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Insurance Abstract
The present systems and methods enable an insurance underwriter
to offer group term specified disease coverage. Such policies can
provide lump-sum benefits for occurrences of conditions that are
covered under the policy. In particular, coverages can be provided
for specified diseases such as: (1) various forms of cancer; (2)
heart attack; (3) coronary artery bypass graft; (4) kidney failure;
(5) major organ transplant; (6) stroke; and (7) skin cancer. As
will be recognized, different types of cancer may also result in
varying levels of coverage. For example, there may be benefit differences
for cancers termed "full coverage cancers," those termed
"partial benefits cancers," and those generally called
"other cancer.".
Insurance Claims
What is claimed is:
1. A computer implemented method for providing insurance comprising:
issuing a group term specified disease insurance policy covering
one or more conditions; receiving a premium payment based at least
in part on said one or more conditions; and in response to data
indicating that said one or more policy terms are met, paying a
claim amount based at least in part on said one or more conditions.
2. The method of claim 1 further comprising the step of electronically
calculating premiums based at least in part on said one or more
conditions.
3. The method of claim 1 wherein said one or more conditions comprises
at lease one of: 1) full benefit cancer, 2) partial benefit cancer,
3) heart attack, 4) coronary artery bypass graft, 5) kidney failure,
6) major organ transplant, 7) stroke, 8) skin cancer, and 9) other
cancer.
4. A system of insurance policy maintenance comprising: a database
component operable to store information related to one or more group
term specified disease insurance policies, said group specified
disease insurance policy comprising information related to one or
more conditions; an insurance maintenance component operable to
update said database with information related to said one or more
group term disease insurance policies; and a payment component operable
to send a notification that a claim amount should be paid, said
notification sent in response to data indicating that said one or
more policy terms have been met.
5. The system of claim 4 further comprising a premium calculation
component, said premium based at least in part on said one or more
conditions.
6. The system of claim 4 wherein said one or more conditions comprises
at least one of: 1) full benefit cancer, 2) partial benefit cancer,
3) heart attack, 4) coronary artery bypass graft, 5) kidney failure,
6) major organ transplant, 7) stroke, 8) skin cancer, and 9) other
cancer.
Insurance Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit of U.S. Provisional
Application No. 60/578,996, filed Jun. 11, 2004. The entire contents
of the above application are incorporated herein by reference.
SUMMARY
[0002] The present systems and methods enable an insurance underwriter
to offer group term specified disease coverage. Such policies can
provide lump-sum benefits for occurrences of conditions that are
covered under the policy. In particular, coverages can be provided
for specified diseases such as: (1) various forms of cancer; (2)
heart attack; (3) coronary artery bypass graft; (4) kidney failure;
(5) major organ transplant; (6) stroke; and (7) skin cancer. As
will be recognized, different types of cancer may also result in
varying levels of coverage. For example, there may be benefit differences
for cancers termed "full coverage cancers," those termed
"partial benefits cancers," and those generally called
"other cancer."
[0003] In one embodiment, a member of a group pays a premium for
coverage of one or more specified diseases. Such premiums can reflect
coverage for all diseases coverable under the policy, or may only
reflect coverage for one or more diseases from the full list of
diseases coverable under the policy. As will be recognized by those
skilled in the art, the group policy may have premiums paid by the
group policyholder, by the individual members, or by a combination
of the two.
[0004] As illustrated below, in certain embodiments, different
members will have their premiums calculated in different ways. Such
premiums may have adjustments based on the covered member's relationship
to the entity providing the group policy. Additionally, policy premiums
may be at a standard rate for both employees as well as dependents
of the employees covered under the policy.
[0005] In one embodiment, a computer system is operable to maintain
a database of policy related data. Such data can include the premium
amounts, policy amounts, coverage amounts, policy terms, parties
to the policy, group entity, and other group insurance related terms.
The database may contain a single entry for all data, or related
entries comprising all information for a particular member, policy,
group or other policy related member. For example, one database
entry may contain the name, regarding the policy amount, premium
amount, coverage amount, and other policy related information.
[0006] The computer system may further be operable to calculate
premium amounts, determine benefit payouts, send and receive notifications
regarding the policy, and provide an interface for policyholders,
members, or the insurance provider to maintain, update, edit, review,
or otherwise access information about the policy. For example, the
policyholder may be provided a mechanism to add new employees to
the group policy; the member may be able to add a new dependent;
and the provider may be able to add a new coverage, or modify the
payout amount for a particular condition.
FIGURES
[0007] FIG. 1 is a flow diagram illustrating one embodiment of
the present systems and methods.
DETAILED DESCRIPTION
[0008] As shown in FIG. 1, in step 102, an underwrite or policy
provider issues a group term specified disease policy. Terms of
such policies are described below. The policy can be issued to an
employee of the group holding the policy, and may cover the employee
as well as the spouse and dependents of the employee. In step 104,
premiums are received for the policy. As will be recognized, such
premiums may come from the employee, the group policyholder, or
a combination of both. In step 106, a benefit is paid to a person
covered under the policy based on meeting criteria specified in
the terms of the policy. As will be recognized, the premiums and
benefits may be calculated for each group, and may also be modified
based on new criteria as appropriate.
[0009] In one embodiment, a group specified disease coverage policy
provides the following terms and descriptions.
Section XXXVI
Group Specified Disease Coverage
[0010] I. The group policy provides a lump-sum benefit for the
first occurrence of a covered condition in a covered person's lifetime
either in accordance with a specified schedule of insurance, or
in amounts which are optional to the employee. Benefits amounts
will be offered for sale in even increments of $1,000. In no event
shall coverage on any single individual exceed $500,000. For certain
clearly identifiable forms of diseases with significantly lower
treatment costs, lesser amounts may be offered, but in no event
shall any such amount be lower than $250. Coverage may be offered
on a non-contributory basis with premiums paid by the group policyholder
or on a contributory basis with premiums paid by group certificate
holders.
[0011] Coverage may also be provided for dependent spouses and
dependent children of employees.
[0012] II. Policies Providing Benefits According to a Specified
Schedule of Insurance with Premiums to be Paid by the Group Policyholder
[0013] A. Specified Schedule of Insurance
1 COVERED CONDITION STANDARD OFFERING BENEFIT Full Benefit Cancer
100% of Total Benefit Amount Partial Benefit Cancer Lesser of {$15,000,
25% of Total Benefit Amount} Heart Attack 100% of Total Benefit
Amount Coronary Artery Bypass Graft Lesser of {$15,000, 25% of Total
Benefit Amount} Kidney Failure 100% of Total Benefit Amount Major
Organ Transplant 100% of Total Benefit Amount Stroke 100% of Total
Benefit Amount Skin Cancer $250 Other Cancer $1,000
[0014] The Total Benefit Amount means the maximum amount payable
under the policy per covered person for all Covered Conditions combined
as specified in the Schedule of Insurance.
[0015] B. Standard Monthly Premium Rates for Specified Schedule
of Insurance on Employees
[0016] The standard monthly premium rates per $1,000 of coverage
for each group applicable to policyholder paid employee coverage
will be computed based on the demographics of the group and the
principal industry of employment of that group according to the
following algorithm.
