HomeMy WebLinkAbout2017-2018 Employee BenefitsSummary of Benefits
Vision Plan
Services
In- Network
Out -of- Network
Eye Exam
$10 Copay
Up to $35 Reimbursement
Materials
$15 Copay
Reimbursement
Frequency of Services
In- Network
Out -of- Network
Examination
12 Months
Lenses Contact Lenses
12 Months
Frames
24 Months
Lenses
In- Network
Out -of- Network
Single
$15 Copay
Up to $20 Reimbursement
Bifocal
$15 Copay
Up to $40 Reimbursement
Trifocal
$15 Copay
Up to $60 Reimbursement
Frames
In- Network
Out -of- Network
Reimbursement
$15 Copay
Up to $30 Reimbursement
Contact Lenses
In- Network
Out -of- Network
Non Elective (Medically Necessary)
Paid in Full
Up to $150 Reimbursement
Elective'
$100 Allowance
Up to $100 Reimbursement
Tier of Coverage
Bi- Weekly
Monthly
Employee
0.00
0.00
Employee Family
3.03
6.05
it Vision Insurance
Human a/Co mpB en efits
Customer Service: (800) 865 -3676
www.visioncare.com
The City will continue to offer a Vision plan through Humana /CompBenefits. A highlight of this plan is provided below
followed by a summary of the plan's schedule of benefits. For details regarding the entire plan's coverages, exclusions and
stipulations, please refer to your Humana /CompBenefits vision benefit summary.
Vision Insurance Per Pay Period Premium Deductions
Network Benefits
The Vision plan through Humana offers you and your covered dependents a benefit option that covers routine eye care,
including eye exams, eyeglasses (lenses and frames) or contact lenses. To schedule an appointment, covered members can
select any optometrist or ophthalmologists that participates in the Humana vision network. At the time of service, routine
vision examination services will be covered in full after you pay a $10 copay. Cosmetic services and upgrades will be extra if
chosen at the time of your appointment. To obtain a listing of providers that participate in the Humana /CompBenefits vision
network, contact Customer Service or visit Humana /CompBenefits online at www.visioncare.com.
Covered members may also choose to receive services from vision providers that do not participate in the Humana vision
network. If so, the cost of the services received would be paid to that provider at the time of the scheduled appointment.
Humana will then reimburse the covered members based on the plan's out -of- network reimbursement schedule upon receipt
of services rendered.
Please note the following:
Members receive additional fixed copayments on lens options including anti- reflective and scratch- resistant coatings.
Members also receive a 20% retail discount on a second pair of eyeglasses. This discount is available for 12 months
after the covered eye exam, and is available through the VCP network provider who sold the initial pair of eyeglasses.
After copay, standard polycarbonate available at no charge for dependents under age 19.
This allowance is paid with the same frequency as lenses, in place of all other benefits.
All benefits in this booklet are subject to change. This is an Employee Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract. 9
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Effective Date: July 1, 2010
Vision Insurance RFP Evaluation
050410 City of Sebastian RFP Evaluation (C
H iw/ M A A
Specialty Benefits
July 28, 2009
Sincerely,
cc: Gehring, Kurt
Please
City of Sebastian Group #VS3142
Attn: Debbie Krueger
1225 Main Street
Sebastian, FL 32958
Dear Group Benefits Administrator:
Your renewal rates for the next benefit period are as follows:
Renewal Date and Rate Guarantee Period: 10/1/09 9/30/11
Luz Martinez
Humana Specialty Benefits
uthorized Signature)
Title: Ci ty Manager
Date: 08/27/09
100 Mansell Court East, Suite 400, Roswell, Ga 30076
800 663 -1262 www.humanavision.com
HumanaVision Vision Care Plan (VCP), the vision product of Humana Specialty Benefits, agrees to
renew your vision care contract for an additional twenty -four (24) months at the following rates, effective
October 1, 2009.
Current Monthly Rates Renewal Monthly Rates
Employee Only $4.59 $4.59
Family $16.69 $16.69
CC
Your plan will automatically renew thereafter for consecutive twelve (12) month periods unless
terminated by either party with written notice provided sixty (60) days prior to the plan anniversary date.
Please feel free to contact either our office or your agent should you have any questions. We appreciate
your business.
ow acknowledging your agreement to continue your vision care coverage as stated above.
HUMANA.
July 28, 2009
Specialty Benefits
City of Sebastian Group #VS3142
Attn: Debbie Krueger
1225 Main Street
Sebastian, FL 32958
Dear Group Benefits Administrator:
HumanaVision Vision Care Plan (VCP), the vision product of Humana Specialty Benefits, agrees to
renew your vision care contract for an additional twenty -four (24) months at the following rates, effective
October 1, 2009.
Your renewal rates for the next benefit period are as follows:
Renewal Date and Rate Guarantee Period: 10/1/09 9/30/11
Current Monthly Rates Renewal Monthly Rates
Employee Only $4.59 $4.59
Family $16.69 $16.69
Your plan will automatically renew thereafter for consecutive twelve (12) month periods unless
terminated by either party with written notice provided sixty (60) days prior to the plan anniversary date.
Please feel free to contact either our office or your agent should you have any questions. We appreciate
your business.
Sincerely,
Luz Martinez
Humana Specialty Benefits
cc: Gehring, Kurt
100 Mansell Court East, Suite 400, Roswell, Ga 30076
800 663 -1262 www.humanavision.com
enefits
July 20, 2007
City of Sebastian Group #VS3142
Attn: Benefits Administrator
1225 Main St
Sebastian, FL 32958
Dear Group Benefits Administrator:
VisionCare Plan, the premier vision product of CompBenefits Corporation, agrees to renew your vision
care contract for an additional twenty -four (24) months at the following rates, effective October 1, 2007.
Your renewal rates for the next benefit period are as follows:
Renewal Date and Rate Guarantee Period: 10/1/07 9/30/09
Current Monthly Rates Renewal Monthly Rates
Employee Only $4.59 $4.59
Family $16.69 $16.69
Your plan will automatically renew thereafter for consecutive twelve (12) month periods unless
terminated by either party with written notice provided sixty (60) days prior to the plan anniversary date.
We are also pleased to announce an enhancement to the current Lasik benefit available to your
employees. For information on our new TruVision Advantage Program, please visit our website at
ticvision.com or call 888 358 -3937.
Please feel free to contact either our office or your agent should you have any questions. We appreciate
your business.
Sincerely,
Lisa Schmelzle, Account Manager
CompBenefits
cc: Gehring, Kurt
The Gehring Group
5775 Blue Lagoon Drive, Suite 400, Miami, FL 33126
877 647 -3678 www.compbenefits.com
`yrV CompBenefits
1511 North Westshore Blvd.
Suite 1000
Tampa, Florida 33607
(813) 289-2020 Fax: (813) 349 -5588
www.compbenefits.com
July 29, 2005
Mr. Kurt Gehring
The Gehring Group
11505 Fairchild Gardens Ave. #202
Palm Beach Gardens, 33410
Re: City of Sebastian
VS3142 Vision Care Contract
Dear Mr. Gehring:
VisionCare Plan, the premier vision product of CompBenefits Company, agrees to renew the above group's vision
care contract for an additional twenty -four (24) months at the current plan, benefits, and rates, effective October 1,
2005.
Their plan will automatically renew thereafter for consecutive twelve (12) month periods unless terminated by either
party with written notice provided sixty (60) days prior to the plan anniversary date. VisionCare Plan will provide
written notice of any change in their benefits or rates sixty (60) days prior to their plan anniversary date.
We look forward to providing for their continued vision care needs.
By:
r
Peter O. Collins
Assistant Vice President, Underwriting and Actuarial
POC /cp
cc: Martha Plagge
Please refer
for signature acknowledging their receipt and acceptance of the renewal as stated above.
