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HomeMy WebLinkAboutStop Loss Insurance/HM 2007 ~! ,~I 1~1 1~1 .""'! l~l I~ Jl ;; I~r [.I 1"11 ;~j !~1 Ir~i 1,1''11 $:.), j(tl 1~1 i~1 !N, i~i h~! l~' f~1 1,~~g.I, I ! , I 1'1 \ I ,\ 1'.1 I I i I I HM LIFE INSURANCE COMPANY FIFTH AVENUE PLACE, 120 FIFTH AVENUE, PITTSBURGH, PA 15222-3099 1-800-328-5433 I j' I i~h I i \ I l~l li,i, I i~1 lei l~l ~l !~I !~l ~I i~l ~I ;>.,"..;,J II \~ !~ 11\ I~ I I I I I \ I POLICY NUMBER 401850-A NAME OF POLICYHOLDER City of Oshkosh TYPE OF COVERAGE STOP LOSSINSlJR.ANCE EFFECTIVE DATE January 1,2007 POLICY TERM January 1,2007 through December 31, 2007 POLICY DELIVERED IN Wisconsin and governed by the laws of that state. HM Life Insurance Company agrees to pay the benefits provided by this Policy, in accordance with the provisions of this Policy. The consideration for this Policy is the application of the Policyholder and the payment by the Policyholder of premiums as provided herein. This Policy provides benefits to the Policyholder when Eligible Claims Expenses, which are actually Paid by the Policyholder through the Covered Underlying Plan(s), exceed the levels defined in this Policy. The benefits of this Policy are explained in the Declaration Page, General Definitions, and Benefits provisions of this Policy and are subject to Disclosure, and/or receipt of Claim Information, the Exclusions and Limitations and other provisions of this Policy. This Policy will terminate automatically upon the failure of the Policyholder to pay any premium within the Grace Period. Termination of this Policy for any reason other than nonpayment of premium will occur following written notice by the Policyholder or us. All provisions on this and the following pages are a part of this Policy. The definitions of terms apply whenever the terms are used anywhere in this Policy. "We", "us", and "our" refer to HM Life Insurance Company. Other defined terms are printed with an initial capital letter. HM Life Insurance Company By :f/:;4/f~ ~~.~ Secretary President This is a Non-Participating Plan of Coverage HL601-SL (905) ~, r-\ r'\ WISCONSIN NOTICE KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem. Address and Telephone Number of HM Life Insurance Company: HM Life Insurance Company 120 Fifth Avenue, Fifth Avenue Place, Pittsburgh, PA 15222-3099 1-800-328-5433 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by writing to: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 or you can call 1-800-236-8517 outside of Madison or 266-0103 in Madison, and request a complaint form. I~ '0 i~ l~,i )~ I~ 'I i~~II", ~ ~' I, I I. I I(ll l~t i~1 .tll !~ll INI II I~i i~) Iii h J ~j I,;: I~I HM LIFE INSURANCE COMPANY FIFTH AVENUE PLACE, 120 FIFTH AVENUE, PITTSBURGH, PA 15222-3099 1-800-328-5433 DECLARATION PAGE A. POLICY INFORMATION 1. Policy Number 2. Policyholder 3. Affiliates 4. Employer 5. Policy Term 6. Type Of Coverage 7. Covered Underlying Plan Names Name 8. Designated TPA B. SPECIFIC BENEFIT SCHEDULE 401850-A I~ I I i' . I 1~1 I," 1!1 l~ I~ ,~ Ie I'" I City of Oshkosh Winnefox Library System City of Oshkosh January 1,2007 through December 31, 2007 Stop Loss Insurance City of Oshkosh PPO 1 City of Oshkosh PPO 2 Prairie States Enterprises Inc 1. Covered Claims Basis For all Eligible Claims Expenses except those to which a Special Risk Limitation applies: Incurred & Paid: Eligible Claims Expenses Incurred from 01/01/07 through 12/31/07 and actually Paid from 01/01/07 through 03/31/08. 2. Specific Eligible Claims Expenses include: Health Care 181 Dental 0 Vision 0 Prescription Drug Card 181 Short Term Disability 0 Other 0 HL601-SL/DP (905) 12/01/2006 1 , , \' ! I I 401850-A Declaration Page Stop Loss 0: 3. Number of Covered Units Single + 1: 198 Single: 184 Family: 271 Composite: 653 4. Specific Deductible per Participant $75,000 per Participant 5. Specific Payable Percentage (in excess of Specific Deductible) 100% 6. Annual Aggregating Specific Loss Fund DYes 181 No 7. Maximum Specific Benefit (per Participant in excess of the Specific Deductible) Per Lifetime $925,000 8. Specific Terminal Liability Benefit Included DYes 181 No C. AGGREGATE BENEFIT SCHEDULE For all Eligible Claims Expenses except those to which a Special Risk Limitation applies: 1. Covered Claims Basis n Incurred & Paid: Eligible Claims Expenses Incurred from 01/01/07 through 12/31/07 and actually Paid from 01/01/07 through 03/31/08. 2. Aggregate Eligible Claims Expenses include: Health Care 181 Dental 0 ~~on 0 Prescription Drug Card 181 Short Term Disability 0 Other 0 3. Number of Covered Units Single + 1: 198 Single: 184 Family: 271 Composite: 653 4. Aggregate Payable Percentage (excess of Deductible) 100% 5. Aggregate Attachment Point (Corridor) 125% r\ HL601-SL/DP (905) 12/01/2006 2 401850-A Declaration Page Stop Loss o 6. Minimum Aggregate Deductible $9,766,822 Aggregate Annual Deductible is equal to A, B or C, whichever is greater, where: A = The Aggregate Monthly Deductible Amount for the initial Policy Month multiplied by the number of months applicable to the Paid period for the current Policy Term B = The sum of the Aggregate Monthly Deductible Amount for each Policy Month applicable to the Paid period for the current Policy Term C = The Minimum Aggregate Deductible Note: The Aggregate Annual Deductible cannot be finally determined until the end of the Policy Term. 7. Aggregate Monthly Deductible Amount per Covered Unit~ qit, $1,139.52 per Single + 1 Covered Unit per Policy Month $633.07 per Single Covered Unit per Policy Month $1,740.93 per Family Covered Unit per Policy Month 8. Maximum Aggregate Eligible Claims Expense per Participant $75,000 9. Maximum Aggregate Benefit Per Policy Term $1,000,000 r'\ 10. Mon.thlyA.ggl"egateAcc()Illm6c1ation Benefit Included DYes 181 No 11. Aggregate Terminal Liability Benefit Included DYes 181 No D. PREMIUM Specific Premium per Month dJ"~ Single +: Single Employee: Family: $70.12 $41.77 $102.00 91-") 12 Months ~ ' Initial Specific Rate Guarantee Period: Aggregate Premium per Month Per Covered Unit: $3.16 E. SPECIAL RISK LIMITATIONS: Specific Disabled / Hospital Confined, actively at work, activity of daily living, out of hospital, or similar requirements ~ with Disclosure 181 Yes 0 No ~~ Retirees Included 181 Yes 0 No (\ Other: None HL601-SLjDP (905) 12/01/2006 3 401850-A Declaration Page Stop Loss II (\ r~ Aggregate Disabled / Hospital Confined, actively at work, activity of daily living, out of hospital, or similar requirements waived with Disclosure Retirees Included Other: HM Life Insurance Company By --) ;:Ii:( 4/f#--- Secretary HL601-SLlDP (905) 12/01/2006 4 181 Yes 0 No 181 Yes 0 No None 'D~~.~ President 401850-A Declaration Page Stop Loss n TABLE OF CONTENTS PART 1. BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 PART 2. EXCLUSIONS AND LIMITATIONS .................................................. 2 PART 3. DESIGNATED TPA ................................................................ 4 PART 4. CLAIM PROVISIONS .............................................................. 