HomeMy WebLinkAboutAuxiant/Schedule for Excess Policy 2015 QBE INSURANCE CORPORATION STOP LOSS
Administrative Address: QBSL—0123 (07-02)
Wall Street Plaza
6�BE INS 88 Pine Street, 16`h Floor
coaro�►noN New York, NY 10005
SCHEDULE FOR EXCESS POLICY
This Schedule forms part of the Policy to which it is attached.
Policy Number: LGS00526-15
1. Policyholder:
Citv of Oshkosh
(as it will appear in the Policy)
2. Principal Office Address:
Citv Hall, 215 Church Street Oshkosh WI 54903-1130
(street) (city) (state) (zip)
3. Effective Date: 01/01/2015
4. Expiration Date: 12/31/2015
5. Attached Endorsements: Wisconsin Endorsement QBSL-0130(09-02)
6. Third—Party Administrator(for purpose of claims administration under the Plan):
Name: Auxiant-Alliance Benefit Group Medical Services
Address: 2450 Rimrock Road. Suite 301
City, State, Zip: Madison. WI 53713
Telephone: (800)245-0533
7. COVERAGE
The Coverage shown applies only during the Policy Period and is further subject to all the provisions of the
Policy.
A. SPECIFIC EXCESS LOSS COVERAGE � Yes, included ❑ No, not included
1) Coverage to be included:
Yes No
� ❑ Medical
� ❑ Prescription Drugs
❑ � Dental
❑ � Vision
2) Specific Attachment Point(unless adjusted by Endorsement)
� Per Covered Person: 75 000
❑ Per Covered Family: 0.00
❑Aggregating Specific Deductible: 0.00
3) Specific Reimbursement Percentage: 100 %
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4) Specific Policy Period Maximum Reimbursement per Covered Person: Unlimited upon
satisfaction of snecific deductible.
� Of this amount, reimbursement for treatment of drug or alcohol abuse will be limited to:
� The terms, conditions and limits as stated in the acceQted plan document.
❑ days
❑ days, up to$
❑ Treatment of drug or alcohol abuse considered as any other illness
5) Basis of Specific Excess Loss coverage benefit payment(Benefit Period):
Plan Benefits Incurred from: 01/01/2015 through: 12/31/2015
And paid from: 01/01/2015 through: 03/31/2016
Plan Benefits Incurred prior to the Effective Date (Run-In-Period)will be limited to:
❑ N/A per Covered Person
❑ N/A for all Covered Persons combined
6) Premium Rates (per month):
Covered Unit Description Amount
Sin le 152 94.61
Family 399 230.73
Total 551
7) Minimum Annual Specific Premium: N/A. Estimated specific annual premium based on puoted
enrollment is$1,277,304.00.
B. AGGREGATE EXCESS LOSS INSURANCE � Yes, included ❑ No, not included
1) Coverage to be included:
Yes No
� ❑ Medical
❑ � Dental
❑ � Vision
� ❑ Prescription Drugs
❑ � Weekly Disability Income Maximum ,
per covered employee per Policy Period
❑ � Other:
2) Monthly Aggregate Factor:
Weekly
Covered Unit Prescription Disability
Descriqtion Medical Dental Vision Druas Income Other Total
Sinqle: X X 762.22
Familv: X X 1942.90
3) Number of Covered Units: � Quoted ❑Actual
Weekly
Covered Unit Disability
Descriqtion Medical Dental Vision Prescription Druqs Income
Composite: 551 551
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4) Minimum Annual Aggregate Attachment Point: $ 10,692,894(Estimated)
(12 times Monthly Aggregate Factor(s), times total Number of Covered Units)
5) Aggregate Reimbursement Percentage: 100°/a
6) Individual Claim Limit: 75 000
7) Maximum Aggregate Reimbursement(per Policy Period): $ 1,000,000
8) Basis of Aggregate Excess Loss coverage benefit payment(Benefit Period):
Plan Benefits Incurred from: 01/01/2015 through: 12/31/2015
And paid from: 01/01/2015 through: 03/31/2016
Plan Benefits Incurred prior to the Effective Date(Run-In-Period)will be limited to:
❑ N/A per Covered Person
❑ N/A per all Covered Persons combined
9) Premium Rates (per month):
Covered Unit Description Amount
Composite 2.40
10) Minimum Annual Aggregate Premium: N/A. Estimated annual aqqregate premium based on quoted
enrollment is$ 15,869.