Title: C� NMMry� Date: 7_frO
AUG 1 2005
CompBenefits CompBenefits Company CompBenefits Insurance Company CompBenefits Dental, Inc. CompBenefits of Alabama, Inc.
American Dental Plan of North Carolina, Inc. American Dental Providers of Arkansas, Inc. National Dental Plans, Inc. American Dental Plan of Georgia, Inc.
Texas Dental Plans, Inc. Ultimate Optical, Inc. VisionCare Plan Primary Plus
CoimpBenefits
Corporation
The denial and vision heralds =aunt of choice!
Vision Care, Inc.
1511 North Westshore Blvd.
Suite 1000
Tampa, Florida 33607
(613)269 -2020 Fax: (813)349.5588
www.visionCare.com
www.compbenelits.com
July 31, 2003
Mr. Paul Wagoner
General Services Administration
City of Sebastian
1225 Main Street
Sebastian, FL 32958
Re: VS3142 Vision Care Contract
Dear Mr. Wagoner:
VisionCare Plan, the premier product of Vision Care, Inc., agrees to renew your vision care contract for an
additional twenty -four (24) months at the current rates, effective October 1, 2003.
Your plan will automatically renew thereafter for consecutive twelve (12) month periods unless terminated by either
party with written notice provided sixty (60) days prior to the plan anniversary date. VisionCare Plan will provide
written notice of any change in your benefits or rates sixty (60) days prior to the plan anniversary date.
We are in the process of transitioning all accounts to our enhanced CompBenefits Information System -CBIS. The
benefits and efficiencies of this IBM AS400 based system will allow CompBenefitsNCI to provide a higher level of
customer service. Please note that your policy number has changed from FL207118 to V S3I42.
We look forward to providing for your continued vision care needs.
SigcFrely,
Peter O. Collins
Director, Underwriting and Actuarial
cc: Kurt Gehring
Jeanne Brooks
Plea
By
Title r- fly
thorized Signature).
your agreement to continue your vision care coverage as stated above.
d e
Date 5 �P7�P .A er 1;260 3
ConpDent Compaenefits Insurance Company Amencan Dental Plan, Inc Amercan Dental Plan el North Carolina. Inc.
Orel Health Services, Inc National Dental Plans, Inc. Texas Dental Plans, Inc.
Vision Care, Inc Vernon Care Plan Primary Plus Opllx Ultimata Opecal. Inc.
VISIONCARE PLAN
CONTRACT
Vision Care, Inc.
d /b /a
VisionCare Plan
(A licensed PLHSO under Chapter 636, F.S.)
and
City of Sebastian
(Hereinafter Called Group)
Agree as Follows:
In consideration of the Application made by the Group, a copy of which
is attached hereto and made a part of this Contract, and in consideration of
payment by the Group of the appropriate premiums, VisionCare Plan (Hereinafter
called Plan) shall provide a panel of Doctors to perform services for eligible
persons as described under "Eligibility," subject to the terms and conditions of
this Contract.
This Contract shall commence on the effective date of October 1, 2001
and having an initial term of two (2) years therefrom; this contract shall
automatically renew for additional terms of one (1) year each, unless earlier
terminated as provided herein.
The obligation of the Plan to arrange for the provision of services and
materials described herein to the Group is expressly conditioned upon the Plan's
acceptance of the Group's application and the enrollment forms and approval of
the same in accordance with the Plan's policies and procedures.
In Witness Whereof, the parties have caused this Contract to
be executed this ..3! day of f 200
Vision Care, Inc.
VCI- Grp Policy- 010200 1
FL207118
Peter D. Liane
Chief Operating Officer
(FL)
VISIONCARE PLAN
ELIGIBILITY
Full -time employees who reside in the Service Area are eligible for vision care
coverage on the first of the month following the group's waiting period. "Full
time" is defined as those employees who work at least thirty (30) hours per
week. "Service Area" is defined as the geographical area in which a VisionCare
Plan network provider is available. Dependent coverage shall be effective on
the same day as the employee.
DEPENDENTS Eligible Dependents include the employee's spouse and children a)
from birth to age 19 who are dependent upon the employee for support; or b) 19
years of age through the end of the calendar year in which the child reaches the
age of 25, if the child meets all of the following: i) the child is dependent
upon the employee for support; and ii) the child is living in the employee's
household or is a full -time or part -time student. "Child" includes adopted
children and foster children who live with the employee in a regular parent
child relationship. At the attainment of the applicable limiting age, coverage
as a dependent shall be extended if the individual is and continues to be both
incapable of self sustaining employment for reason of mental retardation or
physical handicap and chiefly dependent upon the employee for support and
maintenance. When a benefit is denied due to the child's attainment of the
limiting age, VisionCare Plan must be provided with required proof of such
child's incapacity
Newborn Child A newborn child is covered from the moment of birth for 31 days.
If the employee elects to cover the newborn under this Contract, then such child
must be enrolled within 60 days from the date of birth or coverage for that
child we terminate at the end of the 31 -day period.
Adopted Child An adopted child will be covered form the earlier of: 1) the
date of birth if a petition for adoption is filed within 30 days of the birth of
such child; 2) the date the employee gains custody of the child under a
temporary court order that grants the employee conservatorship of the child; or
3) the date the child is placed for adoption; and additional premium, if any, is
paid.
TERMINATION OF COVERAGE
An employee or his /her covered dependent (herein after referred to as "Member
shall not have his /her coverage terminated under this provision because of the
amount, variety or cost of services required by such Member. The coverage of
any Member shall, however, terminate:
1. At the end of the month during which a Member ceases to be eligible
for coverage as defined herein. The Group must notify the Plan
within 30 calendar days of the date a Member is no longer eligible.
Coverage will terminate automatically and without notice.
2. At the end of the month for which the last premium payment was paid
by the Group to the Plan, if the Premium was not paid by the end of
the applicable Grace Period. Coverage will terminate automatically
and without notice.
3. Upon forty -five (45) days advance written notice when: 1) the Member
commits any action of fraud or material misrepresentation in
applying for or seeking any benefits under this Contract; 2)
VCI -Grp- Policy 010200 2
FL207118
(FL)
VISIONCARE PLAN
disruptive, unruly, abusive, unlawful, fraudulent or uncooperative
behavior towards a health care provider or administrative staff that
seriously impairs the Plan's ability to provide services to the
Member and /or to other Members; 3) failure to pay, upon notice, fees
or Co- payments which are the responsibility of the Member; 4) misuse
of the documents provided as evidence of benefits available pursuant
to this Contract; and 5) furnishing to the Plan by the Member,
incorrect or incomplete information for the purposes of fraudulently
obtaining services. Prior to termination, the Plan shall make every
effort to resolve the problem through its grievance procedure and to
determine that the Member's behavior is not due to use of the vision
care services provided or mental illness.
4. On the date the Contract is terminated by the Group, provided the
Group gives 60 days advance written notice to the Plan.
On termination of coverage a Member may qualify for:
1. An extension of coverage as described in the extension of benefits
provision;
2. A continuation of coverage under COBRA legislation; and
3. The health conversion provision.
OPEN ENROLLMENT PROVISION
The Plan will offer the Group at least one open enrollment period of not less
than thirty (30) days every eighteen (18) months. Such open enrollment periods
will be offered for as long as the Contract remains in force unless the Plan and
the Group mutually agree to a shorter period of time.
BENEFITS
The following services and materials must obtained through a Plan Network
Provider and are subject to the applicable Co- payment shown below. Any
additional care or services and /or materials not covered under this Contract
shall be at the Member's own expense.