5 PART 5. AMENDMENTS TO THE COVERED UNDERLYING PLAN(S) .......................... 5 PART 6. TERMINATION................................................................... 6 PART 7. PREMIUMS....................................................................... 6 PART 8. GENERAL POLICY PROVISIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 PART 9. RECORDS AND REPORTS ......................................................... 9 PART 10. LIABILITY AND INDEMNIFICATION .............................................. 10 PART 11. ENTIRE CONTRACT, CHANGES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10 p\ PART 12. INCONTESTABLE CLAUSE ....................................................... 10 PART 13. LEGAL ACTIONS ................................................................ 10 PART 14. INSOLVENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11 PART 15. ASSIGNMENT ................................................................... 11 PART 16. GENERAL DEFINITIONS ......................................................... 11 r, f'\ Part 1. BENEFITS Unless otherwise indicated in the Covered Claims Basis section(s) in the Specific Benefit Schedule or the Aggregate Benefit Schedule, benefits under this Policy will only be paid by us based on Eligible Claims Expenses through the Covered Underlying Plan(s) which are Incurred after the Effective Date of this Policy and which are actually Paid by the Policyholder during the Policy Term. The Specific Benefit Schedule, Aggregate Benefit Schedule, and Policy Term are shown on the Declaration Page attached to this Policy. Eligible Claims Expenses shall be overdue if not paid to the Policyholder within 30 days after the proof of loss has been received, the overdue payments shall include simple interest at a rate of 12% per year. A. SPECIFIC BENEFIT We will pay to the Policyholder, subject to the terms and conditions of this Policy, the following Specific Benefits, as shown in the Specific Benefit Schedule, in accordance with the terms of settlement mutually agreed upon by the Policyholder and us. The Specific Benefit payable for the Policy Term with respect to a Participant will be equal to the amount of Eligible Claims Expenses which are actually Paid by the Policyholder for that Participant during that Policy Term, minus A + B, where: A = The Specific Deductible for the Participant. B= Any amounts recovered by the Policyholder for Eligible Claims Expenses which were actually Paid by the Policyholder during the Policy Term for Eligible Claims Expenses which were Incurred by that Participant, or any such amounts which the Policyholder is later able to recover through any recovery provision of the Covered Underlying Plan(s). o We will pay Specific Benefits as they become due following satisfaction of the Specific Deductible, subject to the terms and conditions of this Policy. Specific Benefit does not include any amount actually Paid by the Policyholder for the Policy Term for Excluded Claims Expenses. In no event will the Specific Benefit paid by us with respect to Eligible Claims Expenses which are Incurred by anyone Participant during the lifetime of that Participant exceed the Maximum Specific Benefit shown in the Specific Benefit Schedule. B. AGGREGATE BENEFIT We will pay to the Policyholder, subject to the terms and conditions of this Policy, the following Aggregate Benefit, as shown in the Aggregate Benefit Schedule, in accordance with the terms of settlement mutually agreed upon by the Policyholder and us. The Aggregate Benefit will be equal to the amount of the Eligible Claims Expenses which are actually Paid by the Policyholder during the Policy Term shown in the Aggregate Benefit Schedule as the Covered Claims Basis for Aggregate Benefits, minus A + B + C, where: A = The Aggregate Annual Deductible for the Policy Term. B = The amount in excess of the Aggregate Eligible Claims Expense per Participant. C= Any amounts recovered by the Policyholder for Eligible Claims Expenses that were actually Paid by the Policyholder during the Policy Term, or any amounts which the Policyholder is later able to recover through any recovery provision of the Covered Underlying Plan(s). r\ , . HL601-SL (905) 12/01/2006 1 401850-A Specific & Aggregate Stop Loss r, We will pay the Aggregate Benefit at the end of each Policy Term, subject to the terms and conditions of this Policy. The Covered Claims Basis for the Aggregate Benefit during the Policy Term does not include any amount actually Paid by the Policyholder for Excluded Claims Expenses. In no event will the Aggregate Benefit paid by us for the Policy Term exceed the Maximum Aggregate Benefit per Policy Term shown in the Aggregate Benefit Schedule. Part 2. EXCLUSIONS AND LIMITATIONS No Deductible of this Policy will be satisfied and no benefit of this Policy will be paid for: 1. UNDERLYING PLAN NOT IN EFFECT: Any amount actually Paid by the Policyholder for an expense that is Incurred and/or actually Paid when the Covered Underlying Plan(s) is not in effect. 2. NOT A PARTICIPANT: Any amount actually Paid by the Policyholder for an expense that is Incurred by a person who is not a Participant when the expense is Incurred. 3. NOT COVERED UNDER COVERED UNDERLYING PLAN: Any amount actually Paid by the Policyholder for an expense that is not specifically covered under the terms of the Covered Underlying Plan(s). 4. NOT A COVERED UNDERLYING PLAN: Any amount actually Paid by the Policyholder for an expense that is covered under any employee benefit plan of the Policyholder which is not identified as a Covered Underlying Plan on the Declaration Page. (""""\, 5. TERMS OF THE COVERED UNDERLYING PLAN: Any amount the Policyholder is not required to pay in accordance with the terms of the Covered Underlying Plan(s). 6. WAR: Any amount actually Paid by the Policyholder for Eligible Claims Expenses which arise out of or are caused or contributed to by war or an act of war. WAR means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature. 7. WORK RELATED: Any amount actually Paid by the Policyholder through the Covered Underlying Plan(s) for any injury or illness which is eligible for coverage under a workers' compensation or occupational disease policy or agreement, whether or not such policy or agreement is actually in force and whether or not such benefits are received by the Participant. 8. FELONY: Any amount actually Paid by the Policy for Eligible Claims Expenses for any period caused or contributed to by a Participant committing or attempting to commit a felony. 9. FOREIGN MEDICAL CARE: Any amount incurred by a Participant for the cost of drugs, procedures, services, supplies or treatments rendered or received in person, by mail or otherwise outside the United States if the purpose of such travel or communication is to obtain or receive such drug, procedure, service, supply or treatment. 