Aetna Life Insurance Company
Hartford, Connecticut 06156
Extraterritorial Certificate Rider
(GR-9N-CR1)Policyholder:
The TLC Companies
Group Policy No.:
GP-811431
Rider:
Florida ET Medical
Issue Date:
February 27, 2009
Effective Date:
January 1, 2009
This certificate rider forms a part of the booklet certificate issued to you by Aetna describing the benefits provided under the policy specified above. This extraterritorial certificate-rider takes the place of any other medical
extraterritorial certificate-rider issued to you on a prior date.
Note: The provisions identified herein are specifically applicable ONLY for:
Benefit plans which have been made available to you and/or your dependents by your Employer; Benefit plans for which you and/or your dependents are eligible;
Benefit plans which you have elected for you and /or your dependents;
The benefits in this rider are specific to residents of Florida. These benefits supersede any provision in your
booklet certificate to the contrary unless the provisions in your certificate result in greater benefits. You
are only entitled to these benefits, if you are a resident of Florida, and if the benefit value exceeds those benefits covered under the group policy and booklet certificate.
Note: The codes appearing on the left side of certain blocks of text are required by the Department of Insurance.
In regards to All Medical Plans:
Dependent Eligibility
You may cover your:• wife or husband; and
• unmarried children who live in your household as a dependent until the end of the calendar year in which the child
attains age 25.
Any other unmarried child who: depends on you for support; and does not live in your household: may be covered:
until the end of the calendar year in which the child attains age 25 if he or she goes to school on a regular basis, (full-time or part-time);
otherwise, until the child attains age 19. Your children include:
In regards to All Medical Plans:
Pregnancy Coverage
Benefits are payable for pregnancy-related expenses of female employees and dependents on the same basis as for a disease.
In the event of an inpatient confinement:
• Such benefits will be payable for inpatient care of the covered person and any newborn child for: the length of stay
which is determined to be medically necessary in accordance with the guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists. If, after consultation with the attending physician, a person is discharged earlier, benefits will be payable for 2 post-delivery home visits by a health care provider.
• Certification of the first 48 hours of such confinement following a vaginal delivery or the first 96 hours of such
confinement following a cesarean delivery is not required. Any day of confinement in excess of such limits must be certified. You, your physician, or other health care provider may obtain such certification by calling the number shown on your ID Card.
In most cases, the expenses must be incurred while the person is covered under this Plan. Health Expenses incurred after the person's coverage ceases will be considered for benefits as follows:
• If a pregnancy started before the group contract discontinues as to the class of which you are a member and while
coverage was in force for a person, benefits will be available for such person if coverage ceases because of such discontinuance. The benefits are available for up to 12 months from the date the group contract discontinues. The benefits are available for services and supplies needed in connection with such pregnancy.
• As to any other pregnancy, benefits will be available as provided in Continuation of Health Benefits After
Termination. They are available only if evidence is furnished to Aetna that the person has been totally disabled since her coverage ceased. The evidence must be acceptable to Aetna.
Prior Plans: Any pregnancy benefits payable by previous group medical coverage will be subtracted from medical benefits payable for the same expenses under this Plan.
In regards to All Medical Plans:
Handicapped Dependent Children
Health Expense Coverage for your fully handicapped dependent child may be continued past the maximum age for a dependent child. However, such coverage may not be continued if the child has been issued a personal medical conversion policy.
Your child is fully handicapped if:
• he or she is not able to earn his or her own living because of mental retardation or a physical or mental handicap
which started prior to the date he or she reaches the maximum age for dependent children; and
• he or she depends chiefly on you for support and maintenance.
Coverage will cease on the first to occur of:
• When he or she is no longer dependent on you. • Cessation of the handicap.
In regards to All Medical Plans:
Child Health Supervision Services Expenses
The charges below are included as Covered Medical Expenses even though they are not incurred in connection with an injury or disease. They are included only for a dependent child under 17 years of age.
Child Health Supervision Services Expenses are the charges for Child Health Supervision Services.