Vision Examinations Each Member is eligible for a complete analysis of the
eyes and related structures to determine vision problems and other
abnormalities, which shall include: 1) personal and family history; 2) visual
acuity (unaided or acuity with present correction); 3) external exam; 4)
pupillary exam; 5) visual field testing (confrontation); 6) internal exam
(direct or indirect ophthalmoscopy recording cup disc ratio, blood vessel status
and any abnormalities: 7) biomicroscopy (binocular or monocular); 8) tonometry;
9) refraction (with recorded visual acuity); 10) extra ocular muscle balance
assessment; 11) diagnosis and treatment plan. VisionCare Plan will cover such
service once in any 12 month period.
Materials Where the vision examination shows new lenses or frames or both are
necessary for proper visual health, such Materials will be covered, together
with certain services as necessary. Services include, but are not limited to:
(1) prescribing and ordering proper lenses; (2) assisting with selection of
frames; (3) verifying accuracy of finished lenses; (4) proper fitting and
adjustments.
Lenses One pair of new prescription lenses, if required by a change in
prescription, once in any 12 month period.
VCI- Grp Policy- 010200 3
FL207118
(FL)
VISIONCARE PLAN
Frames One new frame once in any 24 month period. The Plan Network Provider
will show the Member the frames that the Plan covers in full. Plan Providers
can also order any currently provided frame that a Member may find elsewhere.
If a Member selects a frame that costs more than the amount the Plan covers, the
Member is responsible for the difference in cost.
Contact lenses when necessary One pair of contact lenses under the following
circumstances and only if prior authorization from the Plan is obtained: 1)
following cataract surgery without intraocular lens; 2) correction of extreme
visual acuity problems not'correctable with glasses; 3) Anisometropia greater
than 5.00 diopters and aesthenopia or diplopia, with spectacles; 4) Keratoconus;
or 5) monocular aphakia and /or binocular aphakia where the doctor certifies
contact lenses are medically necessary for safety and rehabilitation to a
productive life. Replacement will not be more often than once in any 12 month
period and only if prior authorization is obtained from the Plan. The Copayment
is waived.
Contact lenses when elective The combined cost of an annual vision exam and
contact lenses up to a maximum of $100.00. Payment will be IN LIEU OF ALL OTHER
BENEFITS. Replacement will not be more often than once in any 12 month period.
The Copayment is waived.
Co Payment A Member's Co- payment is:
1. Vision Examination $10
2. Materials
$15
WHEN COVERED SERVICES ARE OBTAINED FROM A PLAN NETWORK PROVIDER, THE MEMBER IS
ONLY RESPONSIBLE FOR THE CO- PAYMENT AMOUNT LISTED ABOVE.
LIMITATIONS AND EXCLUSIONS
Limitations In no event will coverage exceed the lesser of:
1. The actual cost of covered services or materials; or
2. The limits of the Contract, shown in the Benefits section;
Materials covered by the Contract that are lost or broken will only be replaced
at normal intervals as provided for in the Benefits section.
The Plan will pay only for the basic cost for lenses and frames covered by the
Contract. The Member is responsible for extras selected, including but not
limited to:
1. Blended lenses;
2. Progressive multifocal lenses;
3. Photo chromatic lenses; tinted lenses, sunglasses, prescription and
plane;
4. Coating of lens or lenses;
5. Laminating of lens or lenses.
VCI -Grp- Policy- 010200 4
FL207118
(FL)
Exclusions- The Plan will not cover:
2. DEFINITIONS.
1. Orthopic or vision training and any associated supplemental testing;
2. Two pair of glasses, in lieu of bifocals or trifocals;
3. Medical or surgical treatment of the eyes;
4. Any services and /or materials required by an Employer as a condition
of employment;
5. Any injury or illness covered under any Workers' Compensation or
similar law;
6. Sub normal vision aids, aniseikonic lenses or non prescription
lenses;
7. Services rendered or materials purchased outside the U.S.
8. Eyeglasses when no change in the prescription is made or is
necessary;
9. Charges incurred after: (a) the Contract ends; or (b) the Member's
coverage under the Contract ends, except as stated in the Contract.
10. Experimental or non conventional treatment or device;
11. Contact lenses, except as specifically covered by the Contract.
1. APPLICABILITY.
VISIONCARE PLAN
COORDINATION WITH OTHER BENEFITS PROVISION
This Coordination With Other Benefits provision applies to This Plan when the
Member has vision care coverage under more than one Plan. For the purposes of
this section only, "Plan" and "This Plan" are defined below. If this provision
applies, the Order of Benefit Determination Rules should be looked at first.
Those rules determine whether the benefits of This Plan are determined before or
after those of another Plan. The benefits of This Plan: (a) will not be reduced
when, under the Order of Benefit Determination Rules, This Plan determines its
benefits before another Plan; but (b) may be reduced when, under the Order of
Benefit Determination Rules, another Plan determines its benefits first. The
above reduction is described in Section 4, Effect on the Benefits of This Plan.
A "Plan" is any group insurance or group type insurance, whether insured or
uninsured, which provides benefits for, or because of, vision care or treatment.
This also includes 1) group or group -type coverage through HMOs and other
prepayment, group practice and individual practice plans; 2) group coverage
under labor- management trusteed plans, union welfare plans, employer
organization plans, employee benefit organization plans or self insured employee
benefit plans; and 3) medical benefits coverage in group, group type, and
individual automobile "no- fault" type contracts or group or group -type
automobile "fault" contracts. It does not include school accident type
coverages, coverage under any governmental plan required or provided by law, or
any state plan under Medicaid. Each contract or other arrangement for coverage
is a separate Plan. Also, if an arrangement has two parts and coordination
applies only to one of the two, each of the parts is a separate Plan.
"This Plan" means this Contract.
"Primary Plan"/"Secondary Plan". The Order of Benefit Determination Rules
state whether This Plan is a Primary Plan or Secondary Plan as to another Plan
covering the person. When This Plan is a Primary Plan, its benefits are
determined before those of the other Plan and without considering the other
Plan's benefits. When This Plan is a Secondary Plan, its benefits are
VCI- Grp Policy- 010200 5
FL207118 (FL)
determined after those of the other Plan and may be reduced because of the other
Plan's benefits. When there are more than two Plans covering the person, This
Plan may be a Primary Plan as to one or more other Plans, and may be a Secondary
Plan as to a different Plan or Plans.
VISIONCARE PLAN
"Allowable Expenses" means the allowed amount as shown in the Schedule of
Benefits.
"Claim Determination Period" means a benefit year. However it does not include
any part of a year during which a person has no coverage under This Plan, or any
part of a year before the date this provision or a similar provision takes
effect.
3. ORDER OF BENEFIT DETERMINATION RULES.
This Plan determines its order of benefits using the first of the following
rules which applies:
(a) The benefits of the Plan which covers the person as an employee, member
or subscriber (that is, other than as a dependent) are determined
before those of the Plan which covers the person as a dependent; except
that if the person is also a Medicare beneficiary, Medicare is
secondary to the Plan covering the person as a dependent and primary to
the Plan covering the person as other than a dependent, then the
benefits of the Plan covering the person as a dependent are determined
before those of the Plan covering that person as other than a
dependent. Except in the case of legal separation or divorce (further
described below), when This Plan and another Plan cover the same child
as a dependent of different persons, called "parents
(1) the benefits of the Plan of the parent whose birthday falls
earlier in a year are determined before those of the Plan of the
parent whose birthday falls later in that year; but
(2) if both parents have the same birthday, the benefits of the Plan
which covered the parent longer are determined before those of
the Plan which covered the other parent for a shorter period of
time. However, if the other Plan does not have the rule
described immediately above, and if, as a result, the Plans do
not agree on the Order of Benefits, the rule in the other Plan
will determine the order of benefits.
