Underwritten by United States Fire Insurance Company
Limited Fixed Indemnity Benefit Plan
MultiPlan Limited Benefit Plan Network
Members under this plan receive access to the MulitPlan Limited Benefit Plan network, and may choose to be treated in or out of this network. This network membership entitles members access to doctors and hospital facilities who are contracted to provide specific medical care at negotiated rates.
Disclaimer: The amount of reduction varies by state and type of medical service received. Members must pay for all services, no portion of any provider’s fees will be reimbursed or otherwise paid by MultiPlan Limited Benefit Plan network. MultiPlan Limited Benefit Plan network does not process claims, they only provide a network of providers who have agreed to accept negotiated rates. The list of participating providers is subject to change without notice. The MultiPlan Limited Benefit Plan network is not affiliated with United States Fire Insurance Company and the insurance benefits provided are not dependent on the use of this network. For more information about this network please visit www.multiplan.com.
This is not insurance and is not affiliated with the Choice Fixed Indemnity Insurance Plan provided by United States Fire Insurance Company.
Limitations & exclusions
Pre-Existing Conditions will not be covered for a period of the first 12 months after the Covered Person’s Effective Date of Coverage. Pre-Existing Condition means a disease or physical condition for which medical advice or treatment was recommended or received by the Covered Person during the 12 months prior to the Covered Person’s Effective Date of Coverage.
The Policy does not cover any loss resulting in whole or part from, or contributed to by, or as a natural or probably consequence of any of the following:
*This is a brief description of coverage, and is subject to the terms, conditions, limitations and exclusions of the policy. Please see the policy and certificate for complete details. Coverage may vary or may not be available in all states. Plans are underwritten by United States Fire Insurance Company, Eatontown, NJ
Please note certain words used in this document have specific meanings. The male pronoun includes the female whenever used. Additional terms may be defined within the provision to which they apply.
The capitalized terms used herein are defined as follows:
"Accident" means a sudden, unforeseeable external event which:
(1) Causes Injury to one or more Covered Persons; and
(2) Occurs while coverage is in effect for the Covered Person.
“Certificate Holder” means a person to whom an insurance certificate has been issued evidencing coverage under the Policy.
“Child” means the Insured Person’s natural Child, adopted Child (or Child placed in the Insured Person’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Insured Person has legal guardianship (proof will be required). A Child must reside with the Insured Person in a parent-Child relationship and be eligible to be claimed as an exemption on the Insured Person’s federal income tax return. NOTE: In the event the Insured Person shares physical custody of the Child with another parent, the requirement that the Child reside with the Insured Person will be waived.
“Civil Union Partner” means the parties to a civil union who are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded to spouses. Throughout the Policy, a party to a civil union shall be included in any definition or use of the terms such as spouse, family, dependent, next of kin, and other terms descriptive of spousal relationships. This includes the terms 'marriage' or 'married' or variations thereon. The term spouse or dependent includes civil union couples whenever used.
“Company” means United States Fire Insurance Company. Also hereinafter referred to as We, Us and Our.
“Complications of Pregnancy” means a condition which:
When pregnancy is not terminated, requires medical treatment and whose diagnosis is distinct from pregnancy but is adversely affected by or are caused by pregnancy, such as: (a) acute nephritis; (b) nephrosis; (c) cardiac decompensation; (d) missed abortion; (e) eclampsia; (f) puerperal infection; (g) R.H. Factor problems; (h) severe loss of blood requiring transfusion; and (i) other similar medical and surgical conditions of comparable severity related to pregnancy.
When pregnancy is terminated: (a) non-elective cesarean section; (b) ectopic pregnancy that is terminated; and (c) spontaneous termination of pregnancy during a period of gestation in which a viable birth is not possible.
Complications of Pregnancy will not include:
Delivery by cesarean section is considered a complication of pregnancy if the cesarean section is non-elective. A cesarean section will be considered non-elective if the fetus or mother is determined to be in distress and is in immediate danger of death, Sickness or Injury if a cesarean section is not performed. A cesarean section beyond one performed in any previous pregnancy will also be considered non-elective if vaginal delivery is medically inappropriate, or a vaginal delivery is attempted but discontinued due to immediate danger of death, Sickness or Injury to the Child or mother.
“Covered Accident” means an Accident that occurs while coverage is in force for a Covered Person and results in a Covered Loss for which benefits are payable.
“Covered Loss or Covered Losses” means an accidental death, dismemberment or other Injury or Sickness covered under the Policy and indicated on the Schedule of Benefits.
"Covered Person" means an Insured Person and Dependent eligible for coverage as identified in the Enrollment/Application for whom proper premium payment has been made when due, and who is therefore insured under the Policy.
“Dependent” means an Insured Person’s:
The age limitations will not apply to an Insured Person’s unmarried Child who is incapable of self-support due to a mental or physical incapacity. Proof of such incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation. Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.