Child Health Supervision Services means physician-delivered or physician supervised services which shall include as the minimum benefit coverage for services delivered at the intervals and scope stated below. Included are:
• A review and written record of the child's complete medical history. • Physical Examination.
• Developmental and behavioral assessment. • Anticipatory Guidance.
• Appropriate Immunizations. • Laboratory Test.
All of the above in keeping with prevailing medical standards.
Covered Medical Expenses will only include charges of one physician for Child Health Supervision Services performed at birth and at approximately each of the following ages:
2 months 4 months 6 months 9 months 12 months 15 months 18 months 2 years 3 years 4 years 5 years 6 years 8 years 10 years 12 years 14 years 16 years
Covered Medical Expenses for Child Health Supervision Services are not subject to the Calendar Year Deductible.
In regards to All Medical Plans:
Routine Mammogram
Covered Medical Expenses include charges incurred by a female for a routine mammogram. This is only done in the absence of a disease or injury.
In regards to All Medical Plans:
Conversion of Medical Expense Coverage for Florida Residents Only
This Plan permits certain persons whose Medical Expense Coverage has ceased to convert to a personal medical policy. No medical exam is needed. You and your family members may convert when all coverage ceases for any reason except: ceasing to contribute; or discontinuance of Medical Expense Coverage when succeeding group coverage is available within 31 days of discontinuance.
The personal policy may cover:
• you only; or
• you and all of your family members who are covered under this Plan when your coverage ceases; or
• if you die before you retire, all of your family members, or your spouse only, who are covered under this Plan when
You may convert when you become a retired employee. If this Plan permits retired employees to continue Medical Expense Coverage, and you choose to do so, this conversion privilege will not again be available to you.
The personal policy must be applied for within 63 days after coverage ceases; or would otherwise cease without a provision to continue coverage for retired employees. The 63 days start on the date coverage ceases even if the person is still eligible for benefits because the person is totally disabled or because of treatment for a specific disease or injury. However, if coverage ceases due to the discontinuance of Medical Expense Coverage when succeeding group coverage is not available within 31 days of discontinuance, the 63 days start on the date a notice of termination of coverage is mailed to the person, even if the person is still eligible for benefits because the person is totally disabled or because of treatment for a specific disease or injury.
Aetna may decline to issue the personal policy if:
• On the date of conversion, a person is covered, eligible or has benefits available under one of the following:
any other hospital or surgical expense insurance policy;
any hospital service or medical expense indemnity corporation subscriber contract; any other group contract;
any statute, welfare plan or program;
and that with the converted policy, would result in overinsurance or match benefits.
• The person is or could be covered under Medicare (Title XVIII of the Social Security Act, as amended).
No one has the right to convert if you have been insured under this Plan for less than 3 months. Also, no person has the right to convert if:
• he or she has used up the maximum benefit; or
• he or she becomes eligible for any other Medical Expense Coverage under this Plan.
The personal policy form, and its terms, will be of a type, for group conversion purposes:
• as required by law or regulation; or
• as then offered by Aetna under your Employer's conversion plan.
It will not provide coverage which is the same as coverage under this Plan. The level of coverage may be less and an overall Lifetime Maximum Benefit will apply.
The personal policy may contain either or both of:
• A statement that benefits under it will be cut back by any like benefits payable under this Plan after your coverage
ceases.
• A statement that Aetna may ask for data about your coverage under any other plan. This may be asked for on any
premium due date of the personal policy. If you do not give the data, expenses covered under the personal policy may be reduced by expenses which are covered or provided under those plans.
If you or your dependent want to convert:
• Your Employer should be asked for a copy of the "Notice of Conversion Privilege and Request" form. • Send the completed form to the address shown.
If a person is eligible to convert, information will be sent about the personal policy for which he or she may apply. The first premium for the personal policy must be paid at the time the person applies for that policy. The premium due will be Aetna's normal rate for the person's class and age, and the form and amount of coverage.
The personal policy will take effect on the day after coverage terminates under this Plan.
Ronald A. Williams
Chairman, Chief Executive Officer, and President Aetna Life Insurance Company