(b) If two or more Plans cover a person as a dependent child of divorced or
separated parents, benefits for the child are determined in this order:
(1) first, the Plan of the parent with custody of the child; (2) then,
the Plan of the spouse of the parent with custody of the child; and (3)
finally, the Plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the
parents is responsible for the health care expenses of the child, and
the entity obligated to pay or provide the benefits of the Plan of that
parent has actual knowledge of those terms, the benefits of that Plan
are determined first. This paragraph does not apply with respect to any
Claim Determination Period or Plan Year during which any benefits are
actually paid or provided before the entity has that actual knowledge.
(c) The benefits of a Plan which covers a person as an employee who is
neither laid off, retired or continuing coverage under a right of
continuation (or as a dependent of the person) are determined before
those of a Plan which covers that person as a laid off, retired or
continuing coverage (or as a dependent of that person) If the other
VCI -Grp- Policy- 010200 6
FL207118
(FL)
Plan does not have this rule, and if, as a result, the Plans do not
agree on the Order of Benefits, this rule is ignored.
(d) If none of the above rules determines the Order of Benefits, the
benefits of the Plan which covered an employee, member, or subscriber
longer are determined before those of the Plan which covered that
person for the shorter time.
4. EFFECT ON THE BENEFITS OF THIS PLAN.
VISIONCARE PLAN
This section applies when, in accordance with Section 3. Order of Benefit
Determination Rules, This Plan is a Secondary Plan to one or more other Plans.
In the event the benefits of This Plan may be reduced under this section. Such
other Plan or Plans are referred to as "the Other Plans
The benefits of This Plan will be reduced when the sum of: (a) the benefits that
would be payable for the Allowable Expenses under This Plan in the absence of
this provision; and (b) the benefits that would be payable for the Allowable
Expenses under the other plans, in the absence of provisions with a purpose like
that of this provision, whether or not claim is made; exceeds those Allowable in
a Claim Determination Period. In that case, the benefits of This Plan will be
reduced so that they and the benefits payable under the Other Plans do not total
more than those Allowable Expenses. When the benefits of This Plan are reduced
as described above, each benefit is reduced in proportion. It is then charged
against any applicable benefit limit of This Plan.
5. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION.
Certain facts are needed to apply these rules. Vision Care, Inc. has the right
to decide which facts are needed. Vision Care, Inc. may get needed facts
from, or give them to, any other organization or person. Vision Care, Inc.
need not tell, or get the consent of, any person to do this. Each person
claiming benefits under This Plan must give Vision Care, Inc. any facts deemed
necessary to pay the claim.
6. FACILITY OF PAYMENT.
A payment made under another Plan may include an amount which should have been
paid under This Plan. If it does, Vision Care, Inc. may pay that amount to the
organization which made that payment. That amount will then be treated as though
it were a benefit paid under This Plan. Vision Care, Inc. will not have to pay
that amount again. The term "payment made" includes providing benefits in the
form of services, in which case, "payment made" means reasonable cash value of
the benefits provided in the form of services.
7. RIGHT OF RECOVERY.
If the amount of the payments made by Vision Care, Inc. are more than should
have been paid under this provision, Vision Care, Inc. may recover the excess
from one or more of: (a) the persons for whom payment has been made; (b)
insurance companies or other organizations providing benefits under another
Plan.
CONVERSION PROVISION
The Plan shall offer a converted contract to any Member whose coverage has been
terminated, and who was continuously covered under this Contract for at least
VCI -Grp- Policy 010200 7
FL207118
(FL)
VISIONCARE PLAN
three (3) consecutive months immediately prior to termination. The converted
contract will provide coverage and benefits similar to this Contract. A Member
shall not be entitled to have a converted contract issued if termination of
coverage occurred for any of the following reasons: 1) failure to pay any
required premium or contribution; 2) replacement of any discontinued coverage by
similar coverage within thirty -one (31) days; 2) fraud or material
misrepresentation in applying for any benefit under this Contract; 3)
disenrollment for cause as specified; 4) misuse of the documents provided as
evidence of benefits available pursuant to this Contract; 5) furnishing to the
Plan by the Member, incorrect or incomplete information for the purposes of
fraudulently obtaining services; or 6) the Member has left the Service Area with
the intent to relocate or establish a new residence outside the Service Area.
Subject to the conditions set forth above, the conversion privilege shall also
be available to: 1) the surviving spouse and /or children, if any, at the death
of the employee, with respect to the spouse and such children whose coverage
under plan contract terminate by reason of such death; 2) to the former spouse
whose coverage would otherwise terminate due to annulment or dissolution of
marriage, if the former spouse is dependent for financial support; 3) to the
spouse of the employee upon termination of coverage of the spouse, while the
employee remains covered under a group contract, by reason of ceasing to be a
qualified family Member under the group contract; 4) to a child solely with
respect to himself or herself, upon termination of his or her coverage by reason
of ceasing to be a qualified family Member under a group contract.
VCI- Grp Policy- 010200 8
FL207118
EXTENSION OF BENEFIT PROVISION
If service for an eligible person hereunder is being rendered as of the
termination date of this coverage, such service shall be continued to completion
but in no event beyond ninety (90) days after the termination date of the
contract.
PLAN GRIEVANCE PROCEDURES
Informal Grievances:
Any Member who has a suggestion for improving services or registering a
complaint for any matter arising out of this Contract or for covered services
rendered or materials received thereunder may submit an informal oral grievance
to the Plan. Assistance with the Plan's grievance procedures, including
assistance with informal oral grievances, may be obtained by calling the
customer Care Department at the address and telephone number listed below. Oral
grievances shall be submitted to the Plan's Grievance Coordinator. Informal
oral grievances shall be responded to as soon as possible by the Grievance
Coordinator. If the informal oral grievance involves an eyecare related matter
or claim, the Plan's Medical Director shall be involved in resolving said
grievance. The Member has the right to file a formal written grievance with the
Plan and to grieve directly to the state of Florida Department of Insurance.
Submission of Formal Grievances:
Any Member who has a suggestion for improving services or registering a
complaint for any matter arising out of this Contract or for covered services
rendered or materials received thereunder may submit a formal written grievance
to the Plan. such written statement shall be specifically identified as a
grievance, shall be submitted to the Plan within one (1) year from occurrence of
the events upon which the grievance is based, and shall contain a statement of
(FL)
the action requested, the Member's name, address, telephone number, Member
number, signature and the date. The statement should be sent to the Plan's
grievance Coordinator. More information on and assistance with the Plan's
grievance procedures may be obtained by calling the Plan's Member Services
Department at the Plan.
Response to Formal Grievances:
The Grievance Coordinator will investigate the problem, gather all of the
relevant facts and forward the grievance to the Quality Assurance and
Improvement Committee. A Member of the committee will review the case in
confidence with the appropriate parties and shall recommend a solution and plan
of action, in writing to the Member and the Plan's Network Provider, if
appropriate, within ten (10) days of completion of the coordinator's review. If
the grievance involves an eyecare related matter or claim, the Plan's Medical
director shall be involved in resolving said grievance. If the grievance
involves denial of benefits or services the written decision shall reference the
specific provisions of the Contract upon which the denial is based. All
grievances shall be processed within sixty (60) days by the Plan. However, if
the grievance involves collection of information from outside the Plan's service
area, an additional thirty (30) days will be allowed for processing.
Appeal of Decision:
If the Member is dissatisfied with the decision of the Quality Assurance and
Improvements Committee, the Member may request reconsideration by the Quality
Assurance and Improvements Committee and may request a person appearance before
the committee. Such requests for reconsideration must be made within sixty (60)
days after receipt of the Committee's initial written decision. In addition, a
Member has the right to grieve directly to the State of Florida Department of
Insurance.
Contact Information:
Vision Care, Inc.
