CONTRACT HEALTH INSURANCE FOR FBIS FSN EMPLOYEES

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP85-00024R000300220001-7
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 17
• Document Creation Date: December 20, 2016
• Document Release Date: October 3, 2007
• Sequence Number: 1
• Publication Date: July 27, 1981
• Content Type: MEMO

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2 7 JUL 1981 -C/AG
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C/ADMIN
201 FILE
THROUGH: Deputy Director for Science and Technology
Director, Foreign 'Broadcast Information Service
STAT
SUBJECT: Contract Health Insurance for FBIS FSN Employees
1. Paragraph five contains a request for your approval.
2. The Foreign Broadcast Information Service (FBIS) employs
a number of Foreign Service National (FSN) employees who are not
eligible for or do not have available to them health insurance benefit
plans. While FSN employees are prohibited by law from membership
in U.S. Government group health insurance programs, most are covered
by local health or social insurance programs. However, at present
99 FBIS FSN employees are enrolled in Contract Health Insurance (CHI)
because such local coverage is not available. CHI premiums and claims
are administered internally by the Insurance Branch of the Office
of Personnel.
3. CHI provides health insurance coverage to FSN's which is
comparable to the coverage available to U.S. staff employees. Upon
retirement, however, the FSN's are excluded from group coverage and
must either accept individual coverage with the CHI underwriter or
seek other health insurance coverage. The post-retirement CHI premiums
for individuals are, of course, considerably higher and the benefits
package is not adequate to meet today's high costs of medical care.
Copies of CHI benefits before and after retirement are attached for
comparison purposes. Health insurance coverage under private plans,
especially for individuals of retirement age and uncertain health,
is also very costly and benefits are not comprehensive.
4. During the early days of CHI, the problems mentioned above
were not significant. There were few FSN retirees and the costs
of medical care and health insurance were within the means of most
people. The dramatic rise in health care costs over the past five
to six years has convinced FBIS it is time to review the health insurance
program for retired FSN's.
\3 EXEC. REG.
'An INhI1lclTnayn,r - nitrnu.. .... .
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AMINI TRATIVE == INTERNAL USE ONLY
SUBJECT: Contract Health Insurance for FBIS FSN Employees
5. It is requested that the Insurance Branch of the Office
of Personnel be directed to explore with the CHI underwriter the
possibility of continuing group health insurance coverage for FSN
retirees who have been enrolled in CHI. Of the 99 FSN's currently
enrolled in CHI, two will reach mandatory retirement age during the
next three years. Nine FSN retirees over the past three years have
had CHI at retirement. Thus, it does not appear that inclusion of
FSN retirees in group CHI, if that proves technically possible, would
significantly increase the administrative workload on the Insurance
Branch.
Attachment:
As stated
Deputy Director for Science and Technology
STAT
STAT
DDS{T/FBIS-Pers/I I (23 July 1981)
Distribution:
Orig - Addressee, w/att, Yet. to FBIS
1 - D/OP, w/att
2 - DDS&T, w/att
1 - IB, w/att
4 - Retained in FBIS
1 - D/FBIS, wd/att
1 - AS Chrono, w/att
1 - PETB Chrono, w/att
a - FBIS Reg., w/att
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EFFECTIVE 1-1-81
(Payable without a Deductible)
LH I
1. ROOM AND BOARD AND HOSPITAL EXTRAS
*Full cost of semi-private room and hospital extras for up
to 365 days, including intensive care units (Major Medical
Benefits thereafter). If private room is used, patient pays
the cost in excess of the hospital's average semi-private
rate unless the Plan determines that isolation is necessary
to contain a communicable disease. Included in this benefit
is: up to $50.00 for private ambulance service and charges
for outpatient preadmission tests rendered within 48 hours of
admission to the hospital.
*Basic Benefits of up to $20.00 per visit will be payable
for each doctor's visit to hospital inpatients for up to 365
days for each confinement - when the visit is unrelated to
surgery.
