy of the SPD (booklet) must be filed with the Department of Labor within 120 Days after the Plan becomes subject to ERISA’s reporting and disclosure requirements and you must give each participant a copy of the SPD within the above 120-day period or within 90 days after the participant begins to get benefits.
Therefore, it is important that your Plan Document be reviewed and signed in a timely manner to assure that booklets can be prepared, printed, filed and distributed to Participants to assure compliance with ERISA’s requirements.
*Employee welfare benefit plans must file annual reports with the IRS on IRS/DOL/PBGC Forms 5500 or 5500-C/R. Form 5500 applies to Plans that cover 100 or more participants at the beginning of a Plan Year. Form 5500-C/R is a somewhat abbreviated filing and applies to Plans that cover fewer than 100 participants at the beginning of the Plan Year.
The 5500 form must be filed by the last day of the seventh month following the end of the Plan Year. An extension of up to 2.5 months may be granted for the filing of such forms.
NOTE: The Secretary of Labor may assess a civil penalty against a Plan Administrator for failure or refusal to file an annual report.
If you have any questions or concerns about these accounting requirements, talk to your broker/consultant, claims (contract) administrator, or accounting professional.
ADOPTION OF THE PLAN DOCUMENT
Adoption
Plan Sponsor hereby adopts this Plan Document as the written description of its employee welfare benefit plan (the “Plan”). This Plan Document replaces any prior statement of the health care coverages of the Plan and is effective on the date shown below.
Purpose of the Plan
The purpose of the Plan is to provide certain benefits for eligible Participants of the Participating Employer and their eligible Dependents. The benefits provided by the Plan include:
Medical Care Coverage (Hospital, Physician services, etc.)
Dental Care Coverage
Prescription Coverage
Intent to Comply with ERISA
It is intended that the Plan Document will serve to describe the nature, funding and benefits of the Plan. It is also intended that the Plan will conform to the requirements found in the Employee Retirement Income Security Act of 1974 (ERISA), as amended from time to time, as that act applies to employee welfare benefit plans. If any portion of the Plan does now, or in the future, conflict with ERISA or Federal regulations, such regulations will govern.
Conformity with Law
If any provision of this Plan is contrary to any law to which it is subject, such provision is hereby amended to conform to the minimum requirements of such law.
Participating Employers
The Employer participating in this Plan is as stated in the section entitled General Plan Information.
The Plan Sponsor may act for and on behalf of all matters pertaining to the Plan, and every act, agreement, or notice by the Plan Sponsor will be binding on the Employer.
Acceptance of the Plan Document
IN WITNESS WHEREOF, the Plan Sponsor has caused this instrument (pages 1-63 inclusive) to be executed, effective as of September 1, 2002.
Londen Insurance Group, Inc.
By:______
Title:______
TABLE OF CONTENTS
Page
INTRODUCTION OF THE PLAN DOCUMENT 1
MEDICAL BENEFITS
Utilization Management Program 2
Plan Maximums 4
Medical Provisions 5
Schedule of Benefits 7
Eligible Medical Expenses10
Limitations and Exclusions 16
Special Restrictions for Pre-Existing Conditions20
DENTAL BENEFITS
Schedule of Benefits21
Pre-Treatment Estimate22
Eligible Dental Expenses23
Limitations and Exclusions25
PRESCRIPTION DRUG BENEFITS
Covered Drugs27
Limitations and Exclusions27
General Health Care Coverage Exclusions 28
Coordination of Benefits (COB)30
Subrogation33
Eligibility and Effective Dates34
Termination of Coverage40
Extension(s) of Coverage41
Claims Procedures for Health Care Coverage(s)42
DEFINITIONS44
GENERAL PLAN INFORMATION50
PRIVACY ACT56
CONTINUATION OF COVERAGE OPTION (COBRA)58
STATEMENT OF RIGHTS 61
SUMMARY PLAN INFORMATION62
TO ALL PARTICIPANTS
We are all aware of the financial disaster to a family which often occurs as a result of a serious or prolonged illness or accident. The medical benefits outlined in this Summary Plan Description (SPD) provide protection for you and your family against such a disaster.