[0017] Step 1A: Cross multiply the base monthly premium rates shown
in Table XXXVI.IA with the applicable proposed coverage amounts
(in thousands) determined using a complete census of the insured
classes of employees or eligible classes of employees provided by
the group policyholder. Sum the result obtained for each age and
gender cell across all age and gender cells.
[0018] Step 1B: Cross multiply the base monthly premium rates shown
in Table XXXVI.IB with the applicable proposed coverage amounts
(in thousands) for skin cancer coverage (0.250 for the standard
offering benefit) determined using a complete census of the insured
classes of employees or eligible classes of employees provided by
the group policyholder. Sum the result obtained for each age and
gender cell across all age and gender cells.
[0019] Step 2: Sum the results of Step 1A and Step 1B.
[0020] Step 3: Sum the total proposed coverage amounts across the
entire census used in Step 1A.
[0021] Step 4: Divide the result of Step 2 by the result of Step
3.
[0022] Step 5: Multiply the result of Step 4 by the applicable
Industry Adjustment Factor from Table XXXVI.2.
[0023] Step 6: Multiply the result of Step 5 by the appropriate
Volume Adjustment Factor from Table XXXVI.3.
[0024] Step 7: Adjust the results from Step 6 to reflect an increasing
trend in claim cost. The baseline rates derived from Step 6 will
be multiplied by 1.xxxT, where T is the elapsed time (measured in
years) from Jul. 1, 2005 to the mid-point of the prospective policy
period.
[0025] Step 8: Broker commissions payable in accordance with Section
XXX of this manual will be included in the final premium rates if
applicable.
[0026] Step 9: Round the results of Step 8 to 3 decimal places
to determine the final result.
[0027] C. Adjustments to Standard Monthly Premium Rates for Specified
Schedule of Insurance on Employees
[0028] 1. If any of the Covered Conditions outlined in Section
II.A are to be included with a different benefit percentage, the
premium rate determined in Step 1A should be multiplied by a factor
(f.sub.Bj) for each age j, before proceeding to Step 2, where f.sub.Bj
is defined as
f.sub.Bj=1-.SIGMA..sub.i((1-B.sub.i)*C.sub.ji), i=1,6
[0029] where
[0030] j is the index for age (17.ltoreq.j.ltoreq.100),
[0031] B.sub.i is the ratio of the new benefit percentage to the
standard benefit percentage for Covered Condition i, and
[0032] C.sub.ji is the age-dependent weight of Covered Condition
i, as outlined in Table XXXV1.4, Part A.
[0033] D. Standard Monthly Premium Rates for Specified Schedule
of Insurance on Dependent Spouses
[0034] The standard monthly premium rates per $1,000 of coverage
for each group applicable to policyholder paid, dependent spouse
coverage will be computed based on the demographics of the group
and the principal industry of employment of that group according
to the following algorithm.
[0035] Step 1A: Cross multiply the base monthly premium rates shown
in Table XXXVI.1A with the applicable proposed coverage amounts
(in thousands) determined using a complete census of the insured
classes of dependent spouses or eligible classes of dependent spouses
provided by the group policyholder. Sum the result obtained for
each age and gender cell across all age and gender cells. In the
event a dependent spouse census is not available, an employee census
may be used assuming spouses are of the opposite sex of the employee
and employing a suitable age differential between employees and
spouses.
[0036] Step 1B: Cross multiply the base monthly premium rates shown
in Table XXXVI.IB with the applicable proposed coverage amounts
(in thousands) for skin cancer coverage (0.250 for the standard
offering benefit) determined using a complete census of the insured
classes of dependent spouses or eligible classes of dependent spouses
provided by the group policyholder. Sum the result obtained for
each age and gender cell across all age and gender cells. In the
event a dependent spouse census is not available, an employee census
may be used assuming spouses are of the opposite sex of the employee
and employing a suitable age differential between employees and
spouses.
[0037] Step 2: Sum the results of Step 1A and Step 1B.
[0038] Step 3: Sum the total proposed coverage amounts across the
entire census used in Step 1A.
[0039] Step 4: Divide the result of Step 2 by the result of Step
3.
[0040] Step 5: Multiply the result of Step 4 by the applicable
Industry Adjustment Factor from Table XXXVI.2.
[0041] Step 6: Multiply the result of Step 5 by the appropriate
Volume Adjustment Factor from Table XXXVI.3.
[0042] Step 7: Adjust the results from Step 6 to reflect an increasing
trend in claim cost. The baseline rates derived from Step 6 will
be multiplied by 1.xxxT, where T is the elapsed time (measured in
years) from Jul. 1, 2005 to the mid-point of the prospective policy
period.
[0043] Step 8: Broker commissions payable in accordance with Section
XXX of this manual will be included in the final premium rates if
applicable.
[0044] Step 9: Round the results of Step 8 to 3 decimal places
to determine the final result.
[0045] E. Adjustments to Standard Monthly Premium Rates for Specified
Schedule of Insurance on Dependent Spouses
[0046] 1. If any of the Covered Conditions outlined in Section
II.A are to be included with a different benefit percentage, the
premium rate determined in Step 1A should be multiplied by a factor
(f.sub.Bj) for each age j, before proceeding to Step 2, where f.sub.Bj
is defined as
f.sub.Bj=1-.SIGMA..sub.i((1-B.sub.i)*C.sub.ji), i=1,6
[0047] where
[0048] j is the index for age (17.ltoreq.j.ltoreq.100),
[0049] B.sub.i is the ratio of the new benefit percentage to the
standard benefit percentage for Covered Condition i, and
[0050] C.sub.ji is the age-dependent weight of Covered Condition
i, as outlined in Table XXXVI.4, Part B.
[0051] F. Standard Monthly Premium Rates for Specified Schedule
of Insurance on Dependent Children
[0052] If the policy provides standard benefits for dependent children,
the standard monthly premium rates per $1,000 will be based on the
age at which dependent child coverage ends as contained in the policy
as shown in the following table:
2 Dependent Child Definition Monthly Premium Rate per $1,000 To
age 18 To age 19* To age 20* To age 21* To age 22* To age 23* To
age 24* To age 25* To age 26* *provided the child is a full time
student
[0053] III. Policies Providing Voluntary Amounts with Premiums
to be Paid by the Participants of the Group Policy
[0054] A. Standard Schedule of Voluntary Insurance
3 COVERED CONDITION STANDARD OFFERING BENEFIT Full Benefit Cancer
100% of Total Benefit Amount Partial Benefit Cancer Lesser of {$15,000,
25% of Total Benefit Amount} Heart Attack 100% of Total Benefit
Amount Coronary Artery Bypass Graft Lesser of {$15,000, 25% of Total
Benefit Amount} Kidney Failure 100% of Total Benefit Amount Major
Organ Transplant 100% of Total Benefit Amount Stroke 100% of Total
Benefit Amount Skin Cancer $250 Other Cancer $1,000
[0055] The Total Benefit Amount means the maximum amount payable
under the policy per covered person for all Covered Conditions combined
as selected by the covered person and as specified in the certificate.