P.O. Box 30349
Tampa, FL 33630 -3349
Attn: Vision Care Customer Care Department
or call, toll free at (800) 665 -3676
VISIONCARE PLAN
Florida Division of Insurance Consumer Assistance
200 East Gaines Street
Tallahassee, FL 32399
or call, toll free the Consumer Hotline at (800) 342 -2762
GENERAL PROVISIONS
1. The Plan assumes responsibility of fulfilling the terms of this Contract.
Under no circumstances shall the Plan or Group be liable for the negligence,
wrongful acts, or omissions of any doctor, laboratory or other person or
organization performing services or supplying materials in connection with this
Contract. Group agrees that neither Group nor its representatives or employees
shall engage in referring members of Group to any particular doctor, or doctors,
whether or not a Plan Network Provider.
VCI -Grp- Policy- 010200 9
FL207118
(FL)
VISIONCARE PLAN
2. The Plan shall have the right at all reasonable times to inspect such records
of Group as the Plan deems necessary to determine the number and eligibility of
eligible persons, and Group agrees to make such records available at such times
and on request.
3. All notices provided hereunder shall be deemed as having been properly made
upon depositing the same in the United States mail, postage prepaid, and
addressing such notices to the Plan at its main office, or to Group at the
address appearing last on the books of the Plan.
4. Upon receipt by the Plan of a request for benefits from a Member of Group,
the Plan will issue a Benefit Form to such Member provided: (A) The request is
certified by Group; or (B) The Member appears eligible by reason of the latest
information available to the Plan, furnished by the Group. Benefit Forms so
issued shall be assigned an expiration date, allowing a reasonable period of
time for the Member to obtain services. Such Benefit Form, properly used within
the effective period, shall constitute a claim against the plan, irrespective of
later loss of eligibility by the Member or cancellation of this Contract.
5. Benefit Forms authorizing services will not be issued under this Contract on
or after the date of expiration of the Contract.
6. This Contract in writing, together with the application and any endorsement
attached hereto, constitute the entire Contract between the Plan and the Group.
No agent of the Plan other than a corporate officer of the Plan is authorized to
establish, change or waive any of the provisions of this Contract. No change or
amendments to this Contract shall be valid unless evidence by an endorsement,
rider or amendment to the Contract and is signed by an authorized representative
of the Plan.
7. Neither this Contract, nor any benefits hereunder, including the payment of
money, is assignable, except with prior consent of the Plan.
8. If any provision of this Contract is declared invalid or unenforceable, the
remaining provisions hereof shall remain in full force and effect. The failure
of either party to protest any default or breach shall not constitute a waiver
of such party's rights under this Contract, or such party's rights upon any
subsequent default or breach.
9. This Contract shall be governed by and construed under the laws of the State
of Florida.
10. This Contract may be amended from time to time by mutual written agreement
of both Group and the Plan.
11. Each party represent it has all requisite legal power and authority and has
taken all action necessary or appropriate to enter into this Contract and that
its representative executing this Contract is duly empowered to do so.
12. With respect to indemnification, each party shall be liable for its own acts
and /or omissions and shall be liable therefor in accordance with applicable law.
13. The Plan may increase Co- payments or delete, amend, or limit any benefits
under this Contract upon not less than [45 days] prior written notice to the
Group prior to renewal of this Contract. It is the responsibility of the Group
to notify all Members of such any changes to the Contract.
VCI- Grp Policy- 010200 10
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(FL)
VISIONCARE PLAN
PREMIUM RATES
Payments are due on the first day of each month, a grace period
days is provided for late premium payments. If the premium is
end of the grace period the contract will be cancelled for
premiums effective the first day of the grace period. A premium
for the grace period.
VCI- Grp Policy- 010200 11
FL207118
of thirty (30)
not paid by the
non payment of
will be payable
$4.59 per covered employee /member per month
$16.69 per covered employee plus family per month
Premium rates charged by the Plan may be changed upon not less than sixty (60)
days advance written notice to the Group. The Group shall notify all Members of
such change in premiums
(FL)
100 Mansell Court East
COMPBENEFITS INSURANCE COMPANY
Group Vision Insurance Policy
POLICYHOLDER: City of Sebastian
POLICY NUMBER: FL207118
POLICY EFFECTIVE DATE: October 1, 2001
CONTRACT PERIOD: October 1 September 30
STATE OF DELIVERY: Florida
Read Your Policy Carefully
This Policy is a legal contract between the Policyholder and CompDent Insurance Company (hereinafter referred to
as "Comp Dent"). The consideration for this contract is the group application and the payment of premiums as
provided hereinafter.
Agreement
This Policy is the entire contract with the Policyholder and CompDent. Only authorized officers may make changes
for CompDent. Such changes must be in writing and attached to this Policy. CompDent reserves the right to amend
the Policy from time to time. CompDent will pay, with respect to each Insured, the insurance benefit provided in this
Policy. Payment is subject to the conditions, limitations and exceptions of this Policy. Eligibility requirements to be
insured under this Policy are stated in the section entitled Becoming Insured. This Policy is governed by the laws of
the state shown above.
Roswell, GA 30076 (800) 749 -5855
Certificates
CompDent will furnish a Certificate to each Insured person which will contain the benefits provided by this Policy.
Incorporation Provision
The provisions of the attached certificate and all rider(s) issued to amend this Policy after the effective dates are
made a part of this Policy. This Policy was signed by the Policyholder on the Group Application form. We sign here
on behalf of CompDent.
President
VGRP- POLICY.001 1
*id&
100 Mansell Court East
COMPBENEFITS INSURANCE COMPANY
Roswell, GA 30076 (800) 749 -5855
CERTIFICATE
OF
GROUP VISION INSURANCE
This Certificate contains the features of the Group Vision Insurance Policy issued to the Policyholder by
CompBenefits Insurance Company (hereinafter referred to as "CompBenefits Read it carefully to become familiar
with Your coverage In this Certificate, the masculine pronouns include both masculine and feminine gender unless
the context indicates otherwise. Your coverage may be terminated or amended in whole or in part under the terms
and provisions shown in this Certificate.
If you should have any questions, or to obtain coverage information or assistance in resolving complaints, please call
(800) 749-5855.
Signed for CompBenefits Insurance Company
VGRP- CERT.001 (FL)
President
(rev. 11/29/00)
TABLE OF CONTENTS
Section I- Definitions 2
Section II- Becoming Insured 3
Section III- Procedures for Using Benefits 3
Section IV- Limitations and Exclusions 4
Section V- Coordination With Other Benefits 5
Section VI- Premiums 7
Section VII- Claims 7
Section VIII -Notice of Continuation of Group Health Coverage Rights (COBRA) 8
Section IX- General Provisions 9
Section X- Schedule of Benefits 9
SECTION I- DEFINITIONS
You will need to know what is meant by certain terms used in this Certificate. They are defined below.
Benefit Form or Claim Form- means a form provided by Us for the purpose of filing a claim for reimbursement.
Schedule of Benefits means the part of this Certificate showing what is paid.
Co- payment- means the amount an Insured is required to pay when a covered service is rendered or covered
Materials are purchased.
Dependent- means any of the following persons:
I. Your spouse;
2. Your child;
a) from birth to age 19 and dependent upon You for support; or
b) 19 years of age through the end of the calendar year in which the child reaches the age of 25,
if the child meets all of the following:
(a) The child is dependent upon You for support; and.
(b) The child is living in Your household, or the child is a full-time or part-time student.
"Child" includes adopted children and foster children who live with You in a regular parent -child relationship. At
the attainment of the applicable limiting age, coverage as a dependent shall be extended if the individual is and
continues to be both incapable of self sustaining employment for reason of mental retardation or physical handicap
and chiefly dependent upon the employee for support and maintenance. When a benefit is denied due to the child's
attainment of the limiting age, the Plan must be provided with required proof of such child's incapacity
Group means the aggregate of individuals eligible to be covered under the Policy. Group also refers to the
subgroup participating under the Policy for the benefit of its group members.
Insured means You and Your Dependent(s) covered under the Policy.
