What is included?

Hospital Stays Benefits

This plan includes a hospital stays benefit - which means you will receive a set amount when you are confined in a hospital. The benefits are paid directly to you or your designee.

• Inpatient Hospital Stay :$500/day
• Maximum Benefit Days (per Plan Year): 30
• Maximum Benefit Amount (per Plan Year): $15,000

Doctor Visits Benefits

This plan includes a doctor visit benefit - which means you will receive a set amount if you have to visit the doctor. The benefits are paid directly to you or your designee.

• Physician Office Visit: $100/visit
• Maximum Visits (per Plan Year): 3
• Maximum Benefit Amount (per Plan Year): $300

Also included

Teladoc

A telemedicine solution that solves the three biggest issues in healthcare: Access, Cost, and Quality:

• 24/7 availability
• Available in all states

How it works

• Request a visit with a doctor 24 hours a day, 365 days a year, by web, phone, or mobile app. Want to see the doctor? Choose “video” as the method for your visit. Feeling camera shy? Choose “phone.” Got a busy schedule? Select a time that’s best for you by choosing “schedule” instead of “as soon as possible.” We’ll search our national network of U.S. board- certified physicians, dermatologist and therapists and pair you with a doctor licensed in your state. The doctor will review your medical records. Your medical history provides valuable information to the doctor regarding past conditions, medications, allergies as well as information about your family’s medical history.
• Talk to the doctor. Take as much time as you need…. there’s no limit! We lead the market with the industry’s most comprehensive suite of telehealth services. You can receive convenient, quality care from a variety of licensed healthcare professionals.
• If medically necessary, a prescription will be sent to the pharmacy of your choice. Receive the treatment you need in a timely, expedient manner. In addition, you have the ability to send your visit results to your primary care physician.

Just call 1-800-Teladoc and provide your Teladoc account information.

Karis360

Karis360 takes the hassle out of healthcare by helping members with questions about insurance claims, medical billing, and where to go for care:

• Concierge services for members so they don’t have to deal with their healthcare questions and issues alone.
• Unlimited assistance from a Personal Advisor who works directly with a member’s healthcare providers to help reduce their out-of-pocket medical bills.

Who is it for?

Legion Limited Medical is ideal for people who are looking for:

• A wellness visit for an insured child under age 4: If you have a young child, this plan will provide an annual office visit with a $50 copay to monitor and maintain your child’s health.
• Access to a national provider network to minimize out-of-pocket costs: First Health has access to more than 5,000 hospitals, over 90,000 ancillary facilities, and over 1 million health care professional service locations in the United States
• Diagnostic, X-ray, and Laboratory benefits: Two days of coverage for class I and II and one day for class IV. Benefit payout is $50/day.

Plan Benefits

This is a brief summary of Legion Limited Medical Plan. Benefits are subject to the policy limitations and exclusions. Refer to the policy, certificate, and riders for complete details.

Exclusions and Limitations

Benefits in connection with a Pre-existing Conditions occurring within the first twelve (12) months of coverage are not payable. “Pre-existing Condition” means an illness, disease, or other condition of the Covered Person, that was treated, diagnosed or required medications in the six (6) month period before the Covered Person’s coverage became effective under this Policy. This Pre-Existing Condition Limitation shall not apply after the end of the Limitation Period shown in the Schedule of Benefits, commencing on the Insured Person’s Coverage Effective Date.

In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section of the insurance certificate:

1. Intentionally self-inflicted injury, suicide or any attempt while sane or insane;
2. ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.
3. Declared or undeclared war or act of war;
4. Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;
5. An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;
6. Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency;
7. Flight in, boarding or alighting from an Aircraft except as: a fare-paying passenger on a regularly scheduled commercial or charter airline; a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;
8. Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
9. Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;
10. Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
11. The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;
12. An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;
13. Alcoholism, drug addiction or the use of any illegal drug or narcotic except as prescribed by a Physician unless specifically provided herein;
14. Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;
15. Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
16. Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.
17. Mental and nervous disorders.
18. Elective surgery or cosmetic surgery, except for reconstructive surgery needed as the result of a Covered Injury or Covered Sickness.
19. Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.
20. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
21. Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery.
22. Services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness.
23. Treatment or services provided by a private duty nurse.
24. Organ or tissue transplants and related services.
25. Personal comfort or convenience items.
26. Rest or custodial cures.
27. Hearing aids.
28. An Injury or Sickness for which the Insured Person is paid benefits under any Workers’ Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

1. Employed or retained by the Policyholder;
2. Living in the Insured Person’s household;
3. An Immediate Family Member of either the Insured Person or the Insured Person’s Spouse;
4. The Insured Person.

Claims

Sometimes a provider will not submit the claim on your behalf. If this occurs, you can submit the claim yourself by followingthese steps:

• Obtain a paid-in-full receipt from the provider that displays CPT/diagnosis code(s), date-of-service(s), amount chargedper code, and total amount paid.
• Write a letter stating that you (the insured) should be the one reimbursed for the services provided.
• Send a copy of your receipt and a copy of your letter to
  • WEB-TPA
  • P.O. Box 99906
  • Grapevine, TX 76099
  • EDI Payor ID: 75261

For claims and questions about your benefits, please call WEB-TPA at: 1-855-457-8178

For policies purchased on or before July 1st 2018:

Administrative Concepts Inc.
994 Old Eagle School Rd., Ste. 1005
Wayne, PA 19087
EDI Payor ID: 22384

For claims and questions about your benefits, please call Administrative Concepts Inc. at: 1-877-301-5421

Preferred Provider (PPO) Network Access
First Health Network
firsthealthlbp.com

Customer Service and Billing

For customer service or billing questions please contact us at:

For simple transactions such as a payment error where you payment information needs to be updated or if you want a refund inside the “free-look period” which is 10 days in most states, this can be done in the member portal @ www.AgileHealthInsurance.com/customers

For other payment errors where you need to process a payment, you need to call Agile at (877) 353-0962 to process the payment.

Other refund requests will have to be escalated, please call (877) 353-0962 for other requests and they will be addressed on a case by case basis in accordance with each individual insurance company’s policy.

AGILE SERVICE PLEDGE

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• Responsive
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• Accountable
• Transparent