10. PRIOR EXPENSE: An expense Incurred by a Participant: (1) prior to the initial Incurred and Paid Period shown on the Declaration Page attached to this Policy, or (2) if after the Effective Date of this Policy, the Policyholder acquires another Affiliate or establishes another class of employees, eligible for coverage through the Covered Underlying Plan(s). o HL601-SL (905) 12/01/2006 2 401850-A Specific & Aggregate Stop Loss r\ o o 11. NONDISCLOSURE: Any amount which is actually Paid by the Policyholder for an expense which is Incurred by a Participant who: a. Was a Participant at the time of the initial underwriting of this Policy, but whose Known medical conditions were not accurately Disclosed to us at that time by the Applicant, Policyholder or Designated TPA. b. Was a Participant at the end of the Policy Term, but whose Known medical conditions were not accurately Disclosed to us by the Applicant, Policyholder or Designated TPA at the time this Policy is renewed. c. Becomes a Participant after the Effective Date of this Policy, but whose Known medical conditions were not accurately Disclosed to us by the Applicant, Policyholder or Designated TPA before the date the Policyholder acquires another Affiliate, or establishes another class of employees eligible for coverage through the Covered Underlying Plan(s). 12. USUAL AND CUSTOMARY CHARGE: Any amount which is actually Paid by the Policyholder in excess of the usual and customary charge for the Covered Service, as defined and/or applied by the Covered Underlying Plan(s). 13. EXPERIMENTAL OR INVESTIGATIONAL: Any amount which is actually Paid by the Policyholder for the cost of drugs, procedures, services, supplies or treatments which are considered experimental or investigational. But only to the extent such drug, procedure, service, supply or treatment is considered a Covered Service for which a benefit is payable under the terms of the Covered Underlying Plan(s). 14. NOT MEDICALLY NECESSARY: Al).y amount which is actually Paid by the Policyholder for the cost of procedures, drugs, treatments, services, or supplies which are not medically necessary and appropriate, as determined by the Food and Drug Administration, the American Medical Association, their successor organization(s), or other generally accepted medical compendia. 15. OTHER COVERAGE: The amount of any expenses for benefits to any Participant with coverage under any other plan, which, when combined with the benefits payable by such other plan, would cause the total paid by that plan and the Covered Underlying Planes) to exceed 100% of the Participant's actual expenses. 16. ADMINISTRATIVE COSTS: Any amount which is actually Paid by the Policyholder for administrative costs, including but not limited to, administrative costs for claim payments, networks, case management fees in excess of the usual and customary charge, PPO access fees and Prescription Drug administration fees. 17. ALLOWABLE AMOUNT: Any out-of-pocket expense(s) Paid by a Participant, or any amount Incurred by a Participant for the cost of drugs, procedures, services, supplies or treatment in excess of any reimbursement negotiated with, scheduled to be actually Paid or due a provider or facility by the Covered Underlying Plan(s); or the usual and customary charge for the Covered Service as defined and/or applied by the Covered Underlying Plan(s), whichever is less. 18. EXCESS REIMBURSEMENT: Any amount in excess of the fee, reimbursement percentage or other form of payment negotiated with a provider or facility by the Applicant, Policyholder or Designated TPA as total reimbursement to the provider or facility for the cost of drugs, procedures, services and supplies through the Covered Underlying Plan(s). 19. CAPITATION FEES: Any amount which is actually Paid by the Policyholder for capitation fees. HL601-SL (905) 12/01/2006 3 401850-A Specific & Aggregate Stop Loss 0. 20. LITIGATION EXPENSES: Any amount which is actually Paid by the Policyholder for the expense of litigation. 21. DAMAGES: Any amount which is actually Paid by the Policyholder for extra-contractual damages, compensatory damages, or punitive damages. 22. EXCLUDED CLAIMS EXPENSES: Any amount which is actually Paid by the Policyholder for an Excluded Claims Expense. 23. LOST PROVIDER DISCOUNTS: Provider discounts of any kind lost due to untimely payment of claims by the Policyholder or the Policyholder's authorized representative. 24. UNFUNDED CLAIMS: Any amount actually Paid by the Policyholder for an Unfunded Claim. Part 3. DESIGNATED TPA A. RESPONSIBILITIES OF THE POLICYHOLDER'S DESIGNATED TPA Without waiving any of its rights under this Policy, and without making the Designated TPA a party to this Policy, we agree to recognize the Designated TPA as respects the normal administration of the Policyholder's Covered Underlying Plan(s), subject to each of the following conditions: 1. The Designated TPA must be responsible on behalf of the Policyholder for auditing, calculating and processing all Eligible Claims Expenses through the Covered Underlying Plan(s) within a reasonable period of time, preparing periodic reports as required by us, and maintaining and making available to us at all times such information as we may reasonably require for proof of payment of Eligible Claims Expenses by the Policyholder. T\. 2. The Designated TPA will secure and keep renewed, at their expense, all licenses, permits, authorizations or certificates of authority in the states where the Third Party Administrator conducts the business of insurance in accordance with statutory requirements. 3. The Designated TPA must perform such other duties as may be reasonably required by us including but not limited to, maintaining an accurate record of the Participants covered through the Covered Underlying Plan(s). 4. The Designated TPA must make Preferred Provider Organization (PPO) network(s), managed care vendors, centers of excellence and other applicable discount networks appropriate for the provision of medical care available to the Policyholder. If the Designated TPA does not have a PPO or discount networks, arrangements or vendors available, the Designated TPA must either utilize an outside vendor of their choice to negotiate discounts all non-network or out of network billings, or use a vendor with whom we have an existing business relationship. 5. We will not be responsible for any compensation due the Designated TPA for functions performed by the Designated TPA for the Policyholder in relation to this Policy. 