2. HOSPITAL OUTPATIENT EXPENSES
Up to $400.00 per person each calendar year. Charges by
a hospital for outpatient services and non4.surgical charges
by a doctor for emergency room treatment only are payable
under this benefit, except for an allowance of up to $50.00
for private ambulance service. Expenses exceeding the $400.00
are payable under Major Medical Benefits.
SPECIAL OUTPATIENT HOSPITAL BENEFIT
100% of outpatient hospital charges for services and
supplies rendered at the time of a surgical operation not re-
quiring hospitalization as an inpatient. This provision also
applies to approved Surgi-Centers. Charges for take home
drugs billed by a hospital are not payable as a hospital
expense, but rather are payable under Major Medical Benefits.
OUT-OF-HOSPITAL ACCIDENTAL BODILY INJURY EXPENSES
PLAN PAYS --
100% of a doctor's reasonable and customary charge for
emergency treatment of accidental, bodily injury.
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3. SURGICAL EXPENSES
100% of reasonable and customary charges for surgery under
basic benefits.
*Surgery by a doctor or surgeon except cosmetic surgery,
unless it is necessary as a result of accidental injury
occurring while covered by this Plan. The initial re-
construction of the breast following a mastectomy which
was performed while covered under the Plan is also
payable.
*Surgical correction of congenital anomalies (including
protruding ear deformities, harelip, birthmarks, webbed
fingers or toes, or other conditions that the Plan may
determine to be congenital anomalies).
*Surgery for operations performed on the jaw or in'the
mouth including removal of impacted teeth (but excluding
dental work).
*Services of a podiatrist on the feet as follows: (a)
repair of lacerations and wounds produced by thermal or
chemical agents, .(b) reduction of fractures or complete
dislocation, (c) surgery requiring incision-through the
true skin, (d) 'the removal of plantar warts by chemo-
surgery, electrosurgery, or cryotherapy, (e) aspiration
and needling, and (f) office visits and x-ray and laboratory
expenses related to the above services.
*Charges incurred for a surgical transplant, whether
incurred by the recipient or donor, will be considered
expenses of the recipient and will be covered the same
as for any other illness or injury.:
*Services of an assistant surgeon are covered.
*Charges for voluntary sterilization are covered the same
as illness or injury.
4. ANESTHESIA
PLAN PAYS
For administration of anesthetic up to $50 or.40% of the
amount payable for -the operation performed, whichever' is greater
provided the surgical procedure is a covered expense. The difference
up to the reasonable and customary charge not payable under this
provision is then paid at 80% without the deductible requirement.
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5. OUT-OF-HOSPITAL X-RAY AND LABORATORY EXPENSES
100% of reasonable and customary charges for expenses in-
curred for x-ray, laboratory examinations and other tests
(except allergy and TB skin tests) necessitated by accidental
bodily injury or sickness and performed by or under the
supervision of a doctor when the service is rendered other than
in a hospital.
6. ALCOHOLISM AFTERCARE TREATMENT PROGRAM
Plan pays up to $150 for services rendered in an outpatient
aftercare. treatment program for alcoholism when the program
immediately follows and is an extension of care received in an
inpatient alcoholic treatment program. (This benefit is
payable only twice per. person per lifetime).
7. MATERNITY EXPENSES
Same benefits as for illness or injury. Bassinet or
nursery charges for days on which mother and child are both
confined are considered maternity expenses of the mother and
not expenses of the child. Also covered are charges for
amniocentesis and related tests on the unborn child when
medically necessary.
*DOCTOR - 100% of the reasonable and customary charge
for normal delivery and Cesarean Section.
*MIDWIFE EXPENSES - 100% of reasonable and customary charges
for normal delivery by a midwife if the services of a
licensed midwife are elected instead of the services of a
doctor.
*NEWBORN CARE - 80% of the reasonable and customary charge
for the initial routine in-hospital examination of a
newborn infant, if that infant is eligible for benefits
under the Plan.
All other expenses of the child are payable only if the
child is covered under a self and family enrollment and if
the confinement is for the treatment'of illness. or injury of
the child..