Materials means lenses, frame and contact lenses covered under the Policy.
Policy means the Policy issued to the Policyholder.
Policyholder means the employer Group to whom the Policy has been issued.
"You" and "Your" means the Certificateholder.
"We "Our "Us and "Plan" means CompBenefits.
VGRP- CERT.001 (FL) 2 (rev. 11/29/00)
VGRP- CERT.001 (FL)
SECTION II- BECOMING INSURED
Your Coverage Begins- You and Your Dependents are covered on the later of:
1. The first of the month following the date first eligible for coverage;
2. The date We accept Your enrollment, if You are not enrolled within 31 days of becoming eligible;
3. The date You first acquire a new Dependent;
4. The date We accept a Dependent's enrollment, if he is not enrolled within 31 days of becoming
eligible.
Newborn Child A child born to You or Your Dependent spouse is covered from the moment of birth for 31 days.
If you choose to insure Your newborn, You must enroll the child within 60 days from the date of birth or coverage
for that child will terminate at the end of the 31 -day period.
Adopted Child A child placed with You for adoption will be covered from the earlier of: 1) the date of birth if a
petition for adoption is filed within 30 days of the birth of such child; 2) the date you gain custody of the child
under a temporary court order that grants You conservatorship of the child; or 3) the date the child is placed with
You for adoption; and additional premium, if any, is paid. You must notify the Plan of the birth or placement of an
adopted child within 30 days after the birth or placement in Your residence. If timely notice is given, additional
premium for the 30 -day notice period will not be charged. If notice is not given within 60 days of the birth or
placement of an adopted child, the Plan may deny coverage for the child due to failure to timely notify the Plan.
Your Coverage Ends Coverage for You and/or Your Dependent will end on the earlier of:
1. The last day of the month in which You cease to be eligible for coverage;
2. The last day of the month in which Your Dependent is no longer a Dependent as defined;
3. Subject to the Grace Period provision, the last day of the month for which a premium has been
paid; or
4. The date coverage ends for any class or Group to which You belong; or
5. The date the Policy ends.
If Your coverage ends it will not prejudice any existing claim. If service is being rendered at the time coverage ends
for an Insured, We will continue to reimburse for such service to completion, but in no event beyond a 3 month
period following the date coverage ended.
SECTION III PROCEDURES FOR USING BENEFITS
The Insured may receive covered services and Materials from a licensed Optometrist or Ophthalmologist of his
choice., We will reimburse covered services and Materials only up to the allowance, as shown in the Schedule of
Benefits after deduction of the applicable Co- payment. The Insured is required to pay directly to the provider the
Co- payment, the costs and fees associated with covered services or Materials in excess of the allowance as shown in
the Schedule of Benefits, and any services or materials NOT covered by the Policy. Determination of benefits
under this Plan will be affected if a covered service or Material was provided under another vision plan.
In order to obtain vision care, an Insured should request a Benefit Form prior to receiving services or Materials.
Benefit Forms may be obtained by: (i) calling the customer care department at 1- 800 865 -FORM (3676); (ii)
contacting Our website at http: /www.visioncare.com; or (iii) by completing the form entitled "Request for Vision
Care" supplied by Us and faxing it toll free to 1- 800 -421 -0100 or mailing it to Us at P.O. Box 30349, Tampa, FL
33630 -3349. Upon determination that the Insured is eligible, a Benefit Form will be sent to the Insured.
CAUTION: Do not make an appointment for services until the Benefit Form is received.
The Insured may pay the provider in full for any service and/or Materials at the time the service is rendered or the
Materials are provided and then submit to Us an itemized statement of charges and the Benefit Form. We will
3 (rev. 11/29/00)
reimburse the Insured-or the Insured may request to have Benefits paid directly to the provider. To do so, fill out and
sign the Benefit Form telling CompBenefits to pay your Benefits this way.
SECTION IV LIMITATIONS AND EXCLUSIONS
Limitations In no event will coverage exceed the lesser of:
1. The actual cost of covered services or Materials;
2. The limits of the Policy, shown in the Schedule of Benefits; or
3. The allowance as shown in the Schedule of Benefits.
Materials covered by the Policy that are lost or broken will only be replaced at normal intervals as provided for in
the Schedule of Benefits.
We will pay only for the basic cost for lenses and frames covered by the Policy. The Insured is responsible for extras
selected, including but not limited to:
1. Blended lenses;
2. Progressive multifocal lenses;
3. Photo chromatic lenses; tinted lenses, sunglasses, prescription and piano;
4. Coating of lens or lenses;
5. Laminating of lens or lenses.
Exclusions We will not cover:
1. Orthopic or vision training and any associated supplemental testing;
2. Two pair of glasses, in lieu of bifocals or trifocals;
3. Medical or surgical treatment of the eyes;
4. Any services and/or materials required by an Employer as a condition of employment;
5. Any injury or illness paid under any Workers' Compensation or similar law;
6. Sub normal vision aids, aniseikonic lenses or non prescription lenses;
7. Services rendered or Materials purchased outside the U.S.
8. Eyeglasses when no change in the prescription is made or is necessary;
9. Charges incurred after: (a) the Policy ends; or (b) the Insured's coverage under the Policy ends,
except as stated in the Policy.
10. Experimental or non conventional treatment or device;
11. Contact lenses, except as specifically covered by the Policy;
SECTION V COORDINATION WITH OTHER BENEFITS
1. APPLICABILITY.
This Coordination With Other Benefits provision applies to This Plan when You or Your covered dependents have
vision care coverage under more than one Plan. For the purposes of this section only, "Plan" and "This Plan" are
defined below. If this provision applies, the Order of Benefit Determination Rules should be looked at first. Those
rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits
of This Plan: (a) will not be reduced when, under the Order of Benefit Determination Rules, This Plan determines its
benefits before another Plan; but (b) may be reduced when, under the Order of Benefit Determination Rules, another
Plan determines its benefits first. The above reduction is described in Section 4, Effect on the Benefits of This Plan.
2. DEFINITIONS.
A "Plan" is any group insurance or group type insurance, whether insured or uninsured, which provides benefits for,
or because of vision care or treatment. This also includes 1) group or group -type coverage through HMOs and
VGRP-CERT.001 (FL)
4 (rev. 11/29/00)
other prepayment, group practice and individual practice plans; 2) group coverage under labor management trusteed
plans, union welfare plans, employer organization plans, employee benefit organization plans or self insured
employee benefit plans; and 3) medical benefits coverage in group, group type, and individual automobile "no-fault"
type contracts or group or group -type automobile "fault" contracts. It does not include school accident type
coverages, coverage under any governmental plan required or provided by law, or any state plan under Medicaid.
Each contract or other arrangement for coverage is a separate Plan. Also, if an arrangement has two parts and
coordination applies only to one of the two, each of the parts is a separate Plan.
"This Plan" means this Policy.
"Primary Plan "Secondary Plan". The Order of Benefit Determination Rules state whether This Plan is a Primary
Plan or Secondary Plan as to another Plan covering the person. When This Plan is a Primary Plan, its benefits are
determined before those of the other Plan and without considering the other Plan's benefits. When This Plan is a
Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other
Plan's benefits. When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one
or more other Plans, and may be a Secondary Plan as to a different Plan or Plans.
"Allowable Expenses" means the allowed amount as shown in the Schedule of Benefits.
"Claim Determination Period" means a benefit year. However it does not include any part of a year during which a
person has no coverage under This Plan, or any part of a year before the date this provision or a similar provision
takes effect.
3. ORDER OF BENEFIT DETERMINATION RULES.
This Plan determines its order of benefits using the first of the following rules which applies:
(a) The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a
dependent) are determined before those of the Plan which covers the person as a dependent; except that if the
person is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and
primary to the Plan covering the person as other than a dependent, then the benefits of the Plan covering the
person as a dependent are determined before those of the Plan covering that person as other than a dependent.