6. This Policy will not be deemed to make us a party to any agreement between the Policyholder and the Designated TPA. B. NOTICE TO POLICYHOLDER AND DESIGNATED TPA r\ For the purpose of any notice required from us under the proVISIOns of this Policy, notice to the Policyholder's Designated TPA will be considered notice to the Policyholder and notice to the Policyholder will be considered notice to the Policyholder's Designated TPA. HL601-SL (905) 12/01/2006 4 401850-A Specific & Aggregate Stop Loss .,-....., f '. Part 4. CLAIM PROVISIONS A. NOTICE OF CLAIM Satisfactory notice of claim must be given to us within 20 days after the occurrence or commencement of any loss covered by this Policy or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Policyholder or the Policyholder's authorized representative, to us or to any of our authorized agents, with information sufficient to identify the Policyholder and Participant will be deemed notice to us. The Policyholder or the Policyholder's authorized representative must provide written notification to us within 20 days of the earlier of the following dates: 1. The date the Policyholder is first notified that a Participant has Incurred Eligible Claims Expenses through the Covered Underlying Plan(s) for a Catastrophic Claim, Large Claim or Shock Loss. 2. The date the Policyholder is first notified that a Participant has Incurred Eligible Claims Expenses through the Covered Underlying Plan(s) that exceed 50% of the Specific Deductible. Failure to give notice within such time will not invalidate or reduce any claim if it is shown not to have been reasonably possible to give such notice in time and that notice was given as soon as was reasonably possible. The notice to us must include: 1. The identity of or unique identifier associated with the Participant. 2. A description of the illness or accident and the prognosis. F'>. 3. A listing of the Eligible Claims Expenses Incurred by or known to the Policyholder to date through the Covered Underlying Plan(s). B. TIME LIMITS FOR FILING A CLAIM The Policyholder must provide satisfactory proof of loss to support a claim within 90 days after the commencement of the period for which we are liable or as soon thereafter as reasonably possible and, in any case, within one year after the end of that 90 day period. Claims not filed within these time limits will be denied and no benefits will be paid by us. These limits will not apply during any period when the Policyholder lacked the legal capacity to file a claim. Upon presentation of satisfactory proof of loss the Policyholder represents that all monies necessary to pay for services and supplies have been paid to the Participant or respective providers of medical services or supplies to which the claim for reimbursement under the Policy relates. Part 5. AMENDMENTS TO THE COVERED UNDERLYING PLAN(S) We reserve the right to approve any substantive change to the Covered Underlying Plan(s). The Policyholder or its authorized representative must furnish us with a copy of each change to the Covered Underlying Plan(s) prior to the effective date of the change. If we do not give our prior written approval of a change to the Covered Underlying Plan(s), then we will have the right to exercise one of the following options by giving written notice to the Policyholder: 1. If we accept the change, we will consider such change approved on the later of the: (1) date of the change; or (2) first day of the month following the date we were notified of the change. Payment of any benefits under this Policy based on the changes to the Covered Underlying Plan(s), is contingent on the Policyholder's written acceptance of any necessary adjustment to the premium. F\ . HL601-SL (905) 12/01/2006 5 401850-A Specific & Aggregate Stop Loss r\ 2. We may decline to approve the change and pay benefits under this Policy as if the Covered Underlying Plan(s) had not been changed. Other options may be mutually agreed upon by the Policyholder and us. Part 6. TERMINATION This Policy and all coverage under this Policy will terminate at 12:01 a.m. Eastern Standard Time on the earliest of the following dates: 1. At the end of the 31 day Grace Period from last period for which premiums were paid. 2. The Premium Due Date next following receipt by us of written notice from the Policyholder that this Policy is to be terminated. 3. The end of any Policy Term following 60 days prior written notice to the Policyholder of termination. 4. The Premium Due Date following 60 days prior written notice to the Policyholder that we are planning to terminate this Policy because: a. there are fewer than 50 Covered Units through the Covered Underlying Plan(s); b. we have refused to accept a change to the Covered Underlying Plan(s); or c. the Policyholder has refused to accept any necessary adjustment to the premium due to a change in the Covered Underlying Plan(s). r\ 5. The date of termination of the Covered Underlying Plan(s), after a 10 day notice has been given to the Policyholder. Notice by the Policyholder to terminate the Covered Underlying Plan will not reduce or deny any Eligible Claim Expense if incurred during the Covered Claims Basis as defined in the schedule of benefits. If this Policy terminates prior to the end of the Policy Term, the Covered Claims Basis of this Policy will be limited to Eligible Claims Expenses Incurred and actually Paid prior to 12:01 a.m. Eastern Standard Time on the day after the date this Policy terminates. Part 7. PREMIUMS A. AMOUNT OF PREMIUMS Premium is calculated based upon the number of Covered Units covered by the Covered Underlying Plan(s) in any given Policy Month. The estimated number of Covered Units for the first Policy Month is shown in the Schedule on the Declaration Page attached to this Policy, based on the estimated initial enrollment. ~, , The number of Covered Units for each Policy Month will be determined in accordance with the definition of a Participant. If the Specific and/or Aggregate Benefit Schedule shows that the "Single EmployeelFamily" method is used, then the total number of "Single Employees" and the total number of "Families" is each multiplied by the appropriate rate for each classification. If the Specific and/or Aggregate Benefit Schedule shows that the "Composite" method is used, then the "Composite" total is multiplied by the appropriate rate. The rates for this Policy are set by us. The Specific Benefit Schedule, if any, and the Aggregate Benefit Schedule, if any, is shown on the Declaration Page attached to this Policy. HL601-SL (905) 12/01/2006 6 401850-A Specific & Aggregate Stop Loss '~ ! J B. CHANGES IN PREMIUM RATES We reserve the right to change any rate or percentage used in determining the monthly premium. The change may occur on one of the following dates: 1. On any Premium Due Date, if the number of Covered Units covered by the Covered Underlying Plan(s) fluctuates by more than 10% from the number on the Effective Date of this Policy or the number on the date of the last Policy Anniversary, whichever is the later date. 2. Retroactively to the beginning of the Policy Term, if we determine that claim payments are not being made in accordance with the terms and conditions of the Covered Underlying Plan(s). 3. On the later of: (1) the effective date of any change in the Covered Underlying Plan(s) approved by us; or (2) first day of the month following the date we were notified of such change. 4. Retroactively to the effective date of a signed administrative agreement between the Policyholder and a new Designated TPA provided we have consented to the Policyholder's selection in writing. 5. On any Policy Anniversary. 