[0056] B. Monthly Premium Rates for Standard Schedule of Voluntary
Insurance for Employee Coverage
[0057] Uni-sex rates per $1,000 of voluntary coverage will be developed
by smoking status in 5-year age brackets for each group policy.
The premiums charged to covered persons will be based on the actual
amount of coverage elected by the covered person, the covered person's
attained age, and the covered person's smoking status. A schedule
of uni-smoker rates will also be available.
[0058] A premium schedule of monthly unisex rates per $1,000 of
coverage for each group applicable to voluntary employee coverage
will be computed based on the demographics of the group and the
principal industry of employment of that group according to the
following algorithm.
[0059] Step 1: Determine the expected distribution of employee
coverage between male and female employees. If a group specific
employee census is available, the percentage of males and females
within the overall group should be determined directly from the
data. If no census is available, the expected overall percentage
of male employees should be determined by using the factors in Table
XXXVI.2 and the Standard Industrial Classification ("SIC")
code of the group. The percentage of female employees is then calculated
by subtracting the percentage of male employees thus determined
from 1.
[0060] Step 2: Using the male and female percentages determined
in Step 1, blend the male and female non-smoker base rates from
Table XXXVI.5 within each 5-year age bracket using the following
formula:
Blended Non Smoker ("NS") Base Rate.sub.i=(% male).times.(male
NS base rate).sub.i+(% female).times.(female NS base rate).sub.i
for each age bracket i.
[0061] Step 3: Using the male and female percentages determined
in Step 1, blend the male and female smoker base rates from Table
XXXVI.5 within each 5-year age bracket using the following formula:
Blended Smoker ("S") Base Rate.sub.i=(% male).times.(male
S base rate).sub.i+(% female).times.(female S base rate).sub.i for
each age bracket i.
[0062] Step 4: Multiply each 5-year bracket rate in the non-smoker
step rate table derived in Step 2 and each 5-year bracket rate in
the smoker step rate table derived in step 3 by the applicable Industry
Adjustment Factor from Table XXXVI.2.
[0063] Step 5: Multiply each 5-year bracket rate in the non-smoker
step rate table derived in Step 4 and each 5-year bracket rate in
the smoker step rate table derived in Step 4 by the appropriate
Volume Adjustment Factor from Table XXXVI.7. Use the appropriate
factor from Table XXXVI.7 based on the anticipated enrollment methodology
to be employed in marketing coverage to the group.
[0064] If the group policyholder prefers an uni-smoker rate structure,
a schedule of uni-smoker rates may be developed. Instead of blending
non-smoker and smoker base rates in Steps 2 and 3, the uni-smoker
base rates in Table XXXVI.5 can be used directly in Step 1 to derive
the sex-blended base rates.
[0065] Step 6: Adjust the results from Step 5 to reflect an increasing
trend in claim cost. The baseline rates derived from Step 5 will
be multiplied by 1.xxxT, where T is the elapsed time (measured in
years) from Jul. 1, 2005 to the mid-point of the prospective policy
period.
[0066] Step 7: Broker commissions payable in accordance with Section
XXX of this manual will be included in the final premium rates if
applicable.
[0067] Step 8: Round the results from Step 7 to 2 decimal places
to determine the final result.
[0068] C. Adjustments to Standard Monthly Premium Rates for Voluntary
Insurance on Employees
[0069] 1. If any of the Covered Conditions outlined in Section
II.A are to be included with a different benefit percentage, the
premium rate determined in Step 3 should be multiplied by a factor
(f.sub.Bj) for each age bracket j, before proceeding to Step 4,
where f.sub.Bj is defined as
f.sub.Bj=1-.SIGMA..sub.i((1-B.sub.i)*C.sub.ji), i=1,6
[0070] where
[0071] j is the index for age bracket,
[0072] B.sub.i is the ratio of the new benefit percentage to the
standard benefit percentage for Covered Condition i, and
[0073] C.sub.ji is the age- and sex-dependent weight of Covered
Condition i, as outlined in Table XXXVI.4, Part C and D.
[0074] D. Monthly Premium Rates for Standard Schedule of Voluntary
Insurance on Dependent Spouses
[0075] The standard monthly premium rates per $1,000 of coverage
for each group applicable to voluntary dependent spouse coverage
will be computed based on the demographics of the group and the
principal industry of employment of that group according to the
following algorithm.
[0076] Step 1: Determine the expected distribution of coverage
between male and female dependent spouses. If a group specific dependent
spouse census is available, the percentage of male and female dependent
spouses within the overall group should be determined directly from
the data. If no dependent spouse census is available, the expected
overall percentage of male dependent spouses should be determined
by subtracting the percentage of female employees in the group from
1. The percentage of female dependent spouses is then calculated
by subtracting the percentage of male dependent spouses thus determined
from 1.
[0077] Step 2: Using the male and female percentages determined
in Step 1, blend the male and female spouse non-smoker base rates
from Table XXXVI.6 within each 5-year age bracket using the following
formula:
Blended Non Smoker ("NS") Base Rate.sub.i=(% male).times.(male
NS base rate).sub.i+(% female).times.(female NS base rate).sub.i
for each age bracket i.
[0078] Step 3: Using the male and female percentages determined
in Step 1, blend the male and female spouse smoker base rates from
Table XXXVI.6 within each 5-year age bracket using the following
formula:
Blended Smoker ("S") Base Rate.sub.i=(% male).times.(male
S base rate).sub.i+(% female).times.(female S base rate) for each
age bracket i.
[0079] Step 4: Multiply each 5-year bracket rate in the non-smoker
step rate table derived in Step 2 and each 5-year bracket rate in
the smoker step rate table derived in step 3 by the applicable Industry
Adjustment Factor from Table XXXVI.2.
[0080] Step 5: Multiply each 5-year bracket rate in the non-smoker
step rate table derived in Step 4 and each 5-year bracket rate in
the smoker step rate table derived in step 4 by the appropriate
Volume Adjustment Factor from Table XXXVI.7. Use the appropriate
factor from Table XXXVI.7 based on the anticipated enrollment methodology
to be employed in marketing coverage to the group.
[0081] If the group policyholder prefers an uni-smoker rate structure,
a schedule of uni-smoker rates may be developed. Instead of blending
non-smoker and smoker base rates in Steps 2 and 3, the uni-smoker
base rates from Table XXXVI.6 can be used directly in Step 1 to
derive the sex-blended base rates.
[0082] Step 6: Adjust the results from Step 5 to reflect an increasing
trend in claim cost. The baseline rates derived from Step 5 will
be multiplied by 1.xxxT, where T is the elapsed time (measured in
years) from Jul. 1, 2005 to the mid-point of the prospective policy
period.
[0083] Step 7: Broker commissions payable in accordance with Section
XXX of this manual will be included in the final premium rates if
applicable.
[0084] Step 8: Round the results from Step 7 to 2 decimal places
to determine the final results.