“Domestic Partner” means an opposite or same sex partner who, for at least 6 consecutive months, has resided with the Insured Person and shared financial assets/obligations with the Insured Person. Both the Insured Person and the Domestic Partner must: (1) intend to be life partners; (2) be at least the age of consent in the state in which they reside; and (3) be mentally competent to contract. Neither the Insured Person nor the Domestic Partner can be related by blood to a degree of closeness that would prohibit a legal marriage, be married to anyone else, or have any other Domestic Partner. The Company requires proof of the Domestic Partner relationship in the form of a signed and completed Affidavit of Domestic Partnership.
“Eligibility Waiting Period” means the period of time of continuous membership in an Eligible Class that a Covered Person must satisfy before their coverage under the Certificate is effective.
“Enrollment Period” means the period agreed upon by the Policyholder and Us when an Eligible Person may enroll for coverage or an Insured may change benefit elections under the Policy.
"He", "His" and "Him" includes "she", "her" and "hers."
“Hospital” means an institution licensed, accredited or certified by the State that:
Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.
We will not deny a claim for services solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability, and the Hospital is accredited by any one of the following:
In addition, We will not deny a claim for a Skilled Nursing Facility if it meets the definition of such a facility and is a Covered Benefit under the Policy.
Hospital does not include a place, special ward, floor or other accommodation used for: custodial or educational care; rest, the aged; a nursing home or an institution mainly rendering treatment or services for mental illness or substance abuse, except as specifically stated.
"Hospital Stay or Hospital Confinement" means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.
“Immediate Family Member” means a Covered Person’s spouse, Domestic Partner, Civil Union Partner, parent, Child(ren) (includes legally adopted or step Child(ren), brother, sister, grandchild(ren), or in-laws
"Injury" means bodily Injury caused by the direct result of an Accident occurring after the effective date of a Covered Person's coverage under the Policy, while the Policy is in force as to the person whose Injury is the basis of the claim which results, directly and independently of disease, bodily infirmity and all other causes, in a Covered Loss. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single Injury.
“Insured Person” means a member of the Policyholder who is eligible, who enrolls for coverage and for whom the required premium is paid making insurance in effect for that person under the Policy. A Dependent covered under the Policy is not an Insured Person.
“Life Status Change” means an event recognized by the Policyholder and Us that qualifies the Insured Person to make changes in coverage at any time other than an Enrollment Period. The following events are all considered Life Status Changes:
“Medical Emergency” means a Sickness or Injury for which the Covered Person seeks immediate medical treatment at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are sufficiently severe (including severe pain) that without immediate medical care a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would cause:
Treatment for Medical Emergency will be paid only for Sickness or Injury which fulfills the above conditions.
"Medically Necessary" or "Medical Necessity" means a treatment, drug, device, service, procedure or supply that is:
When specifically applied to Hospital confinement, it means that the diagnosis or treatment of symptoms or a condition cannot be safely provided on an outpatient basis.
A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:
“Mental Illness or Nervous Disorder” means any condition or disease, regardless of its cause, listed in the most recent edition of the International Classification of Diseases as a Mental Disorder on the date the medical care or treatment is rendered to a Covered Person.
"Nurse" means either a professional, licensed, graduate registered nurse (R.N.) or a professional, licensed practical nurse (L.P.N.).
“Optionally Renewable” means renewal is at the option of United States Fire Insurance Company.
“Physician” means a person who is a qualified practitioner of medicine. As such, He or She must be acting within the scope of his/her license under the laws in the state in which He or She practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include a Covered Person, a Covered Person’s Spouse, Domestic Partner or Civil Union Partner, son, daughter, father, mother, brother or sister or other relative.”
“Policy Period” means, initially, the period of time from the Effective Date of the Policy until the first Policy Anniversary Date, and thereafter each subsequent 12 consecutive months provided coverage remains in force.
“Policyholder” means the entity shown as the Policyholder in the Schedule of Benefits.
“Pre-existing Condition” means a disease or physical condition for which medical advice or treatment was recommended or received by the Covered Person during the 12 months prior to the Covered Person’s Effective Date of coverage.
“Prescription Drug” means drugs dispensed by a licensed pharmacist by written prescription under Federal law, and approved for general use by the Food and Drug Administration.
“Sickness” means an illness, disease or condition of the Covered Person that causes a loss for which a Covered Person receives medical treatment while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.
“Skilled Nursing Facility” means a facility that provides skilled nursing 24 hours a day, seven days a week, under the supervision of a registered nurse, and/or skilled rehabilitative services at least five days per week. The emphasis is on skilled nursing care, with restorative, physical, occupational, and other therapies available. A Skilled Nursing Facility provides services that cannot be efficiently or effectively rendered at home or in an intermediate care facility. The service provided must be directed towards the patient achieving independence in activities of daily living, improving the patient’s condition, and facilitating discharge.
“Spouse” means lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Partner.
“Substance Abuse” means the use of any drug or substance(s) for non-therapeutic purposes; or use of medication for purposes other than those for which it is prescribed.
“We, Our, Us” means United States Fire Insurance Company underwriting this insurance or its authorized agent.
“You, Your, Yours, He or She” means the Covered Person who meets the eligibility requirements of the Policy and whose insurance under the Policy is in force.
*Definitions may vary by state. Please see the policy and certificate for complete details. Coverage may vary or may not be available in all states. Plans are underwritten by United States Fire Insurance Company, Eatontown, NJ
About the association
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