8. Eligible for coverage:
Yes No
� ❑ Retired Employees
� ❑ COBRA Continuee
� ❑ Disabled Persons
� ❑ Employees who are not Actively at Work
❑ � Late Entrants
� ❑ Transplants(Secondarv)
❑ � Other:
9. Additionallnformation
a. Policy Information:
1. Your PPO is: Trilogv with HPS Solutions. First Health wrap.
2. Your Utilization Review Provider is: AHH.
3. Eliaible Expenses do not include anv expenses for solid orqan or tissue transplants that
are covered under the National Union Fire Policv, or that would have been covered in
the event the Transplant Rider is no lonqer in force. Transplant coverape under the
Excess Loss Policv is extended to the Plan as secondarv. All notification provisions of
the Policv shall applv.
4. The definition of Specific Lifetime Maximum Reimbursement in the Definitions Section of this
Policy, is deleted and replaced with:
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Specific Policy Period Maximum Reimbursement means the maximum amount WE will reimburse YOU
with respect to any Covered Person under this Policy during the Policy Period shown in the Schedule. The
Policy Period Maximum excludes the Specific Attachment Point amount. The Policy Period Maximum will
not exceed the lesser of:
1. the amount shown in the Schedule; and
2. the maximum benefit amount set forth in the Plan.
5. Section II, Specific Excess Loss Coverage, is deleted and replaced with the following:
Section II, SPECIFIC EXCESS LOSS COVERAGE
WE will reimburse YOU for Plan Benefits Paid in excess of the Specific Attachment Point, not to exceed the
Policy Period Maximum Reimbursement amount shown in the Schedule. WE will reimburse YOU after
YOU have provided an acceptable proof of loss and satisfactory proof of Paid Plan Benefits.
The Specific Excess Loss benefit applies to a Policy Period or fraction thereof (due to termination). As
determined with regard to each Covered Person, it is the lesser of:
1. the Policy Period Maximum Benefit; and
2. eligible Plan Benefit Payments made with regard to a Covered Person, less the Specific
Attachment Point, the result of which is then multiplied by the Specific Reimbursement Percentage.
In addition,the Specific Excess Loss Benefits Payable under this Policy will be reduced by the Aggregating
Specific Deductible.
b. Special Limitations: Jessie Miller has an Alternative Specific Attachment Point of$150,000
and an Aqctrectate Individual Claim Limit of$75,000.
10. Minimum Plan Enrollment: N/A Covered Units, or 75% of initial enrollment
ACCEPTED BY THE POLICYHOLDER:
Signed at � ���� 1- � �L
City, Sta � �' J Q�����
Date ,�/ ����� Policyhol et(correct IQ,gal t,�ney /�_
� �-- ��'"7��Z
By(Offic 's name and title)
Signature of Policyholder's Broker/A nt of Record
�-14��.. ��d r� `�t� (�v,�f�v�, G,����
Print Broker/Agent of Rec d
ACCEPTED BY THE COMPANY:
Signed at Marblehead. Massachusetts / y� �_
On b of the ompany �—
QBE Insurance Corporation
Date: l�`� ��1� Steven L.Gransburv
Chief Oaeratina Officer-Specialtv
QBE North America
By(Officer's name and title)
QBSL—0123(07-02) QBE INSURANCE CORPORATION Page 4 of 4
�^` STOP LOSS
►�� QBSL-0130(09-02)
6lBE INS
CORPORATION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WISCONSIN ENDORSEMENT
This endorsement modifies insurance provided under the foliowing:
SECTION V— LIMITATIONS
SECTION VI —EXCLUSIONS
SECTION VII— PREMIUMS AND FACTORS
SECTION VIII —TERMINATION
SECTION X—CLAIMS PROVISIONS
SECTION XI —GENERAL PROVISIONS
This endorsement changes the policy effective on the Policy Effective Date unless another date is indicated below.
Policy Number: Endorsement Effective:
LGS00526-15 01/01/2015
Named Insured: Signed for the Company by:
City of Oshkosh
�'�.a�z �____
David Duclos, President
(If no entry appears above, information required to complete this endorsement will be shown in the Schedule as
applicable to this endorsement.)
SECTION V—LIMITATIONS has been revised as follows:
The Disclosure provision has been deleted in its entirety and replaced with the following:
Disclosure
WE have relied upon the information provided by YOU and YOUR TPA in the issuance of this Policy. Should
subsequent information become known which, if known prior to issuance of this Policy, would affect the
premium rates, factors, terms or conditions for coverage thereunder, WE will have the right to revise the
premium rates, factors, terms or conditions as of the Effective Date, by providing written notice to YOU.