WHEN AND FOR WHOM MATERNITY BENEFITS ARE PAYABLE -
Benefits are payable, without a waiting period.,.for the
care of pregnancies which terminate while covered by the Plan,
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for an enrollee and all eligible family members under a self
and family enrollment.
MAJOR MEDICAL BENEFITS
1. THE DEDUCTIBLE
The "Deductible" is the $100 you must pay before the Plan
starts paying "Major Medical Benefits". There is a separate,,
"Deductible" for each member of your family. The "Deductible"
is applied once in a calendar year for each person, regardless
of how many different illnesses or accidents the person may have.
However, under a family enrollment covering-three or more persons
only two deductibles need be satisfied in any calendar year.
Furthermore, if two or more covered members of your family are
injured in the same accident, the deductible need be applied
only once for those members for all expenses relating to the
accident.
PLAN PAYS -- After application of the $100 deductible,
80% of reasonable and customary charges for the following
services and supplies to the extent they are not paid for by
Basic Benefits:
a. HOSPITAL INPATIENT EXPENSES in excess of the basic bene-
fits, excluding any charge for private accommodations in
excess of the hospital's average semi-private rate.
b. HOSPITAL OUTPATIENT EXPENSES in excess of the basic
benefits.
c. THE FOLLOWING SERVICES AND SUPPLIES either in or out of
hospital, which are not otherwise covered by this Plan and
which are recommended by the attending doctor in the diagnosis
and treatment of an accident or sickness:
DOCTORS' SERVICES, including doctors' office, home, and
hospital visits (unrelated to surgery).
DENTAL SERVICES AND TREATMENT (including initial replace-
ment of natural.teeth and dental x-rays) for repair of
accidental injury to the jaw or sound natural teeth
occurring while insured under this Plan, if received
within 24 months from the date of the accident.
CASTS, SPLINTS, BRACES, CRUTCHES, CANES, CERVICAL COLLARS,
CERVICAL TRACTION KITS, AND TRUSSES.
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X-RAYS AND SPECIAL TESTS in excess of basic benefits shown
on page 3.
ONE PAIR OF EYEGLASSES OR CONTACT LENSES and examinations
for them per lifetime when required to correct an impairment
directly caused by accidental ocular injury or intraocular
surgery and obtained within one year of the injury or surgery.
ONE HEARING AID and examination per lifetime if required to
correct an impairment directly caused by accidental injury
or intra-aural surgery and obtained within one year thereof.
LOCAL AMBULANCE SERVICE or if a special and unique hospital
treatment which is not available; locally is required,
transportation by professional am ulance, railroad or
commercial airline on a regularly scheduled flight, within
the United States or Canada to the nearest hospital equipped
to furnish the treatment, is also a covered expense. This
benefit does not apply to transportation necessary to obtain
the services of a doctor or any other practitioner.
RENTAL (or purchase at the option of the Plan) OF DURABLE
MEDICAL.EQUIPMENT. See definition page 9.-
PRIVATE DUTY NURSING. Charges for full-time or visiting
nursing care by a registered nurse (R.N.) or licensed
practical nurse (L.P.N.) are covered only when the care--
*is ordered by the attending doctor; and
*the doctor identifies the specific professional skills
of the R.N. or L.P.N. which the patient requires as well
as length of time needed; and
*when hospitalized as a bedpatient, the hospital and
doctor indicate that the hospital's general nursing staff
could not provide the care needed.
Charges for private nursing requested by, or for the
convenience of, the patient or the patient's family or
which consists primarily of bathing, feeding, exercising,
moving the patient, giving oral medication, or acting as
a companion or sitter are not covered.
OXYGEN and rental of equipment for its administration.
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OF A REGISTERED PHYSICAL THERAPIST OR A REGISTERED
SERVICES
OCCUPATIONAL THERAPIST for administration of physical therapy
in accordance with a doctor's specific instructions as to
type, frequency, and duration.
SERVICES of an independent consulting doctor for services
in relation to a second opinion regarding the necessity
for anticipated surgery.
SERVICES and supplies for renal dialysis and chemotherapy.
TWO EXTERNAL BREAST PROSTHESES and two bras per mastectomy
per calendar year designed exclusively for use with an
external prosthesis.