[0085] E. Adjustments to Standard Monthly Premium Rates for Voluntary
Insurance on Dependent Spouses
[0086] 1. If any of the Covered Conditions outlined in Section
II.A are to be included with a different benefit percentage, the
premium rate determined in Step 3 should be multiplied by a factor
(f.sub.Bj) for each age bracket j, before proceeding to Step 4,
where f.sub.Bj is defined as
f.sub.Bj=1-.SIGMA..sub.i((1-B.sub.i)*C.sub.ji), i=1,6
[0087] where
[0088] j is the index for age bracket,
[0089] B.sub.i is the ratio of the new benefit percentage to the
standard benefit percentage for Covered Condition i, and
[0090] C.sub.ji is the age- and sex-dependent weight of Covered
Condition i, as outlined in Table XXXVI.4, Part C and D.
[0091] F. Standard Monthly Premium Rates for Voluntary Insurance
on Dependent Children
[0092] If the policy provides voluntary benefits for dependent
children, the standard monthly premium rates per $1,000 will be
based on the age at which dependent child coverage ends as contained
in the policy as shown in Table XXXVI.8.
[0093] IV. The provisions of a particular employer's plan may call
for variations in approved benefit designs not explicitly outlined.
Appropriate interpolation or extrapolation methods will be used
to determine premium rates for plans or benefits with specifications
different from those shown in this section.
4TABLE XXXVI.1A Base Monthly Premium Rates per $1,000 for Non-Contributory
Coverage Age Male Female Age Male Female 17 18 . . . 99 100
[0094]
5TABLE XXXVI.1B Skin Cancer Base Monthly Premium Rates per $1,000
for Non- Contributory Coverage Age Male Female Age Male Female 17
18 . . . 99 100
[0095]
6TABLE XXXVI.2 Industry Adjustment Factors Male SIC* Industry Description
Percent Factors 100 Agricultural Production, Crops 200 Agricultural
Production, Livestock 700 Agricultural Services, N.E.C 800 Forestry
900 Fishing, Hunting, And Trapping 1000 Metal Mining 1100 Anthracite
Mining 1200 Coal Mining 1220 Bituminous Coal 1230 Anthracite Mining
1300 Oil And Gas Extraction 1400 Nonmetallic Mining And Quarrying,
Except Fuel 1500 General Building Contractors 1600 Heavy Construction
Contractors 1700 Special Trade Contractors 2000 Food And Kindred
Products 2100 Tobacco Manufacturers 2200 Textile Mill Products 2300
Apparel And Other Finished Textile Products 2400 Lumber And Wood
Products, Except Furniture 2500 Furniture And Fixtures 2600 Paper
And Allied Products 2700 Printing, Publishing, And Allied Products
2710 Newspaper Publishing And Printing 2750 Commercial Printing
2800 Chemicals And Allied Products 2900 Petroleum And Coal Products
3000 Rubber And Miscellaneous Plastics Products 3100 Leather And
Leather Products 3140 Footwear, Except Rubber And Plastic 3200 Stone,
Clay, Glass, And Concrete Products 3290 Miscellaneous Nonmetallic
Mineral And Stone Products 3300 Primary Metal Industries 3310 Blast
Furnaces, Steelworks, Rolling, And Finishing Mills 3320 Iron And
Steel Foundries 3400 Fabricated Metal Industries 3440 Fabricated
Structural Metal Products 3500 Machinery And Computing Equipment
3530 Construction And Material Handling Machines 3540 Metal Working
Machinery 3550 Machinery And Computing Equipment 3560 General Industrial
Machinery 3570 Computers And Related Equipment 3580 Service Industry
Machines 3600 Electrical Machinery, Equipment, And Supplies 3610
Electrical Test and Distributing Equipment 3620 Electrical Industrial
Apparatus 3630 Household Appliances 3660 Radio, T.V., And Communication
Equipment 3670 Electrical Machinery, Equipment, And Supplies, N.E.C.
And Not Specified 3700 Transportation Equipment 3710 Motor Vehicles
And Motor Vehicle Equipment 3720 Aircraft And Parts 3800 Professional
And Photographic Equipment, And Watches 3900 Miscellaneous And Not
Specified Manufacturing Industries 4000 Railroads 4100 Bus Service
And Urban Transit 4200 Trucking & Warehousing 4210 Trucking,
Local & Long Distance 4300 U.S. Postal Service 4400 Water Transportation
4500 Air Transportation 4600 Gas And Steam Supply Systems 4700 Services
Incidental To Transportation 4800 Communications 4900 Utilities
And Sanitary Services 4910 Electric Light And Power 4920 Gas And
Steam Supply Systems 4930 Electric and gas, and other combinations
5000 Durable Goods 5100 Non-Durable Goods 5200 Lumber And Building
Material Retailing 5300 Miscellaneous General Merchandise Stores
5310 Department Stores 5400 Food Stores, N.E.C 5410 Grocery Stores
5500 Motor Vehicle Dealers 5600 Apparel And Accessory Stores, Except
Shoe 5700 Furniture And Home Furnishings Stores 5800 Eating And
Drinking Places 5900 Drug Stores 6000 Banking 6010 Federal Reserve
Banks 6020 Commercial & Stock Savings Banks 6100 Credit Agencies,
N.E.C 6200 Security, Commodity Brokerage, And Investment Companies
6300 Insurance Carriers 6400 Insurance Agents, Brokers, & Services
6500 Real Estate, Including Real Estate-Insurance Offices 6600 Combination
Real Estate, Insurance, Etc. 6700 Holding And Other Investment Offices
7000 Hotels And Motels 7200 Personal Services, Except Private Household
7300 Business, Automobile, And Repair Services 7370 Computer And
Data Processing Services 7500 Automotive Repair And Related Services
7600 Miscellaneous Repair Services 7800 Theaters And Motion Pictures
7900 Entertainment And Recreation Services 8000 Professional And
Related Services 8100 Legal Services 8200 Educational Services 8210
Elementary And Secondary Schools 8220 Colleges And Universities
8300 Social Services, N.E.C 8400 Museums, Art Galleries, And Zoos
8600 Membership Organizations, N.E.C 8610 Business Associations
8630 Labor Unions 8660 Religious Organizations 8700 Engineering/Accounting/R
& D 8710 Engineering & Architectural Services 8720 Accounting,
Auditing, And Bookkeeping Services 8730 Research, Development, And
Testing Services 8800 Private Households 8900 Miscellaneous Professional
And Related Services 8910 Engineering & Architectural Services
8920 Non-Commercial Research 8930 Accounting And Auditing 9100 Executive
And Legislative Offices 9200 Justice, Public Order, And Safety 9300
Public Finance, Taxation, And Monetary Policy 9400 Administration
Of Human Resources Programs 9500 Administration Of Environmental