Subject to the Time Limit on Certain Defenses provision any fraudulent statement will render this Policy null
and void and claims, if any, will be forfeited.
SECTION VI —EXCLUSIONS has been deleted in its entirety and replaced with the following:
QBSL-0130 (09-02) QBE Insurance Corporation Page 1 of 5
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�� QBSL-0130(09-02)
616E INS
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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SECTION VI
EXCLUSIONS
WE will not reimburse YOU for any loss or expense caused by or resulting from:
[1.] expenses Incurred while the Plan is not in force with respect to the Covered Person, or for a
person not covered under the Plan;
[2.] expenses covered by Plan changes made prior to OUR written approval of such changes;
[3.] expenses which result from any prescription care service, mail order prescription plan or any
pre-paid prescription drug plan, dental, vision, or weekly disability income benefits, unless
specifically included on the Schedule and approved by US.
[4.] liability or obligations assumed by YOU under any contract or service agreement other than the
Plan;
[5.] expenses for services or supplies which are in violation of any law;
[6.] expenses for services or supplies billed above the Usual and Customary Charges for the area
where provided or which are greater than the Plan benefit;
[7.] expenses resulting from or caused by war, whether declared or undeclared, civil war, invasion,
hostilities, riot or resistance to armed aggression;
[8.] expenses for an injury or sickness arising out of, or in the course of an employment for wage or
profit or for a sickness for which the Covered Person is entitled to benefits under any Workers'
Compensation or occupational disease law, whether or not the Covered Person applies for such
benefits.
[9.] cost of the administration of claims, including cost of investigation, payments, or other service(s)
provided by YOUR TPA, consulting fees and/or expenses of any litigation;
[10.] expenses from the commission of or attempt to commit any felony;
[11.J any amount used to satisfy deductibles or coinsurance amounts under the Plan;
[12.] expenses or costs resulting from noncontractual damages, court costs and legal fees, including
but not limited to compensatory, exemplary and punitive damages, fines or statutory penalties;
[13.] medical expenses in connection with Experimental or Investigational surgery or treatment as
defined in this Policy.
(14.] Payments recoverable through YOUR Plan's Coordination of Benefits or similar provision;
[15.] expenses Incurred by an employee or dependent of an employee of any affiliated or subsidiary
company not included in the Application, unless added by Endorsement;
[16.] legal expenses and fees including legal expenses and fees Incurred on behalf of any Covered
Person in obtaining medical treatment or expenses Incurred in connection with a judgment or
settlement arising out of YOUR negligence in providing, arranging, or falling to provide or
arrange a benefit to a Covered Person;
[17.] Payments YOU make under YOUR Plan for services and supplies which are not included in
YOUR Plan or which are outside the requirements of YOUR Plan Document or this Policy;
[18.] expenses Incurred after the Expiration Date;
(19.] in the event this Policy is terminated before the Expiration Date, expenses Incurred after the
date of such termination;
[20.] YOUR TPA's failure to provide timely Payment to providers which results in non-receipt of any
discounted fees for services or supplies. WE will reimburse only for the amount of the
discounted amount had timely Payment been made by YOUR TPA.
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�� QBSL-0130(09-02)
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CORPORATION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SECTION VII — PREMIUMS AND FACTORS has been revised as follows:
The Grace Period provision has been deleted in its entirety and replaced with the following:
Grace Period
A Grace Period of 31 days from the due date will be allowed for the payment of each premium after the first
premium payment. During the Grace Period, the coverage will remain in effect, provided the premium is paid
before the end of the Grace Period. If YOU do not pay the premium during the Grace Period, this Policy will
terminate without further notice, at the end of the Grace Period. YOU will be liable for the payment of a pro
rata premium for the time the policy was in force during the Grace Period.
SECTION VIII —TERMINATION has been deleted in its entirety and replaced with the following:
SECTION VIII
TERMINATION
This Policy and all coverage hereunder will end upon the earliest of the following:
1. At the end of any Grace Period for which the premium is paid, if the subsequent premium is not
paid as provided in the Grace Period provision.
2. On the date YOU tell US YOU want to cancel this Policy, provided YOU have given US at least
31 days advance written notice. If YOU cancel within 30 days after the Effective Date, YOU
may ask for a full refund of the premium. If YOU do so, this Policy will terminate on the Effective
Date. If YOU cancel this Policy at a later date, WE may keep the premium earned to the date of
termination.
3. The Expiration Date of this Policy.
4. On the date stated in the notice of termination, if, within 60 days after the Effective Date:
a. YOU fail to provide US any information or materials requested by US; or
b. YOU fail to comply with any condition imposed by US when this Policy is issued.