Except in the case of legal separation or divorce (further described below), when This Plan and another Plan
cover the same child as a dependent of different persons, called "parents
(I) the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of
the Plan of the parent whose birthday falls later in that year; but
(2) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are
determined before those of the Plan which covered the other parent for a shorter period of time. However,
if the other Plan does not have the rule described immediately above, and if, as a result, the Plans do not
agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits.
(b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child
are determined in this order: (1) first, the Plan of the parent with custody of the child; (2) then, the Plan of the
spouse of the parent with custody of the child; and (3) finally, the Plan of the parent not having custody of the
child. However, if the specific terms of a court decree state that one of the parents is responsible for the health
care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has
actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply
with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or
provided before the entity has that actual knowledge.
(c) The benefits of a Plan which covers a person as an employee who is neither laid oft retired or continuing
coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan
which covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the
other Plan does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is
ignored.
(d) If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered an
employee, member, or subscriber longer are determined before those of the Plan which covered that person for
the shorter time.
4. EFFECT ON THE BENEFITS OF THIS PLAN.
VGRP- CERT.001 (FL) 5 (rev. 11/29/00)
This section applies when, in accordance with Section 3. Order of Benefit Determination Rules, This Plan is a
Secondary Plan to one or more other Plans. In the event the benefits of This Plan may be reduced under this section.
Such other Plan or Plans are referred to as "the Other Plans
The benefits of This Plan will be reduced when the sum of: (a) the benefits that would be payable for the Allowable
Expenses under This Plan in the absence of this provision; and (b) the benefits that would be payable for the
Allowable Expenses under the other plans, in the absence of provisions with a purpose like that of this provision,
whether or not claim is made; exceeds those Allowable in a Claim Determination Period. In that case, the benefits of
This Plan will be reduced so that they and the benefits payable under the Other Plans do not total more than those
Allowable Expenses. When the benefits of This Plan are reduced as described above, each benefit is reduced in
proportion. It is then charged against any applicable benefit limit of This Plan.
5. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION.
Certain facts are needed to apply these rules. CompBenefits has the right to decide which facts are needed.
CompBenefits may get needed facts from, or give them to, any other organization or person. CompBenefits need not
tell, or get the consent of, any person to do this Each person claiming benefits under This Plan must give
CompBenefits any facts deemed necessary to pay the claim.
6. FACILITY OF PAYMENT.
A payment made under another Plan may include an amount which should have been paid under This Plan. If it
does, CompBenefits may pay that amount to the organization which made that payment. That amount will then be
treated as though it were a benefit paid under This Plan. CompBenefits will not have to pay that amount again. The
term "payment made" includes providing benefits in the form of services, in which case, "payment made" means
reasonable cash value of the benefits provided in the form of services.
7. RIGHT OF RECOVERY.
If the amount of the payments made by CompBenefits are more than should have paid under this provision,
CompBenefits may recover the excess from one or more of: (a) the persons for whom payment has been made; (b)
insurance companies or other organizations providing benefits under another Plan.
SECTION VI- PREMIUMS
Premium Payments All premiums are payable in advance for coverage under the Policy on the first day of each
calendar month in accordance with the premium rate schedules of CompBenefits in effect for each premium due
date.
Grace Periods Unless the Policy is terminated, a grace period of [31] days is allowed for payment of each
premium due after the first premium. If any premium is not paid prior to the end of the grace period, the coverage to
which the premium applies will lapse at the end of the grace period [as of the first of the month for which the
premium is in default.] We will charge a pro -rata premium for the time coverage under the Policy remained in force
for any Group during such grace period.
Change in Premiums Premiums are payable to CompBenefits or Our authorized agent. Premiums may be
increased for a contract period on the anniversary date of the contract. Notice of the maximum amount of a premium
increase will be mailed to the Policyholder not less than [60] days prior to the anniversary of the contract period.
Reinstatement If any renewal premium is not paid within the time granted the Policyholder for a payment, a
subsequent acceptance of premium by CompBenefits or by any agent authorized by CompBenefits to accept such
premium without requiring in connection therewith an application for reinstatement shall reinstate the policy;
provided, that if CompBenefits or such agent requires an application for reinstatement and issues a conditional
receipt for the premium tendered, the policy will be reinstated upon approval of such application by CompBenefits,
or lacking approval, upon the forty-fifth day following the date of such conditional receipt unless CompBenefits has
previously notified the Policyholder in writing of its disapproval of such application. The reinstated policy shall
VGRP- CERT.001 (FL) 6 (rev. 11/29/00)
cover only loss resulting from such accidental injury as maybe sustained after the date of reinstatement and loss due
to such sickness as may begin more than ten (10) days after such date. In all other respects, the Policyholder and
CompBenefits shall have the same rights thereunder as they had under the Policy immediately before the due date of
the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the
reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which
premium has not been previously paid, but not to any period more than sixty (60) days prior to the date of
reinstatement.
Termination This Policy may be terminated if CompBenefits elects to discontinue offering this type of group
insurance coverage by this form of Policy or if CompBenefits elects to discontinue all types of coverage, in
accordance with applicable state and federal laws. Unless otherwise permitted under state law, except for
nonpayment of the required premium or the failure to meet continued underwriting standards, CompBenefits will
not terminate this Policy prior to the first anniversary date of the Effective Date of the Policy as specified herein. A
notice of termination will be mailed to the Policyholder not less than [60] days prior to the effective date of the
termination of the Policy. Termination by CompBenefits will be without prejudice to any expenses originating prior
to the effective date of termination.
This section does not apply to a termination for nonpayment of premium by the Policyholder. In the event that the
Policyholder fails in a timely manner to pay premiums, the Policy will termination on the last date for which
premium was paid.
SECTION VII- CLAIMS
How to Claim Benefits You can get the forms You need for claiming benefits by calling Us at (800) 865 -FORM
(3676) or writing Us at P.O. Box 30349, Tampa, FL 33630 -3349. If the forms are not sent to You before the
expiration of ten working days after the giving of notice, You shall be deemed to have complied with the
requirements of the Policy as to proof of loss upon submitting, within the time fixed in the Policy for filing proof of
loss, written proof covering the occurrence, character, and extent of the loss for which claim is made. When making
a claim for benefits You must give proof of each charge. It is important that You have copies of bills for all charges.
The bills must be itemized to show the service for which each charge is made. You may have benefits paid directly
to the provider. To do so, fill out and sign the claim form telling CompBenefits to pay Your benefits this way.
Notice and Proof of Claim Written notice of claim must be given to Us within one year after the date of such loss
began. Notice given by or on behalf of You or Your beneficiary to Us at P.O. Box 30349, Tampa, FL 33630 -3349,
or to any authorized agent of Us, with information sufficient to identify the Insured, shall be deemed notice to Us.
Failure to give notice within that time shall neither invalidate nor reduce any claim if it shall be shown not to have
been reasonably possible to give the notice and that notice was given as soon as was reasonably possible.
All benefits of the Group Policy will be paid as they accrue. Benefits will be paid upon receipt of written proof on
standard claim forms acceptable to CompBenefits. The proof must describe the event for which the claim is made.
CompBenefits will pay benefits for covered expenses to a managing conservator on behalf of a person who is Your
Dependent if an order issued by a court of competent governmental jurisdiction names such person the managing
conservator of the dependent. To be entitled to receive benefits, a managing conservator of a Dependent must
submit to CompBenefits written notice along with the proof of claim, that such person is the managing conservator.