Quality And Housing Programs 9600 Administration Of Economic Programs
9700 National Security And International Affairs 9900 Non-Classifiable
Establishments *The appropriate NAICS Code may be used in lieu of
the SIC Code
[0096]
7TABLE XXXVI.3 Non-Contributory Coverage Volume Adjustment Factors
Volume Annual Specified Disease Premium Adjustment Factor LE $30,000
$30,001 to $50,000 $50,001 to $100,000 $100,001 to $250,000 $250,001
to $500,000 $500,001 to $1,000,000 $1,000,001 to $3,000,000 $3,000,001
to $5,000,000 $5,000,001 to $10,000,000 $10,000,001+ Footnotes to
Table XXXVI.3: For the following additional expense items, the increase
to premium would fall in the range of 0.xx% to xx.x% for each item:
Customized marketing material Customized proposals More complex
administrative structure (due to multiple separations, etc.) Customized
quotation and underwriting tools Customized legal and contractual
arrangements Customized billing and collections procedures Special
customer reporting Special customer meetings Special customer service
requirements Special printing requirements Customized administration
manuals Special solicitation materials Performance guarantees
[0097] The provider may enter into agreements with third parties
under which the allowance, if any, paid to the third party for performing
certain functions is less than the corresponding allowance implied
by the factors above. The provider may reduce the premium up to
xx.x % for each of the following performed by a third party:
[0098] Billing and collection
[0099] Preparation of quotes
[0100] Payment of claims
[0101] Payment of broker commissions
[0102] Marketing and promotion
[0103] Issuance of certificates
8TABLE XXXVI.4 Premium Adjustment Factors for Covered Conditions
Different from the Standard Covered Conditions Outlined in Section
II.A A. Employer Paid, Employee Coverage C.sub.j6 C.sub.j1 C.sub.j3
C.sub.j5 Coronary Kidney C.sub.j2 Major Organ C.sub.j4 Cancer (all
Artery Age (j) Failure Heart Attack Transplant Stroke benefit types)
Bypass Graft <25 25-29 30-34 . . . 80-84 85+ B. Employer Paid,
Dependent Spouse Coverage C.sub.j6 C.sub.j1 C.sub.j3 C.sub.j5 Coronary
Kidney C.sub.j2 Major Organ C.sub.j4 Cancer (all Artery Age (j)
Failure Heart Attack Transplant Stroke benefit types) Bypass Graft
<25 25-29 30-34 . . . 80-84 85+ C. Voluntary Coverage, Male C.sub.j6
C.sub.j1 C.sub.j3 C.sub.j5 Coronary Kidney C.sub.j2 Major Organ
C.sub.j4 Cancer (all Artery Age (j) Failure Heart Attack Transplant
Stroke benefit types) Bypass Graft <25 25-29 30-34 . . . 80-84
85+ D. Voluntary Coverage, Female C.sub.j6 C.sub.j1 C.sub.j3 C.sub.j5
Coronary Kidney C.sub.j2 Major Organ C.sub.j4 Cancer (all Artery
Age (j) Failure Heart Attack Transplant Stroke benefit types) Bypass
Graft <25 25-29 30-34 . . . 80-84 85+ Note: j is the index denoting
age bracket.
[0104]
9TABLE XXXVI.5 Voluntary Employee Monthly Base Premium Rates per
$1,000 Employee Male Male Male Female Female Female Age Bracket
Non-Smoker Smoker Uni-Smoker Non-Smoker Smokier Uni-Smoker Less
than 25 25 to 29 30 to 34 . . . 80 to 85 85+
[0105]
10TABLE XXXVI.6 Voluntary Dependent Spouse Monthly Base Premium
Rates per S1,000 Female Female Female Male Spouse Male Spouse Male
Spouse Spouse (Male Spouse (Male Spouse (Male (Female (Female (Female
Employee Employee) Employee) Employee) Employee) Employee) Employee)
Age Bracket Non-Smoker Smoker Uni-Smoker Non-Smoker Smoker Uni-Smoker
Less than 25 25 to 29 30 to 34 . . . 80 to 85 85+
[0106]
11TABLE XXXVI.7 Voluntary Coverage Volume Adjustment Factors No
Face-to-Face With Face-to- Annual Specified Disease Enrollment Face
Enrollment Premium Methods Methods LE $30,000 $30,001 to $50,000
$50,001 to $100,000 $100,001 to $250,000 $250,001 to $500,000 $500,001
to $1,000,000 $1,000,001 to $3,000,000 $3,000,001 to $5,000,000
$5,000,001 to $10,000,000 $10,000,001+ Footnotes to Table XXXVI.7:
1) For the following additional expense items, the increase to premium
would fall in the range of xx.x% to xx.x% for each item: a) Customized
marketing material b) Customized proposals c) More complex administrative
structure (due to multiple separations, etc.) d) Customized quotation
and underwriting tools e) Customized legal and contractual arrangements
f) Customized billing and collections procedures g) Special customer
reporting h) Special customer meetings i) Special customer service
requirements j) Special printing requirements k) Customized administration
manuals l) Special solicitation materials m) Performance guarantees
[0107] 2) The provider may enter into agreements with third parties
under which the allowance, if any, paid to the third party for performing
certain functions is less than the corresponding allowance implied
by the factors above. The provider may reduce the premium up to
x.x % for each of the following performed by a third party:
[0108] a) Billing and collection
[0109] b) Preparation of quotes
[0110] c) Payment of claims
[0111] d) Payment of broker commissions
[0112] e) Marketing and promotion
[0113] f) Issuance of certificates
12TABLE XXXVI.8 Voluntary Child Coverage Monthly Base Premium Rates
per $1,000 Dependent Child Definition Monthly Premium Rate per $1,000
To age 18 To age 19* To age 20* To age 21* To age 22* To age 23*
To age 24* To age 25* To age 26* *provided the child is a full time
student Covered Covered Person's Age Person's Age at end of at end
of Calendar Monthly Premiums/ Calendar Monthly Premiums/ Year $1,000
of Insurance Year $1,000 of Insurance Portable Rates for Former
Employees and Dependent Spouses of Former Employees Non-Smoker 17
18 . . . . . . 99 100 Portable Rates for Former Employees and Dependent
Spouses of Former Employees Smoker 17 18 . . . . . . 99 100 Portable
Rates for Former Employees and Dependent Spouses of Former Employees
Uni-Smoker 17 18 . . . . . . 99 100
[0114] Portable Certificate Administrative Expense Charge
[0115] To the monthly premium rates per thousand dollars of insurance
specified on Pages 36.19-36.21, add the following administrative
expense charge:
[0116] Up to $xx.xx per month per portable certificate
[0117] In one embodiment, product specifications are determined
by reviewing a product template specification. Such a template is
illustrated below.