6. At the end of any Policy Term. We will give the Policyholder 60 days prior written notice of any change in any rate or percentage used in determining the monthly premium. ~, C. PAYMENT OF PREMIUMS All premiums are due on the applicable Premium Due Date. Each premium is payable by the Policyholder on or before the Premium Due Date direct to us at our Home Office. The payment of each premium as it becomes due will maintain this Policy in force through the date immediately preceding the next Premium Due Date. D. GRACE PERIOD A Grace Period of 31 days will be allowed for the payment of each premium after the first premium. Should a premium which is otherwise due not be paid during the Grace Period, a written notice of cancellation will be provided to the Policyholder. Ten (10) days after written notice of cancellation is received, this Policy will automatically terminate as of the end of the last period for which premiums were paid at 12:01 AM Eastern Standard Time, without further notice to the Policyholder. Our liability will be limited to Eligible Claims Expenses that are actually Paid by the Policyholder during the Grace Period. Part 8. GENERAL POLICY PROVISIONS A. HOLD HARMLESS 1. The Policyholder agrees to hold us harmless from any legal expenses incurred or judgement(s) awarded arising out of any dispute involving a current or former Participant in the Policyholder's Covered Underlying Plan(s), provided such legal expenses or judgments were not incurred as a result of our sole negligence or intentional wrongful acts. r\ .. ) HL601-SL (905) 12/01/2006 7 40 1850-A Specific & Aggregate Stop Loss f", 2. If we are notified that we have been named, or are likely to be named, as a defendant in any action involving a current or former Participant in the Policyholder's Covered Underlying Plan(s), we will give the Policyholder written notice of the dispute within a reasonable time. We will make all probative material available to the Policyholder upon written request from the Policyholder. We will cooperate with the Policyholder in matters pertaining to the dispute. However, such cooperation with the Policyholder will not waive our right to solely defend or settle any such action in any manner we deem prudent. 3. The Policyholder agrees to hold us harmless from any state premium taxes incurred with respect to funds paid to or by the Policyholder through the Covered Underlying Plan(s). Taxes incurred with respect to premiums paid for this Policy will be our responsibility. B. NOTICE OF OBJECTION Any objection, notice of legal action, or complaint received on a claim processed by the Policyholder or the Designated TPA, and on which it reasonably appears a benefit will be payable to the Policyholder under this Policy, must be brought to the immediate attention of our claims department. C. POLICY NONPARTICIPATING This Policy is nonparticipating and does not share in our surplus earnings. D. OFFSET n We have the right to offset any benefits payable to the Policyholder under this Policy against premiums due and unpaid by the Policyholder, but this right will not prevent the termination of this Policy for the nonpayment of premium pursuant to the terms of Part 7. E. RECOVERY The Policyholder must prosecute any and all valid claims that the Policyholder may have against third parties arising out of any occurrence resulting in a payment for Eligible Claims Expenses by the Policyholder and must account to us for any amounts recovered. At that time we may, at our option, bring legal action to recover from the third party the amount of any benefits we paid to the Policy holder in connection with the payment of Eligible Claims Expenses caused by the third party's negligence or wrongdoing. The Policyholder will be required to provide us with any legal instruments, documents, or papers we may need to exercise our right to recover and the Policyholder is prohibited from doing anything to prejudice our right to recover payments from the third party. F. REIMBURSEMENT In the event that the Policyholder recovers from a third party with respect to any Eligible Claims Expenses for which benefits were paid under this Policy, the Policyholder must repay us. The full amount of any and all such funds recovered must be returned to us first before any Deductible under this Policy will be satisfied. No part of any Eligible Claims Expenses which is actually Paid by the Policyholder and for which the Policyholder has been reimbursed by a third party may be used to meet any Deductible under this Policy. This provision will survive the termination of this Policy. G. ARBITRATION r\ In the event of a dispute between the parties to this Policy as to whether coverage is provided under this Policy of Insurance for a claim made by or against the Policyholder, both parties may, by mutual consent, agree in writing to arbitration of the disagreement. HL601-SL (905) 12/01/2006 8 401850-A Specific & Aggregate Stop Loss 0, If both parties agree to arbitrate, each party will select an arbitrator. The two arbitrators will select a third arbitrator. If they cannot agree within 30 days upon a third arbitrator, both parties must request that selection of a third arbitrator be made by a judge of a court having jurisdiction. Unless both parties agree otherwise, arbitration will take place in the county or parish in which the address shown on the Declaration Page, attached to this Policy, is located. Local rules of law as to procedure and evidence will apply. A decision agreed to by any two will be binding. Each party will: 1. Pay the expenses it incurs; and 2. Bear the expenses of the third arbitrator equally. Part 9. RECORDS AND REPORTS A. REPORTING The Policyholder or the Policyholder authorized representative must submit on a timely basis all proofs, reports, and supporting documents requested by us, including, but not limited to, a monthly summary of all Eligible Claims Expenses which were processed by the Policyholder or the Designated TPA. o Clerical error, whether by the Policyholder or by us, in keeping any records pertaining to the coverage, will not invalidate coverage otherwise validly in force nor. continue coverage otherwise validly terminated. B. AUDITS We have the right to inspect and audit all records and procedures of the Policyholder and the Designated TPA. We have the right to require, upon request, proof satisfactory to us that payment has been made to the Participant or the provider of the Covered Services that are the basis for any claim by the Policyholder under this Policy. C. UNDERWRITING INFORMATION We have relied upon the underwriting information and Claim Information provided and Disclosed by the Applicant, Policyholder or the Policyholder's Designated TPA: 1. To issue this Policy; 2. To renew this Policy; and 3. After the Effective Date of this Policy to accept: a. Employees of another Affiliate as Participants; or b. Members of another employee class as, Participants. Should subsequent information become Known which, if Known prior to: 1. Issuance of this Policy, would affect the rates, Deductibles, or the terms and conditions of this Policy, we will have the right to revise the rates, Deductibles, and the terms and conditions of this Policy retroactive to the effective date of this Policy, by providing written notice to the Policyholder. (": HL601-SL (905) 12/01/2006 9 401850-A Specific & Aggregate Stop Loss n 2. Renewal of this Policy, would affect the rates, Deductibles, or the terms and conditions of this Policy, we will have the right to revise the rates, Deductibles, and the terms and conditions of this Policy retroactive to renewal date for the current Plan Year, by providing written notice to the Policyholder. 