RADIUM, RADIOACTIVE ISOTOPES AND X-RAY THERAPY.
DRUGS AND MEDICINES (including generic drugs) which by law
of the United States require a doctor's written prescription;
and insulin.
ARTIFICIAL EYES AND LIMBS, to replace natural eyes and limbs
lost while covered by this Plan.
BLOOD OR BLOOD PLASMA (which is not donated or replaced) and
its administration.
d. FOR NERVOUS AND MENTAL DISORDERS -- In addition to other
services and supplies covered by Basic or Major Medical Benefits,
the following are covered under Major Medical Benefits when
rendered to patients with a mental or nervous disorder:
Services of a clinical psychologist who is duly licensed as
a psychologist or, in States not requiring a license, is
certified by a State psychological association.
Services of a psychiatric social worker under the direct
supervision of a psychiatrist.
Day Care in a qualified day care center as determined by the
Plan. A qualified day care center is one which provides a
planned program of psychiatric care for patients who are at
the center for only part of each day.
Doctors' offices, facilities operating principally as
schools or recreational or training centers, and facilities
primarily providing custodial services will not be recognized
as qualified day care centers.
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e. CHRISTIAN SCIENCE PRACTITIONERS. Charges of a Christian.
Science practitioner are allowable expenses if the practitioner's
services are elected instead of the, services of a doctor. This
election must be made separately for-each individual the first
time a claim is filed each calendar, year and will apply.to
expenses incurred during that year., This election may be
changed the following year if desired. The practitioner must
be listed as such in the Christian Science Journal current at
the time the service is provided. This election will not apply
.to, nor prevent payment of, a doctor's charges under Maternity
Benefits.
3. EXPENSES EXCEEDING $5,000 IN A CALENDAR YEAR
If the sum of allowable major medical expenses incurred in a
calendar year by the enrollee and all covered family members, if
any, reach $5,000, benefits for additional allowable major medical
expenses incurred by them in that calendar year will not be
subject to the Deductible and will be paid at the rate of 100%
of reasonable and customary charges.
DEFINITIONS
For purposes of this Plan --
A "doctor" is a licensed doctor of medicine (M.D.) or a licensed
doctor of osteopathy (D.O.). Dentists, psychologists, optometrists,
and podiatrists operating within the scope of their licenses are
also doctors for the purpose of services covered by this Plan.
In those states designated as MEDICALLY UNDERSERVED, the Plan
will consider charges for medical treatment by any medical
practitioner licensed by the state'to provide such treatment.
Medically underserved states are: Alabama, Alaska, Mississippi,
Missouri, Oklahoma, South Carolina, South Dakota, West Virginia,
Indiana, Kentucky, North Carolina and North Dakota.
A "hospital" is an institution which is accredited as a hospital
under the Hospital Accreditation Program of the Joint Commission
on Accreditation of Hospitals, or any other institution which is
operated pursuant to law, under the supervision of a staff of
doctors and with twenty-four hour a day nursing service, and which
is primarily engaged in providing:
a. General in-patient care and, treatment of sick and injured
persons through medical, diagnostic and major surgical facilities,
all of which facilities must belprovided on its premises, or
b. Specialized in-patient medical care and treatment of sick
or injured persons through medical and diagnostic facilities
(including x-ray and laboratory) on its premises.
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"Reasonable and customary" -- This Plan pays for charges, unless
otherwise indicated, which are comparable with charges incurred
from other providers: for similar services and supplies in the same
geographic area and which meet the Plan's established guidelines
to reasonable and customary charges for that area. The Plan's
guidelines to reasonable and customary charges have been developed
statistically from actual claims received in each geographic area
throughout the United States and are updated at least annually.
"Prescription drugs" are medicines that are obtainable only on a
doctor's written prescription and which must be assigned a
prescription number and dispensed by a registered pharmacist.
Receipts.for these drugs must be on a regular pharmacy billing
form (not cash register receipts) and show patient's name,
prescription name and number, price,' date of purchase, and name
of doctor who ordered the drug.