[0118] Product Specifications Template for Critical Illness Policy
13 NATIONWIDE VERSION Individual Sold Through Group PLAN FEATURE
Individual Channels Group Free Look Provision [10 DAYS] [10 days]
[None] Issue Ages [Principal Insured: [Principal Insured: [Employee:
16-65] 18-65] 18-65] [Spouse: 18-65] [Spouse: 18-65] [Spouse: 16-65]
[Child: Birth to 18 [Child: Birth to 18 [Child: Birth to 18 (to
25 if full-time (to 25 if full-time (to 25 if full-time student)]
student)] student)] [We will need to [We will need to develop an
ADEA develop an ADEA compliant way to limit compliant way to limit
issue age] issue age] Domestic Partner [Yes] [Yes] [Yes] Coverage
Available Eligibility [Major medical [Major medical [Major medical
necessary] necessary] necessary] [Actively at work [Actively at
work requirement] requirement] Premium Rates Based [Issue Age] [Issue
Age] [Attained Age] On [Gender] [Unisex] [Unisex] [Smoker status]
[Smoker status] [Smoker status] [Once covered, [Once covered, Once
covered, rates premium rate does not premium rate does not increase
in 5 year age increase with age] increase with age] bands. Group
experience Premium Rate [Charge for principal [Charge for principal
[Employee only, rates Structure insured based on entry insured based
on entry based on attained age age, additional charge age, additional
charge (5 yr. bands); for spouse based on for spouse based on Employee
and Spouse entry age, flat entry age, flat rates bases on attained
additional charge for additional charge for age (5 yr. bands); dependent
children - dependent children - Employee (with or $5,000 $5,000
without spouse) and children, flat charge to add children - $5,000.
Flat rate for employer contributions. Ability to Change [Premiums
may [Premiums may Premiums based on Rates only be changed only be
changed on group, can be on a class basis] a class basis] changed
annually, [Need definition of [Need definition of or if a significant
class] Class is class] Class is change in size or defined as age,
sex, defined as age, sex, composition of the smoker status, and
smoker status, and group. policy form. policy form. Prospectively
experience rated by group. RATE GUARANTEE Guaranteed renewable Guarantee
renewable Yes, as specified by underwriting PREMIUM [Check-o-matic,
direct [Payroll deduction, [Payroll deduction, PAYMENT METHOD bill,
credit card check-o-matic, direct check-o-matic, direct bill, credit
card bill, credit card Frequency of Premium [Annually, quarterly,
[Monthly, or according [Monthly, or Payment monthly, semi-annually
to employer payroll according to frequency. employer payroll frequency.
Renewability [Guaranteed [Guaranteed Subject to annual Renewable
(principal Renewable (principal mutual agreement of insured has
the right to insured has the right to group policyholder and renew
coverage for as renew coverage for as Provider. long as he/she lives
and long as he/she lives and [Provider cannot either all or a portion
of either all or a portion of change benefits except the principal
insured's the principal insured's as required by law maximum benefit
maximum benefit remains available] remains available] [Provider
cannot [Provider cannot change benefits except change benefits except
as required by law] as required by law] [Provider cannot [Provider
cannot change premiums change premiums except on a class basis]
except on a class basis] Portability/Conversion [Dependents have
the [Dependents have the [Coverage may right to convert to their
right to convert to their continue through a own policies without
own policies without separate portability evidence of insurability
evidence of insurability pool with distinct rates, if coverage for
the if coverage for the and a portable charge dependent under the
dependent under the (per $1,000) applied to principal insured's
principal insured's the respective group policy terminates for policy
terminates for program. reasons other than non- reasons other than
non- Where required, payment of premium. payment of premium. conversion
to an The amount of the The amount of the individual policy form
converted policy converted policy at standard rates will be cannot
exceed the cannot exceed the allowed. A conversion amount of coverage
the amount of coverage the charge (per $1,000) dependent had in
force dependent had in force will be applied to the at the time
coverage at the time coverage respective group. under the original
under the original policy ended.] policy ended.] [Premium is based
on [Premium is based on issue age under the issue age under the
original policy] original policy] Critical Illnesses [First occurrence
of the First occurrence of the [First occurrence of the Covered
(see also following: Invasive following: Invasive following: Invasive
definitions below) Cancer, Cancer In Situ Cancer, Cancer In Situ
Cancer, Cancer In Situ (25%), Heart Attack, 25%), Heart Attack,
(25%), Heart Attack, Stroke, End Stage Stroke, End Stage Stroke,
End Stage Renal Failure, Major Renal Failure, Major Renal Failure,
Major Organ Transplant] Organ Transplant] Organ Transplant] Invasive
Cancer [Cancer (Life- [Cancer (Life- [Cancer (Life- threatening)
means the threatening) means the threatening) means the presence
of one or presence of one or presence of one or more malignant more
malignant more malignant tumors. A malignant tumors. A malignant
tumors. A malignant tumor is to be tumor is to be tumor is to be
characterized by the characterized by the characterized by the uncontrollable
and uncontrollable and uncontrollable and abnormal growth and abnormal
growth and abnormal growth and spread of malignant spread of malignant
spread of malignant cells and the invasion cells and the invasion
cells and the invasion and destruction of and destruction of and
destruction of adjacent tissues for adjacent tissues for adjacent
tissues for which major which major which major interventionist
interventionist interventionist treatment or surgery treatment or
surgery treatment or surgery (excluding endoscopic (excluding endoscopic
(excluding endoscopic procedures alone) is procedures alone) is
procedures alone) is considered medically considered medically considered
medically necessary. Diagnosis necessary. Diagnosis necessary. Diagnosis
must be based on must be based on must be based on microscopic microscopic
microscopic examination examination examination (histologic (histologic
(histologic examination) of fixed examination) of fixed examination)
of fixed tissues or preparations tissues or preparations tissues
or preparations of blood or bone of blood or bone of blood or bone
marrow and marrow and marrow and documented in a documented in a
documented in a written pathology written pathology written pathology
report. This includes report. This includes report. This includes
lymphomas, Hodgkin's lymphomas, Hodgkin's lymphomas, Hodgkin's disease
and disease and disease and leukemia's.] leukemia's.] leukemia's.]
Cancer In Situ [In-situ" cancers [In-situ" cancers [In-situ"
cancers (carcinoma in-situ) (carcinoma in-situ) (carcinoma in-situ)
which is a carcinoma which is a carcinoma which is a carcinoma characterized
by characterized by characterized by malignant cellular malignant
cellular malignant cellular growth of epithelial growth of epithelial
growth of epithelial cells that have not cells that have not cells
that have not invaded beyond the invaded beyond the invaded beyond
the epithelial layer of epithelial layer of epithelial layer of
tissue, classified as Tis tissue, classified as Tis tissue, classified
as Tis N0M0. Such N0M0. Such N0M0. Such conditions are not conditions
are not conditions are not considered life considered life considered
life threatening but will be threatening but will be threatening
but will be covered at 25% of face covered at 25% of face covered
at 25% of face amount for the purpose amount for the purpose amount
for the purpose of critical
illness of critical illness of critical illness coverage.] coverage.