3. After the Effective Date of this Policy should subsequent information become Known which, if Known, prior to the date we accept: (1) any employee, or dependent of such employee, of another Affiliate as a Participant; or (2) any member of another employee class as a Participant would affect the rates, Deductibles, or other terms and conditions of this Policy we will have the right to revise the rates, Deductibles, and the terms and conditions of this Policy retroactive to the date of our acceptance, by providing written notice to the Policyholder. Part 10. LIABILITY AND INDEMNIFICATION A. LIABILITY We will have neither the right nor the obligation under this Policy to directly pay any Participant or provider of Covered Services for any benefit that the Policyholder has agreed to provide through the terms of the Covered Underlying Plan(s). Our sole liability under this Policy is to the Policyholder. B. INDEMNIFICATION o If we suffer any liability, loss or expense due to a misstatement or failure to Disclose any Known or requested information, or failure to provide any additional information requested by us on a Participant or a person named in a Disclosure Statement, or for whom we have requested Claim Information, the Policyholder agrees to indemnify us up to the amount of such liability, loss or expense, and all costs associated with such 1iability, loss or expense. Part 11. ENTIRE CONTRACT, CHANGES This Policy, the Application, a copy of which is attached to this Policy, as well as the Disclosure Statement(s) or Disclosure Form(s), Declaration Page and attached documents, if any, constitute the entire contract of insurance. No change in this Policy will be valid unless it is approved in writing by one of our executive officers and delivered to the Policyholder for attachment to this Policy. This approval must be shown on or attached to this Policy. No agent or Designated TPA has authority to change this Policy or to waive any of its provisions. Part 12. INCONTESTABLE CLAUSE In the absence of fraud, any statement made by the Applicant, Affiliate, Employer or Policyholder is a representation and not a warranty. No statement made by the Applicant, Affiliate, Employer or Policyholder affecting this Policy will be used to deny a claim or to deny the validity of this Policy unless contained in a written instrument signed by the Applicant, Affiliate,Employer or Policyholder and a copy of the written instrument has been given to the Applicant, Affiliate, Employer or Policyholder. Part 13. LEGAL ACTIONS r\ No action at law or in equity may be brought to recover under this Policy until 60 days after written proof of loss has been furnished to us. No such action may be brought more than three years after the time within which proof of loss is required to be furnished. HL601-SL (905) 12/01/2006 10 401850-A Specific & Aggregate Stop Loss ~, r ; Part 14. INSOLVENCY The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors, or dissolution of the Policyholder or the Policyholder's Designated TPA will not impose upon us any liability other than the liability defined in this Policy. Part 15. ASSIGNMENT The Policyholder's rights and benefits under this Policy cannot be assigned. Part 16. GENERAL DEFINITIONS AFFILIATE means a company, division, location or class of employees within such company, location or division while subsidiary to affiliated with or controlled by the Policyholder. This term may include the Employer. AGENT when referring to the Applicant or Policyholder, means the Applicant's or the Policyholder's representative, including but not limited to the agent or broker of record, or Designated TPA. (\ AGGREGATE ANNUAL DEDUCTIBLE means an amount that the total of the Eligible Claims Expenses which are actually Paid by the Policyholder during the Policy Term for all Participants must exceed before Aggregate Benefits become payable to the Policyholder. This amount, which cannot be finally determined until the end of the Policy Term, is based on the number of Covered Units reported by the Policyholder, or the Policyholder's authorized representative, used to determine the Aggregate Monthly Deductible Amount or the Minimum Aggregate Deductible. AGGREGATE ATTACHMENT POINT (Corridor) means the percentage of anticipated Eligible Claims Expenses which the Policyholder must pay before Aggregate Benefits will become payable to the Policyholder. The Aggregate Attachment Point, as shown in the Aggregate Benefit Schedule, is used to determine the amount of the Aggregate Monthly Deductible Amount Per Participant. The Aggregate Benefit Schedule is shown on the Declaration Page attached to this Policy. AGGREGATE BENEFIT means a type of benefit payment provided under this Policy to the Policyholder when Eligible Claims Expenses which are actually Paid by the Policyholder through the Covered Underlying Plan(s) for all Participants combined exceed the Aggregate Annual Deductible shown in the Aggregate Benefit Schedule. The Aggregate Benefit Schedule is shown on the Declaration Page attached to this Policy. AGGREGATE ELIGIBLE CLAIMS EXPENSE means the maximum dollar amount of Eligible Claims Expenses that are actually Paid by the Policyholder for a Participant during the Policy Term which can be used either to satisfy the Aggregate Deductibles or included in the calculation of theAggregate Benefit for that Policy Term, as shown in the Aggregate Benefit Schedule. The Aggregate Benefit Schedule is shown on the Declaration Page attached to this Policy. AGGREGATE MONTHLY DEDUCTIBLE AMOUNT means, for each Policy Month in the Incurred and Paid period shown on the Declaration Page, A multiplied by B, where: A = The Aggregate Monthly Deductible Amount per Covered Unit B = The number of Covered Units as reported by the Policyholder or the Policyholder's authorized representative at the start of that Policy Month. ri HL601-SL (905) 12/01/2006 11 401850-A Specific & Aggregate Stop Loss ri AGGREGATE MONTHLY DEDUCTIBLE AMOUNT PER COVERED UNIT means the monthly dollar amount per Covered Units which is used to calculate the Aggregate Annual Deductible and the Minimum Aggregate Annual Deductible. The Aggregate Monthly Deductible Amount Per Covered Unit is shown in the Aggregate Benefit Schedule. The Aggregate Benefit Schedule is shown on the Declaration Page attached to this Policy. AGGREGATE PAYABLE PERCENTAGE means the percentage of the Aggregate Benefit that will be paid when Eligible Claims Expenses, which are actually Paid by the Policyholder through the Covered Underlying Plan(s), exceed the Aggregate Attachment Point (Corridor). APPLICANT means the Proposed Insured, Proposed Policyholder, or any other entity that has contracted with us to provide Stop Loss coverage. APPLICATION means the written request of an entity through its duly authorized representative(s) for insurance under this Policy on a form acceptable to us. CATASTROPHIC CLAIM means any Known claim for a Covered Claim Expense under a Covered Underlying Plan(s) or another employee benefit plan providing hospital, surgical or medical benefits administered by the Applicant, Affiliate, Employer, Policyholder or Designated TPA Incurred and/or actually Paid, or expected to be Incurred by a Participant that may reasonably be assumed will exceed 50% of Specific Deductible and/or 10% of the Maximum Aggregate Eligible Claim Expense per Participant, in this or the next Plan Year. CLAIM INFORMATION means to provide Complete Details following a Diligent Review of the data requested by us in connection with the application for, or renewal of, this Policy on any on any Claim incurred, paid or pended prior to the Effective Date of this Policy including but not limited to Catastrophic Claims and Shock Losses. (""""', COMPLETE DETAILS means detailed information including, but not limited to the Participant's name and social security number, date of birth, diagnosis, prognosis (unless prognosis cannot be obtained due to reasons beyond the Applicant's, Affiliate's, Employer's, Policyholder's, or their authorized representative's control) and provider name, on any Participant covered by, or eligible for coverage, under a Covered' Underlying Plan or another employee benefit plan providing hospital, surgical or medical benefits administered by the Applicant, Affiliate, Employer, Policyholder or Designated TPA. For purposes of privacy, a unique identifier may be used to identify the Participant in lieu of the person's name, social security number and date of birth. COVERED CLAIMS BASIS means the basis on which Eligible Claims Expenses which are Incurred through the Covered Underlying Plan(s) by a Participant qualify under this Policy to be applied to satisfy the Deductibles of this Policy and for payment of benefits under this Policy. The Covered Claims Basis shown in the Specific Benefit Schedule and the Aggregate Benefit Schedule establishes the period during which an Eligible Claims Expense must be Incurred and/or actually Paid and the period during which it must be actually Paid by the Policyholder. The Specific Benefit Schedule and the Aggregate Benefit Schedule are shown on the Declaration Page attached to this Policy. COVERED SERVICE means a service for which the Participant has Incurred an Eligible Claims Expense and for which benefits are payable through the Covered Underlying Plan(s). This does not include any service excluded under Special Risk Limitations on the Declaration Page attached to this Policy. COVERED UNDERLYING PLAN(S) means the Underlying Plan(s) which are identified in Policy Information on the Declaration Page attached to this Policy. This does not include any plan excluded under Special Risk Limitations on the Declaration Page attached to this Policy. {\ HL601-SL (905) 12/01/2006 12 401850-A Specific & Aggregate Stop Loss 0, COVERED UNIT(S) means a Covered Unit composed of one or more Participants, as shown in the Policy Information on the Declaration Page attached to this Policy. A Covered Unit can be composed of a Single Employee, the Family of the employee, or the Composite of the employee and family, as shown in the Policy Information. The number of Covered Units is used to calculate the premium due each month. The estimated number of Covered Units for the first Policy Month is shown in the Policy Information on the Declaration Page attached to this Policy. DEDUCTIBLE(S) means the Specific Deductible(s) or Aggregate Deductible, as shown in the Specific Benefit Schedule or the Aggregate Benefit Schedule. The Specific Benefit Schedule, if any, and the Aggregate Benefit Schedule, if any, are shown on the Declaration Page attached to this Policy. DESIGNATED TPA means the third party administrator designated by the Applicant, Affiliate, Employer or Policyholder and recognized by us, as described in this Policy. DILIGENT REVIEW means a complete review by the Applicant, Policyholder or Designated TPA of the underlying health plan prior to Disclosure, or the initial underwriting, Effective Date or renewal of this Policy for Known potential large claimants. A claimant is Known if prior to, or at the time Disclosure is requested the Applicant or Policyholder had actual information about the claim, or could have reasonably been assumed to have had such information, had they conducted a Diligent Review. DISCLOSURE OR DISCLOSED means to provide Complete Details following a Diligent Review, and to provide us with all documentation requested including but not limited to the information requested on the Disclosure Form or Disclosure Statement, in connection with the quote/proposal or a renewal offer, census information and Claim Information within the time period(s) specified by us in writing, prior to: (1) the initial underwriting of this Policy; (2) the Effective Date of this Policy; (3) the date an Affiliate is acquired, or another class of employees established; 0, or (4) the date of Renewal following the end of any Policy Term. DISCLOSURE FORM OR DISCLOSURE STATEMENT means the documentation submitted by the Applicant, Policyholder, Agent or Designated TPA following a Diligent Review that provides information, upon which we will rely, in part, to issue or renew the Policy, or to accept additional risk under the Policy at any time during the current Plan Year EFFECTIVE DATE means the date shown on the cover page of this Policy or the Declaration Page attached to this Policy. ELIGIBLE CLAIMS EXPENSE(S) means expenses which are Incurred by a Participant through the Covered Underlying Plan(s) and for which benefits have been actually Paid by the Policyholder in accordance with the terms of the Covered Underlying Plan(s). Eligible Claims Expenses which are covered under the terms of the Covered Underlying Plan(s), actually Paid by the Policyholder, and not excluded under the terms of this Policy can be used either to satisfy the Deductible(s) of this Policy or included in the calculation of the benefits payable under this Policy. This does not include any Excluded Claims Expenses in Special Risk Limitations on the Declaration Page attached to this Policy. EMPLOYER means the entity shown on the Declaration Page attached to this Policy. EXCLUDED CLAIMS EXPENSES means expenses which are Incurred by a Participant for services, supplies and treatment for, or related to, the condition, or resulting complications, of an injury or sickness described in Special Risk Limitations in the Declaration Page attached to this Policy. INCURRED means an Eligible Claims Expense is Incurred on the date the Covered Service is received by the Participant. r\ HL601-SL (905) 12/01/2006 13 4018S0-A Specific & Aggregate Stop Loss ~ g' ..