"Calendar year" is the 12 month period which begins on January 1
and runs through the following December 31. For a newly covered
person, the calendar year begins when coverage begins and runs
through December 31 of that same year. Expenses of a calendar
year are those incurred during that'calendar year.
A "confinement" is an admission (or series of admissions separated
by less than 60 days) to a hospital as an in-patient for any one
illness or injury. There is a new confinement when an admission
is:
(1) for a cause entirely unrelated to the cause for
the previous hospitalization; -
(2) for an enrolled employee who returns to work for
at least one full day before the next admission;
(3) for a dependent or annuitant when admissions are
separated by at least. 60 days.
"Custodial care" - Provision of room and board or other supportive
care in an institution or in the home (with or without routine
nursing care; training in activities of daily living and other
forms of self-care; or supervisory care by a doctor) to a person
who is mentally or physically disabled and who is not under specific
active medical, surgical, or psychiatric treatment to reduce the
disability to the extent necessary to enable the patient to
function without such care or when, despite such treatment, there
is no reasonable likelihood the disability will be so reduced.
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surgery" is any operative, procedure or any portion of
"Cosmetic
an operative procedure performed primarily to improve physical
appearance, treat a mental or nervous disorder through change
in bodily form, and/or change or restore form without correcting
or materially improving a bodily malfunction.
"Durable Medical Equipment" means equipment prescribed by the
attending doctor which: 1) is medically necessary; 2) is not
primarily and customarily used for a nonmedical purpose; 3) is
designed for repeated use; 4) serves a specific therapeutic
purpose in the treatment of an illness or injury; and 5) is of
no use to a person who has no illness or injury.
"Covered family members" - are spouse and unmarried children
under age 22, to include legally adopted children. Unmarried
stepchildren, foster children and recognized natural (illegitimate)
children under age 22 are also included if they live with you in
a regular parent-child relationship. A disabled child age 22 or
over (who became disabled before age 22) and who, because of the
disability, is incapable of self-support may also be eligible for
coverage. Unless covered under the'above exception, unmarried
children when they reach age 22 are~automaticall excluded as
"covered family members." Final determination eligibility is
made by the Plan.
EXCLUSIONS
Charges for the following are not covered by this Plan and
.cannot be counted for any purpose under this Plan:
*Any charges incurred while not covered by this Plan, any
charges which are not reasonable, or any charges for services
or supplies which are not necessary for the treatment of
injury or sickness
*Hospitalization or treatment paid for by any Governmental
body or for which no charge would be made if there were no
insurance
*Cosmetic surgery, except for repair of accidental injury
occurring while insured under this Plan, and the initial
reconstruction of the breast following a mastectomy which
was performed while covered under this Plan
*Eyeglasses (including Contact Lenses), hearing aids, and
examinations for them, except as specifically provided for
under major medical benefits
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*Routine physical examinations and immunizations
*Charges made by immediate relatives or members of the
household of the enrolled employee or patient
*Orthopedic shoes and other supportive devices for the feet
*Weight control or treatment of obesity
*Sex transformations, any treatment related to sexual
dysfunction, or reversals of sterilization
*Personal "comfort" services, such as telephone, radio and
television, beauty and barber services, etc.
*Air conditioners, humidifiers, and purifiers
*X-ray, laboratory, and pathological services, and machine
diagnostic tests not related to ,a specific illness or
injury or a definitive set of symptoms
*Nursing homes, rest homes, or places for the aged, or in
any other place which is not a "hospital"
*Custodial care, even when provided by a hospital
*Blood or blood plasma which is donated or replaced
*Podiatrist's charges, except for certain specified services,
see page 2
*Charges for the removal of cornsor calluses
*Charges for tooth extractions, preparation for orthodontic
treatment or dentures, or other ;dental work or surgery that
involves any tooth or tooth structure, alveolar process,
abscess, periodontal disease, or' disease of the gingival
tissue, except in case of accidental injury and for surgical
removal of impacted teeth
*Any services or supplies not shown as covered even if
recommended by a doctor
*Services and supplies not prescribed by a doctor in
accordance with generally accepted professional medical
standards
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*Types of practitioners not included in the definition of
"doctor" are not considered "doctors" for purposes of this
Plan, except Christian Science' Practitioners, see page 7
*Nutritional and fluoride supplements and vitamins
*Treatment of congenital anomalies related to teeth or
structures supporting teeth
*Infertility (except for the initial diagnostic testing)
*Counselling or therapy for marital, educational and
behavioral problems
*Wigs (except one wig per lifetime up to a maximum of
$150.00 without a deductible when required due to hair loss
in connection with chemotherapy or radiation therapy)
LIMITATIONS
The Double Coverage limitation is intended to prevent
payment of benefits which exceed expenses. It applies when a
person is eligible for benefits under any other kind of group
health coverage, Medicare, or "no-fault" automobile insurance.