coverage.] Skin cancers are not Skin cancers are not Skin cancers
are not covered. covered. covered. Heart Attack [The death of a
portion [The death of a portion [The death of a portion of the heart
muscle as a of the heart muscle as a of the heart muscle as a result
of obstruction of result of obstruction of result of obstruction
of one or more of the one or more of the one or more of the coronary
arteries due coronary arteries due coronary arteries due to atherosclerosis,
to atherosclerosis, to atherosclerosis, spasm, thrombus or spasm,
thrombus or spasm, thrombus or emboli. emboli. emboli. A positive
diagnosis A positive diagnosis A positive diagnosis must be supported
by must be supported by must be supported by three of the four three
of the four three of the four following criteria: following criteria:
following criteria: typical chest pain, typical chest pain, typical
chest pain, electrocardiograph electrocardiograph electrocardiograph
changes indicative of a changes indicative of a changes indicative
of a recent myocardial recent myocardial recent myocardial infarction,
infarction, infarction, elevation of CPK of elevation of CPK of
elevation of CPK of myocardial origin, or myocardial origin, or
myocardial origin, or elevated serum elevated serum elevated serum
troponin levels, troponin levels, troponin levels, confirmatory
imaging confirmatory imaging confirmatory imaging studies such as
studies such as studies such as thallium scan or stress thallium
scan or stress thallium scan or stress echocardiogram] echocardiogram]
echocardiogram Stroke [Cerebro-vascular [Cerebro-vascular [Cerebro-vascular
accident or incident accident or incident accident or incident producing
permanent producing permanent producing permanent neurological sequelae
neurological sequelae neurological sequelae caused by hemorrhage,
caused by hemorrhage, caused by hemorrhage, infarction of brain
infarction of brain infarction of brain tissue or an embolus tissue
or an embolus tissue or an embolus from an extracranial from an
extracranial from an extracranial source. Evidence of source. Evidence
of source. Evidence of permanent permanent permanent neurological
damage neurological damage neurological damage must be produced.
must be produced. must be produced. Prolonged reversible Prolonged
reversible Prolonged reversible ischemic neurological ischemic neurological
ischemic neurological disease and transient disease and transient
disease and transient ischemic attacks are ischemic attacks are
ischemic attacks are not covered. The not covered. The not covered.
The permanent nature of a permanent nature of a permanent nature
of a neurological defect has neurological defect has neurological
defect has to be confirmed by a to be confirmed by a to be confirmed
by a neurologist at the neurologist at the neurologist at the earliest
one (1) month earliest one (1) month earliest one (1) month after
the event and no after the event and no after the event and no claims
can be admitted claims can be admitted claims can be admitted earlier.]
earlier.] earlier.] Organ Transplant [The actual [The actual [The
actual undergoing, as a undergoing, as a undergoing, as a recipient,
of the recipient, of the recipient, of the transplantation of the
transplantation of the transplantation of the heart, lung, liver,
heart, lung, liver, heart, lung, liver, kidney, pancreas or kidney,
pancreas or kidney, pancreas or bone marrow (TBD), bone marrow (TBD)or,
bone marrow (TBD), or any combination any combination or any combination
there of.. thereof. thereof. Transplantation means Transplantation
means Transplantation means the replacement of the the replacement
of the the replacement of the recipient's recipient's recipient's
malfunctioning malfunctioning malfunctioning organ(s) or tissue,
with organ(s) or tissue, with organ(s) or tissue, with the organ(s)
or tissue the organ(s) or tissue the organ(s) or tissue from a donor
suitable from a donor suitable from a donor suitable under generally
under generally under generally accepted medical accepted medical
accepted medical procedures. We will procedures. We will procedures.
We will not pay a benefit for not pay a benefit for not pay a benefit
for organs received from organs received from organs received from
non-human donors.] non-human donors.] non-human donors.] Kidney
Failure [Confirmed diagnosis [Confirmed diagnosis [Confirmed diagnosis
of Renal Kidney of Renal Kidney of Renal Kidney Failure, which is
Failure, which is Failure, which is defined as the end defined as
the end defined as the end stage of chronic stage of chronic stage
of chronic irreversible failure of irreversible failure of irreversible
failure of both kidneys to both kidneys to both kidneys to function,
resulting in function, resulting in function, resulting in regular
renal dialysis regular renal dialysis regular renal dialysis expected
to continue expected to continue expected to continue for at least
6 months, or for at least 6 months, or for at least 6 months, or
resulting in renal resulting in renal resulting in renal transplantation.]
transplantation.] transplantation.] Available Maximum [$10,000 to
$50,000, in [$10,000 to $50,000, in Standard Offering Benefit Amounts
$10,000 increments] $10,000 increments [$10,000 to $50,000, in $5,000
increments.] Desired Variation - $5,000-$1 M. Qualifying Events
for [Marriage] [Marriage] [Marriage] Adding Coverage [Birth or adoption
of [Birth or adoption of [Birth or adoption of child(ren)] child(ren)]
child(ren)] Dependent Benefit [Spouse not to exceed [Spouse not
to exceed [Spouse not to exceed Amounts principal insured's principal
insured`s employee/retiree amount. amount] amount. Child(ren) at
$5,000 Child(ren) at % 5,000 Child(ren) at $5,000 Percentage of
[Cancer In Situ pays [Cancer In Situ pays Standard Offering Maximum
Benefit 25%; all other 25%; all other [Cancer In Situ pays Amount
Payable for conditions are paid at conditions are paid at 25%; all
other Covered Conditions 100%] 100%] conditions are paid at 100%]
Desired variability - change %'s by coverage (0-100%). Benefit Reductions
[Benefit for [May also contain an [May also contain an Due to Age
principal insured ADEA compliant ADEA compliant reduced by 50% at
reduction formula] reduction formula] age 65] [Spouse benefit [Spouse
benefit [Spouse benefit subject to 50% subject to 50% subject to
identical reduction at age 65. reduction at age reduction provision
[Subject to 65. [Subject to based on age of minimum 5-year minimum
5-year spouse] full benefit full benefit [Subject to beginning at
age beginning at age minimum 5-year 65] 65] full benefit [We will
need to beginning at age develop an ADEA 65] compliant reduction
formula] Age at Which Lifetime Lifetime Lifetime Coverage Ends Waiting
Period [90 days for Invasive [90 days for Invasive [90 days for
Invasive Cancer and Cancer In Cancer and Cancer In Cancer and Cancer
In Situ; 30 days for all Situ; 30 days for all Situ; 30 days for
all other covered covered conditions] covered conditions] conditions]
Preexisting Condition [12/12, includes prudent [12/12, includes
prudent [12/12, includes person language] person language] prudent
person language] Benefit Payment [Lump sum [Lump sum [Lump sum Increment
Exhaustion of Benefits [Payment of a partial [Payment of a partial
[Payment of a Maximum Benefit Maximum Benefit partial Maximum Amount
(for cancer in Amount (for cancer in Benefit Amount
situ) reduces the situ) reduces the (for cancer in remaining benefit
amount remaining benefit amount situ) reduces the and premiums charged
and premiums charged remaining benefit therefore for the insured
therefore for the insured amount and person; payment of the person;
payment of the premiums full Maximum Benefit full Maximum Benefit
charged therefore Amount terminates Amount terminates for the insured
coverage for the person coverage for the person person; payment
for whom the Maximum for whom the Maximum of the full Benefit Amount
was paid. Benefit Amount was paid. Maximum Benefit If this is the
principal If this is the principal Amount insured, the policy insured,
the policy terminates terminates and dependents terminates and dependents
coverage for the will have a right to will have a right to person
for whom convert any remaining convert any remaining the Maximum
amount to individual amount to individual Benefit Amount policies.]