} INDIVIDUAL SPECIFJ(:; DEDUCt.I'BLE me aIlS the separate Specificbeductible, if any, shown in Special Risk Limitations for certain Participants who are identified by name, which must be satisfied prior to any Specific Benefit becoming payable under this Policy with respect to those Participants. Special Risk Limitations is shown on the Declaration Page attached to this Policy. KNOWN means information affecting the administration or underwriting of this Policy, which can be reasonably assumed that the Applicant, Affiliate, Employer, Policyholder, or Designated TPA had knowledge of prior to, or at the time of, a request for Disclosure or Claim Information. MAXIMUM AGGREGATE BENEFIT PER POLICY TERM means the maximum dollar amount of the Aggregate Benefit which will be paid by us to the Policyholder for any Policy Term, as shown in the Aggregate Benefit Schedule. The Aggregate Benefit Schedule is shown on the Declaration Page attached to this Policy. MAXIMUM SPECIFIC BENEFIT means the maximum dollar amount of the Specific Benefits which will be paid by us to the Policyholder with respect to Eligible Claims Expenses which are Incurred by anyone Participant during the lifetime of that Participant, as shown in the Specific Benefit Schedule. The Specific Benefit Schedule is shown on the Declaration Page attached to this Policy. MINIMUM AGGREGATE DEDUCTIBLE means the dollar amount shown in the Aggregate Benefit Schedule on the Declaration Page attached to this Policy. F\ PAID means an Eligible Claims Expense is actually Paid by the Applicant, Affiliate, Employer, or Policyholder or their authorized representative on or after the date when funds are disbursed to the Participant who Incurred the Eligible Claims Expense, or to the provider of the Covered Service by the AppliCant, Affiliate, Employer, Policyholder, or their authorized representative. A claim will be deemed actually Paid on the date that the Applicant, Affiliate, Employer, Policyholder or their authorized representative directly tenders payment by mailing or otherwise delivering a draft or check, provided that the account upon which the payment is drawn contains, and continues to contain, sufficient funds to permit the check or draft to be honored. PARTICIPANT or PARTICIPANTS means a person who is an employee, associate or member of an Applicant, Affiliate, or the Employer or Policyholder, and the dependents of such persons who are covered, or who become eligible for coverage, through a Covered Underlying Plan or another employee benefit plan providing hospital, surgical or medical benefits administered by the Applicant, Affiliate, Employer or Policyholder or their designated representative. POLICY means this contract between the Policyholder and us with respect to Stop Loss Insurance. POLICY ANNIVERSARY means each anniversary of the Effective Date of this Policy, unless changed by agreement between the Policyholder and us. POLICY MONTH means successive intervals of time, while this Policy is in effect, determined on a monthly basis starting on the Effective Date of this Policy. Each new interval will begin on a day that corresponds to the Effective Date of this Policy. If there is no such day in any applicable month, then the last day of the month will be used. POLICY TERM means the period from the: ~ 1. Effective Date of this Policy through the end of the period of time, shown in the Covered Claims Basis section of the Specific Benefit Schedule or the Aggregate Benefit Schedule; or 2. Policy Anniversary through the end of the period of time, shown in the Covered Claims Basis section of the Specific Benefit Schedule or the Aggregate Benefit Schedule. The Specific Benefit Schedule, if any, and the Aggregate Benefit Schedule, if any, is shown on the Declaration Page attached to this Policy. Each Policy Term after the initial Policy Term will begin on the Policy Anniversary. The initial Policy Term will begin on the Effective Date of this Policy. HL601-SL (905) 12/01/2006 14 401850-A Specific & Aggregate Stop Loss r, '" , , , POLICYHOLDER means the entity shown on the cover page of this Policy and on the Declaration Page attached to this Policy. PREMIUM DUE DATE means the Effective Date of this Policy and the first day of each following Policy Month. PROPOSED INSURED means the entity that signed our Disclosure Statement. PROPOSED POLICYHOLDER means the Proposed Insured. SHOCK CLAIM OR SHOCK LOSS means any loss that is reasonably likely to result in a potentially Catastrophic Claim, or any other loss due to the nature of the injury, illness or diagnosis that the Applicant, Affiliate, Employer, Policyholder or Designated TPA reasonably assumes will result in a significant medical expense in this or the next Plan Year. SPECIAL RISK LIMITATION means any modification of the terms or conditions of the Aggregate Benefit Schedule or the Specific Benefit Schedule. Special Risk Limitations are shown on the Declaration Page attached to this Policy. SPECIFIC BENEFIT means a type of benefit provided under this Policy to the Policyholder when Eligible Claims Expenses which are actually Paid by the Policyholder through the Covered Underlying Plan(s) for a Participant, exceed the Specific Deductible. SPECIFIC DEDUCTIBLE means the dollar amount(s) shown in the Specific Benefit Schedule as the Specific Deductible which must be satisfied prior to any Specific Benefit becoming payable under this Policy. The Specific Benefit Schedule is shown on the Declaration Page attached to this Policy. r'\ SPECIFIC PAYABLE PERCENTAGE means the percentage of the Specific Benefit that will be paid when Eligible Claims Expenses, which are actually Paid by the Policyholder through the Covered Underlying Plan(s) for a Participant, exceed the Specific Deductible. STOP LOSS INSURANCE means the coverage provided under this Policy, which provides benefits to the Policyholder when Eligible Claims Expenses which are actually Paid by the Policyholder through the Covered Underlying Plan(s) exceed the levels defined in this Policy. UNDERLYING PLAN(S) means the employee benefit plans of the Applicant or Policyholder which provide the benefits identified on the Declaration Page attached to this Policy for the Applicant's, Affiliate's, Employer's or Policyholder's employees, associates or members and their dependents. This Policy insures the Policyholder for excess losses through the employee benefit plans identified on the Declaration Page attached to this Policy as Covered Underlying Plan(s). This term does not include any employee benefit plan of the Policyholder that is not identified on the Declaration Page as a Covered Underlying Plan(s). UNFUNDED CLAIM(S) means any claim payable by the Applicant, Affiliate, Employer, Policyholder, or their authorized representative to a Participant or a provider through a Covered Underlying Plan drawn on an account funded by the Applicant, Affiliate, Employer, or Policyholder that does not contain, or continue to contain, sufficient funds to permit the check or draft to be honored. r' HL601-SL (905) 12/01/2006 15 401850-A Specific & Aggregate Stop Loss