Notice of termination will be sent to YOU at least 10 days prior to the effective date of the
termination. If the policy is terminated, WE will return the premium paid by YOU, less the
amount of any reimbursements WE made to YOU before the time this Policy was terminated. If
the amount reimbursed to YOU exceeds the premium paid to US, YOU will pay US the
difference.
5. The date the Plan terminates.
6. On the date stated in the notice of termination if the administrative agreement befinreen YOU
and YOUR TPA terminates, unless WE consent in writing to YOUR naming of a new TPA. If the
policy is terminated, a notice of termination will be sent to YOU at least 10 days prior to the
effective date of the termination.
7. On the date stated in the notice of termination if YOU fail to maintain the Minimum Plan
Enrollment as stated in the Schedule, unless WE agree in writing to continue coverage. If the
policy is terminated, a notice of termination will be sent to YOU at least 10 days prior to the
effective date of the termination.
8. The date YOU:
a. Suspend active business operations; or
b. are placed in bankruptcy or receivership, or
c. dissolve.
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�� STOPLOSS
� QBSL-0130(09-02)
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CORPORAiION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
9. On the date stated in the notice of termination if YOU do not pay claims or make funds available
to pay claims as required by the Plan. If the policy is terminated, a notice of termination will be
sent to YOU at least 10 days prior to the effective date of the termination.
Concealment or Fraud
Subject to the Time Limit on Certain Defenses provision, this entire Policy will be cancelled:
1. if, before or after a claim or loss, YOU or YOUR TPA have concealed or misrepresented any
material fact or circumstance concerning this Policy, including any claim; (This includes failure
to provide the required disclosure of health history of Disabled Persons, Large Claims or
Potentially Catastrophic Losses.) or
2. in any case of fraud by YOU or YOUR TPA relating to this coverage.
SECTION X—CLAIMS PROVISIONS has been revised as follows:
The Management of Large Claims (LC's) and Potentially Catastrophic Losses (PCL's) provision has been
deleted in its entirety and replaced with the following:
Management of Large Claims (LC's) and Potentially Catastrophic Losses (PCL's)
Notice of LC — YOU or YOUR TPA must notify US in writing of any LC (regardless of whether charges have
been Paid or are pending Payment) as soon as practically possible but in no event later than one year when
the claim exceeds or it appears that the claim will reach or exceed the defined limits for a LC.
Notice of PCL—YOU or YOUR TPA must notify US in writing of any PCL as soon as practically possible but in
no event later than one year when receiving any information indicating that the claim (regardless of whether
charges have been Paid or are pending Payment) is potentially catastrophic.
(See Exhibit I of this Policy.)
Failure to Notifv — If for any reason a LC or PCL is not properly submitted to the TPA, YOU shall promptly
notify the TPA of the claim. In the event YOU or YOUR TPA fails to follow the notification requirements set
forth in this provision, YOUR losses related to such LC or PCL may not be considered for reimbursement
under this Policy.
If YOU receive information that any claim may be or become a PCL, YOU will immediately notify YOUR TPA.
SECTION XI —GENERAL PROVISIONS has been revised as follows:
The Entire Contract provision has been deleted in its entirety and replaced with the following:
Entire Contract
This entire contract consists of:
1. this Policy, including any Endorsements;
2. YOUR Application and Schedule and any attachments thereto, a copy of which is attached to
this Policy, and
3. a copy of YOUR Plan.
QBSL-0130(09-02) QBE Insurance Corporation Page 4 of 5
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�� QBSL-0130 (09-02)
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CORPORAiION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
All statements made by YOU or any Covered Person are, in the absence of fraud, understood to be
representations and not warranties. Such statements will not be used to contest coverage unless contained in
the Application and Schedule or any attachments to the Application and Schedule.
In case of a conflict between the Plan and this Policy, this Policy will prevail. WE have relied on the
information YOU provided to issue this Policy. YOU represent such information is accurate. Should
subsequent information become known which, if known prior to issuance of this Policy, would affect the
premium rates, factors, terms or conditions for coverage thereunder, WE will have the right to revise the
premium rates, factors, terms or conditions as of the Effective Date, by providing written notice to YOU. Any
fraudulent statement will render this Policy null and void and claims, if any, will be forfeited. Any revision to this
Policy or termination of this Policy is subject to the Time Limit on Certain Defenses provision.
THERE ARE NO POLICY CHANGES UNDER THIS ENDORSEMENT OTHER THAN THOSE STATED ABOVE.
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