The written notice will be a certified copy of a court order establishing the person as managing conservator or other
evidence designated by rule of the State Board of Insurance that the person qualifies to be paid the benefits. These
requirements will not apply in the cases of any unpaid medical bill for which a valid assignment of benefits has been
exercised or to claims submitted by You where You have paid any portion of a medical bill that would be covered
under the terms of the Policy. CompBenefits will have the right, at its own expense, to examine the person whose
injury or sickness is the basis of a claim, when and so often as it may reasonably require while a claim is pending.
Time of Payment of Claims All benefits payable under the Policy will be payable immediately upon receipt of
due written proof of such loss. Should We fail to pay the benefits payable under the Policy, upon receipt of due
written proof of loss, We shall have [15] working days thereafter within which to mail You a letter or notice which
states the reasons we may have for failing to pay the claim, either in whole or in part, and which also gives You a
written itemization of any documents or other information needed to process the claim or any portions thereof which
VGRP- CERT.001(FL) 7 (rev. 11/29/00)
are not being paid. When all of the listed documents or other information needed to process the claim have been
received, We shall then have [15] working days within which to process and either pay the claim or deny it, in whole
or in part, giving You the reasons We may have for denying such claim or any portion thereof.
We shall pay interest to the Insured equal to 18 percent per annum on the proceeds or benefits due under the terms
of the Policy for failure to comply with the requirements of the above paragraph.
In the event We fail to pay benefits when due, the person entitled to such benefits may bring action to recover such
benefits, any interest which may accrue as provided above and any other damages as may be allowable by law.
Legal Action No legal action shall be brought to recover on the Policy within 60 days after written proof of loss
has been given as required by the Policy. No such action may be brought after the expiration of the applicable statute
of limitations from the time written proof of loss is required to be given.
SECTION VIII- NOTICE OF CONTINUATION OF GROUP HEALTH
COVERAGE RIGHTS (COBRA) FOR GROUPS SIZE 20 OR MORE
If Your insurance terminates in accordance with the other terms of the Policy, it will be reinstated as of the date of
termination if You elect to continue the insurance in force as described in this section. You may elect to continue
insurance if You are currently insured under the Policy, and if such insurance is terminating due to any of the
following Qualifying Events:
1. Termination of Your employment (for reasons other than gross misconduct);
2. Reduction of work hours including lay -off;
3. Death of the Certficateholder;
4. Divorce or legal separation;
5. A child ceases to be a dependent as defined in the Policy;
6. The Policyholder files for a Chapter 11 bankruptcy petition, and as a result to this You suffer a
loss of coverage under Your retiree coverage.
The maximum continuation of coverage period with respect to a reason described above is: (1) 18 months with
respect to 1 or 2 above. However, if You are disabled as determined under Title II or XVI of the Social Security Act,
then You and any other non disabled eligible individuals will be eligible for an additional 11 months; (2) 36 months
with respect to 3, 4 or 5 above; (3) With respect to 6 above, lifetime coverage for You, whereas Your Dependents
will be covered until the earlier of: (a) Your death; or (b) death of the Dependent If, while insurance is being
continued, further events occur which would entitle You to again elect continuation, the total period of continuation
may not exceed 36 months from the date the initial continuation commenced, other than the coverage due to
bankruptcy filing as described above.
It is Your responsibility to notify the Policyholder of the occurrence of a Qualifying Event other than termination of
employment or reduction in work hours. You must notify the Policyholder within 60 days.
It is the responsibility of the Policyholder to provide You with written notice of Your right to continue coverage
under this Section. Such notice will also contain the amount of monthly premium You must pay to continue
coverage and the time and manner in which such payments must be made.
To continue coverage under the Policy You must notify the Policyholder of Your election within 60 days of the
latest of: (1) the date of Qualifying Event; (2) the date of the loss of coverage; or (3) The date the Policyholder
sends notice of the right to continue coverage.
Payment for the cost of insurance for the period preceding the election must be made to the Policyholder within 45
days after the date of such election. Subsequent payments are to be made to the Policyholder in the manner
described by the Policyholder in the notice. The Policyholder will remit the payments to CompBenefits.
Continuation of insurance will terminate at the earliest of the following dates: (1) The end of the maximum
continuation of coverage period; (2) The last day of the period of coverage for which premiums have been paid, if
VGRP-CERT.001 (FL) 8 (rev. 11129/00)
You fail to make a premium payment when due; (3) Your becoming covered under another group vision care plan as
employee, spouse or dependent child; however, coverage will continue for a pre existing condition for which
treatment has already commenced and which is excluded or limited by the other group vision plan; (4)
Discontinuance of this Vision Care Benefit Provision; or (5) The date Your employer ceases to provide any group
vision plan.
SECTION IX- GENERAL PROVISIONS
Representations and Warranties In the absence of fraud, all statements made by any Insured are deemed
representations and not warranties. No statement made for the purpose of effecting insurance shall avoid the
insurance or reduce benefits unless contained in a written instrument signed by the Policyholder or You, and a copy
of which instrument has been furnished to the Policyholder or You or Your beneficiary.
Worker's Compensation Act The coverage under the Policy is not in lieu of and does not affect any requirement
for coverage by any Worker's Compensation Act, or other similar legislation.
Conformity with. State Statutes Any provision of the Policy which, on its effective date, is in conflict with the
statutes of the state in which the Insured resides on such date is hereby amended to conform to the minimum
requirements of such statutes.
Time Limit on Certain Defenses After the Policy has been in force for a period of two (2) years during the
lifetime of the Insured, excluding any period during which the Insured is disabled, it shall become incontestable as
to the statements contained in the application.
VGRP- CERT.001 (FL)
SECTION X- SCHEDULE OF BENEFITS
VISION BENEFITS
The following services and Materials are covered under the Plan subject to the conditions and limitations stated
herein and up to the allowance shown below after deduction of the applicable Co-payment.
Vision Examinations A complete analysis of the eyes and related structures to determine vision problems and
other abnormalities which shall include: 1) personal and family history; 2) visual acuity (unaided or acuity with
present correction); 3) external exam; 4) pupillary exam; 5) visual field testing (confrontation); 6) internal exam
(direct or indirect ophthalmoscopy recording cup disc ratio, blood vessel status and any abnormalities: 7)
biomicroscopy (binocular or monocular); 8) tonometry; 9) refraction (with recorded visual acuity); 10) extra ocular
muscle balance assessment; 11) diagnosis and treatment plan. We will cover such service once in any 12 month
period.
Materials Where the vision examination shows new lenses or frames or both are necessary for proper visual
health, such Materials will be covered, together with certain services as necessary. Services include, but are not
limited to: (1) prescribing and ordering proper lenses; (2) assisting with selection of frames; (3) verifying accuracy
of finished lenses; (4)proper fitting and adjustments.
Lenses One pair of new prescription lenses, if required by a change in prescription, once in any 12 month period.
Frames One new frame once in any 24 month period.
Contact lenses when necessary One pair of contact lenses under the following circumstances and only if prior
authorization from the Plan is obtained: 1) following cataract surgery without intraocular lens; 2) correction of
extreme visual acuity problems not correctable with glasses; 3)) Anisometropia greater than 5.00 diopters and
aesthenopia or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia and/or binocular aphakia where
the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life.
Replacement will not be more often than once in any 12 month period and only if prior authorization is obtained
from the Plan. The Copayment is waived
9 (rev. 11/29/00)
Contact lenses when elective The combined cost of an annual vision exam and contact lenses up to a maximum
of $100.00. Payment will be IN LIEU OF ALL OTHER BENEFITS. Replacement will not be more often than
once in any 12 month period. The Copayment is waived
Co-Payment An Insured's Co- payment is:
1. Vision Examination $10
2. Materials $15
Allowance:
Vision Examination $35
Single Vision Lens $20
Bifocal Lens $40
Trifocal Lens $60
Lenticular Lens $100
Contact Lenses when elective $100
Contact Lenses when necessary $150
Frame $30
VGRP-CERT.001 (FL)
10 (rev.1129/00)