When Double Coverage exists, this Plan will pay either its
benefits in full or a reduced amount which, when added to the
benefits available from all plans for the same covered expenses,
will not exceed 100 percent of reasonable and customary charges;
but in no case will this Plan pay an amount which is more than what
would have been paid in the absence of other insurance.
This provision applies whether~or not a claim is filed under
Medicare or the other plans. If needed, authorization must be
given to obtain information as to benefits or services available
under the other plans, or to recover overpayments. Insurance
coverage which pays for loss of income or for time lost from
work is not Double Coverage.
TO ASSURE PROMPT PAYMENT OF CLAIMS'
*Always submit claims promptly as they are incurred.
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*Be sure that all questions on the claim form are answered
fully and that all bills are itemized. (Cancelled checks
are not acceptable in lieu of itemized bills).
*Give your policy number and certificate number.
MAJOR MEDICAL CLAIMS
You will need complete and accurate records for each charge
you want to count toward the "Deductible" and for each charge
for which you claim benefits. Benefits for medical expenses are
often payable even though you have not been confined to a
hospital so it is important that you~keep a record of small
expenses. Keep in mind that the "Deductible" is applied once each
calendar year. Major Medical claims will be retained and applied
toward satisfaction of individual family member applicable
"Deductibles." Keep separate records for each member of your family
since the "Deductible" applies separately to each person. All
bills and receipts, including doctors' bills, should be itemized and
should show:
*The date of services and supplies are received
*The name of the family member concerned
*The name of the attending doctor!
*Diagnosis or nature of illness
*The type of service rendered
*The prescription name and number, of drugs and medicines
*The charge for each service
Claims must be filed within 90 drays after the expenses for
which claim is being made was incurred. The Plan is not required
to honor a claim submitted after the~90-day period unless it can
be shown that the claim was submitted as soon as reasonably
possible, but in no event more than two years after the date the
expense was incurred. To avoid the possibility of denial, submit
your claims within the 90-day period!.
Claims for services covered by Medicare and this Plan should
be submitted initially to Medicare. After Medicare has paid its
benefits, this Plan will consider the balance of any covered
expenses to the extent they are reasonable and customary. To be
sure your claims are processed promptly, please submit the payment
voucher from Medicare and duplicates of all bills along with a
complete claim form.
Any savings realized by the Plan because of payments made by
Medicare are used by the Plan to pay the deductible and coinsurance
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which you would have paid in the absence of Medicare coverage.
Such savings, however, can only beapplied toward covered charges
incurred in the year the savings are established and only for the
enrollee generating the savings.
IDENTIFICATION CARDS
Upon request you will be given Identification Cards as
evidence of your enrollment.
HOW PLAN BENEFITS CHANGE IN JANUARY 1981
Under Basic Benefits, the Plan has added coverage for emergency
treatment in a doctor's office in connection with an accidental,
bodily injury.
Under Basic Benefits, the Plan has increased the benefit for the
administration of anesthe.sia to $50'or 40% of the amount payable
for the operation performed,-.payingithe difference-at 80%. without
the deductible.
Under Basic . Benefits, the Plan has 'increased the benefit for out-
of-hospital x-ray and laboratory expenses to 100% of-reasonable
and customary charges.
Under Basic Benefits, the Plan has extended Podiatrist coverage
to include payment for services of aspiration and needling.
Under Basic Benefits, the Plan now pays for-the services of a
licensed midwife.
oil-
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REQUEST FOR GROUP HEALTH CONVERSION
As specified in the conversion privilege of your group certificate .. .
YOU ARE ENTITLED TO CONVERT YOUR GROUP COVERAGE
to one of the conversion plans described in this brochure when you cease to be eligible for your group coverage. You may convert
without evidence of insurability, provided:
(a) you continued your group insurance until the date you left the group and
(b) you apply for the conversion policy after the termination of your group insurance within the time period stated.
NO HEALTH EXAMS REQUIRED TO QUALIFY
This conversion plan will be issued toyou regardless of your present or past health history. However, questions in the application must
be completed. -
YOUR CONVERSION POLICY WILL COVER
you, your spouse and unmarried dependent children who were insured under your group certificate.
YOUR CONVERSION POLICY WILL BE EFFECTIVE
on the date you sign the attached application or on the date of termination of your group insurance, whichever is later. The initial
quarterly, semiannual or annual payment must accompany your !application.
YOUR CONVERSION POLICY
PROVIDES THE FOLLOWING. BENEFITS
HOSPITAL DAILY ROOM AND BOARD BENEFITS
Pays the expenses actually incurred for hospital room, board and nursing services for as long as 70 days for any one period of hospital
confinement - up to the benefit amount stated for your Plan.
MISCELLANEOUS HOSPITAL BENEFITS
Pays for the following services and supplies for actual expenses incurred for any one period of hospital confinement when room and
board benefits are payable - up to the benefit amount stated in' your Plan.
? Operating room, surgical dressings and casts, routine medicines, use of oxygen, X-rays, anesthetics, laboratory services and other
necessary services and supplies (excluding charges for nursing services or physician's services)
? Regular and customary charges for local emergency ambulance service
? Administration of anesthetic by persons other than regular hospital personnel
HOSPITAL OUTPATIENT BENEFITS
When you or an insured dependent is confined in a hospital
(1) as an outpatient within 48 hours of a covered accident or
(2) for a surgery resulting from covered injuries or sickness for which there is no room and board charge,
the policy provides benefits for hospital expenses actually incurred for care, treatment and services as described under the MISCEL-
LANEOUS BENEFIT provision (up to the Maximum Miscellaneous Benefit stated in your Plan).
MATERNITY BENEFITS
Pays benefits (up to the amount stated in your Plan) for maternity which has its inception while the policy is in force. Benefits are also
payable for miscarriage occurring during any pregnancy which normally would have resulted in childbirth which had its inception
while the policy was in force.
This conversion policy will also pay maternity benefits for a pregnancy beginning while the female Insured or dependent wife
was insured under the Group Plan if maternity benefits are not payable under any extended benefits provision of the Group Plan, but
would have been payable had the female Insured or dependent wife remained under such Group Plan.
SURGICAL BENEFITS
Provides benefits on a scheduled basis according to the nature of the operation. Pays benefits regardless of where the operation is
performed - home, hospital or doctors office.
Should multiple operations of the same or related cause take place within three months, this Plan will pay no more than the most
expensive operation scheduled.
In addition to the General Exceptions, Surgical Benefits are not payable for expense incurred because of childbirth, pregnancy or
resulting complications.
IN-HOSPITAL MEDICAL BENEFITS
Pays benefits for one doctor call each day during hospital confinement - up to the maximum benefit for your Plan for any one period
of hospital confinement When treatment requires surgery, your policy will pay either the in-hospital medical benefit or the sched-
uled surgical benefit, whichever is greater. This limitation will not apply if your confinement,following surgery lasts 14 days or
more, in which case benefits would begin on the 15th day.
In addition to the General Exceptions, In-hospital Medical Benefits are not provided for childbirth; pregnancyor resulting complica-
tions; tooth extractions or other dental work or surgery that involves any tooth ortooth structure, alveolar process, abscess, peri-
odontal disease or disease of the gingival tissue; eye refractions or the fitting or cost of eyeglasses or lenses.
-'~ d. Approved For Release 2007/10/19: CIA-RDP85-00024R000300220001-7 y = .~ -
 Approved For Release 2007/10/19: CIA-RDP85-00024R000300220001-7
?
SUMMARY OF COVERAGE
Your renewal agreement
Your policy cannot be terminated because of any future changes in your health or the number of times you receive benefits,
Other than the automatic premium change at specified ages (as shown on the schedule below), your premiums can be changed only
when changed for all policies of the same Form issued to all persons of the same classification in your state. You cannot be singled out
for a premium change.
Immediate coverage for sickness or injury
Covers immediately injuries and sickness resulting in loss while the policy is in force.
Newborn children are automatically covered
Any child of the Insured born while your policy is in force and while at least one other dependent is covered will automatically be
covered until the first day of the second month following birth. Thereafter, coverage can be continued simply by notifying the
Company in writing of a desire to continue the coverage and by paying the additional premium prior to the expiration of the period
of automatic coverage - regardless of health. Coverage for newborn children will be the same as the coverage provided for other
dependent children, or if other dependent children are not covered, the same as the coverage provided for your dependent spouse.
Benefits are not payable for the usual and customary baby care and treatment following full-term or premature birth.
General Exceptions
Benefits are not payable for: confinement beginning or other expense incurred while the conversion policy is not in force;
workmen's compensation or employers liability cases; losses caused by an act of declared or undeclared war or sustained
while in an armed service; loss for which benefits are payable under the Group Policy from which conversion was made;
services provided by or paid for by the Veterans Administration' of the United States Government.
"Hospital" benefits are not payable in any institution which is licensed or used principally as a clinic, convalescent home, rest
home, nursing home or home for the aged, drug addicts or alcoholics.
Termination
All benefits except the Daily Room Benefit terminate at age 65 or eligibility for Medicare, whichever is first.
THERE ARE SEVERAL CONVERSION PLANS AVAILABLE
(based on Daily Room Benefits)
You may apply for the Plan described below that equals the Daily Room (Benefit for which you were insured under the Base Plan of your
Group Policy. If the same Daily Room Benefit is not available, you may select either the next higher oranyother lower plan. If your Group
Policy did not specify a fixed dollar amount for the Daily Room Benefit, you mayconvert to any plan under which the Daily Room Benefit
does not exceed the average semi-private room rate in hospitals in your area of residence.
NOTE: Other insurance you may have will be taken into consideration to determine the conversion Plan you can select
Daily
Daily
Room
Maternity
Hospital Hospital
In-hospital
Plan
Benefits
Benefits
Miscellaneous/Outpatient
Surgical
Medical
1
30 0 _
3 000
$ 400.00
From $5.33 to $400.00 4 00
2
40.00
400.00
600.00
From
6.66 to
500.00
5.00
3
50.00
500.00
800.00
From
8.00 to
600.00
6.00
4
60.00
600.00
1,000.00
From
9.33 to
700.00
7.00
Pays Daily Room Benefit up to 70 days.
QUARTERLY PREMIUMS
Maximum
In-hospital
Medical
$280.00
350.00
420.00
490.00
PLAN
1
2
3
4
AGE
20-29
30-39
40-49
50-59
60-64
65 & Over
$ 48.06
54.06
74.10
120.15
180.21
65.34
MALE(
$ 59.64
67.1 ]
91.95
149.10
223.65
87.12
$ 70.47
79.29
108.63
176.16
264.24
108.90
$.80.64
90.72
124.32
201.63
302.43
130.68
20-29
86.40
FEMALE
108.06
130.38
152.01
30-39
75.15
94.59
112.98
130.56
40-49
90.63
113.16
134.22
154.20
50-59
145.56
181.62
215.31
247.23
60-64
218.34
272.43
322.95
370.86
65 & Over
65.34
87.12
108.90
130.68
Semiannual Premium: 2 times quarterly premiums.
Annual Premium: 4 times quarterly premiums.
Approved For Release 2007/10/19: CIA-RDP85-00024R000300220001-7