policies.] was paid. If this is the employee, the coverage for dependents
is not affected.] Duplicate Benefit [Benefits payable [Benefits
payable [Benefits Payments despite receipt of despite receipt of
payable benefits for same benefits for same despite receipt illness
under separate illness under separate of benefits for insurance
coverage] insurance coverage] same illness under separate insurance
coverage] Diagnosis Diagnosis means the Diagnosis means the Diagnosis
means the definitive definitive definitive establishment of the
establishment of the establishment of the Critical Illness Critical
Illness Critical Illness condition through the condition through
the condition through the use of clinical and/or use of clinical
and/or use of clinical and/or laboratory findings. laboratory findings.
laboratory findings. The diagnosis must be The diagnosis must be
The diagnosis must be made by a Physician made by a Physician made
by a Physician who is also a board- who is also a board- who is
also a board- certified specialist. certified specialist. certified
specialist. Date of Diagnosis is: Date of Diagnosis is Date of Diagnosis
is the date the diagnosis the date the diagnosis the date the diagnosis
is established by the is established by the is established by the
physician. For major physician. For major physician. For major organ
transplant, it is organ transplant, it is organ transplant, it is
the date the procedure the date the procedure the date the procedure
was performed was performed was performed [Diagnosis must be [Diagnosis
must be [Diagnosis must be made by a Physician, made by a made by
a other than the primary Physician, other Physician, other Insured
or the owner, a than the primary than the primary member of the
Primary Insured or the Insured or the Insured's or Owner's owner,
a member owner, a member immediate family, or a of the Primary of
the Primary business associate who Insured's or Insured's or is
duly licensed in the Owner's immediate Owner's immediate United
Sates and acting family, or a family, or a within the scope of his
business associate business associate or her license and is not
who is duly who is duly a member of your licensed in the licensed
in the immediate family. United States and United States and Immediate
family is acting within the acting within the defined as your or
this scope of his or her scope of his or her policy owner's spouse,
license and is not a license. Immediate son, daughter, father, member
of your family is defined as mother, sister or immediate family.
your or this policy brother Immediate family owner's spouse, [What
type of is defined as your son, daughter, diagnosis is or this policy
fater, mother required owner's spouse, sister or brother (pathological
or son, daughter, clinical)] father, mother, sister or brother Return
of Premiums [If the principal [If the principal insured dies from
insured dies from causes other than a causes other than a covered
critical covered critical illness, all illness, all premiums paid
premiums paid under the policy under the policy with respect to
the with respect to the principal insured principal insured are
returned minus are returned minus any amounts paid in any amounts
paid in claims with respect claims with respect to the principal
to the principal insured.] insured.] [Premiums are paid [Premiums
are paid to beneficiary to beneficiary Claims During the [If the
principal insured [If the principal insured [If the principal insured
Waiting Period is first diagnosed with a is first diagnosed with
a is first diagnosed with a covered critical illness covered critical
illness covered critical illness during the waiting during the waiting
during the waiting period, coverage is period, coverage is period,
coverage is rescinded and all rescinded and all rescinded and all
premiums are returned. premiums are returned. premiums are returned.
If a dependent is first If a dependent is first If a dependent is
first diagnosed with a diagnosed with a diagnosed with a covered
critical illness covered critical illness covered critical illness
during the waiting during the waiting during the waiting period,
coverage for period, coverage for period, coverage for that dependent
is that dependent is that dependent is rescinded and rescinded and
rescinded and premiums for that premiums for that premiums for that
dependent are returned dependent are returned dependent are returned
to the principal to the principal to the principal insured.] insured.]
insured.] Exclusions (in addition [Participation in a [Participation
in a [Participation in a to Pre-Existing felony, riot or felony,
riot or felony, riot or Conditions) insurrection] insurrection]
insurrection] [Intentionally [Intentionally [Intentionally causing
a self- causing a self- causing a self inflicted injury] inflicted
injury] inflicted injury] [Committing or [Committing or [Committing
or attempting to attempting to attempting to commit suicide] commit
suicide] commit suicide] [Involvement in any [Involvement in any
[Involvement in any period of war or any period of war or any period
of war or any act of war, even if act of war, even if act of war,
even if war is not declared] war is not declared] war is not declared]
[Loss resulting from [Loss resulting from [Loss resulting from insured
person insured person insured person being intoxicated] being intoxicated]
being intoxicated] [Loss resulting from [Loss resulting from [Loss
resulting from insured person insured person insured person being
under the being under the being under the influence of any influence
of any influence of any controlled controlled controlled substance]
substance] substance] [Loss sustained [Loss sustained [Loss sustained
while engaging in while engaging in while engaging in an illegal
an illegal an illegal occupation] occupation] occupation] [Loss
sustained [Loss sustained [Loss sustained while serving in the while
serving in the while serving in the armed forces or armed forces
or armed forces or auxiliary units] auxiliary units] auxiliary units]
[Do exclusions [Do exclusions [Do exclusions apply to return of
apply to return of apply to return of premium provision] premium
provision] premium provision] Yes, to be Yes, to be consistent Yes,
to be consistent consistent Claim Provisions Written notice of a
Written notice of a Written notice of a claim must be given claim
must be given claim must be given to us within 30 days to us within
30 days to us within 30 days after loss occurs or after loss occurs
or after loss occurs or starts, or as soon as starts, or as soon
as starts, or as soon as reasonably possible. reasonably possible
reasonably possible [Claim provisions in certificate only] Written
proof of Written proof of Written proof of loss must be loss must
be loss must be submitted within 90 submitted within 90 submitted
within 90 days
after the date days after the date days after the date of such
loss. of such loss. of such loss. [Claim [Claim [Claim Investigation:
Investigation: Investigation: Authorization to Authorization to
Authorization to obtain medical obtain medical obtain medical records
and medical records and medical records and medical examinations]
examinations] examinations] [Time of Payment [Time of Payment [Time
of Payment of Claim] of Claim] of Claim] May be changed [Beneficiary]
[Beneficiary] during Primary May be changed May be changed Insurd's
lifetime, during Primary during Primary and does not require Insurd's
lifetime, Insurd's lifetime, consent of and does not require and
does not require Beneficiaryy] consent of consent of [Change of
Beneficiary [ Beneficiary Beneficiary] Reinstatement [Permitted
with full [PERMITTED WITH [PERMITTED FOR underwriting] FULL ENTIRE
GROUP AT UNDER WRITING] PROVIDER'S DISCRETION] Waiver for Disability
[Yes] [Yes] [Yes] Contestability [Incontestable after two [Incontestable
after two [Incontestable after two years except in case of years
except in case of years except in case of fraud] fraud] fraud] Survival
Period (TBD) 28-31 days (TBD). 28-31 days (TBD). 28-31 days (TBD).
10-20%(TBD) of face 10-20%(TBD) of face 10-20%(TBD) of face amount
if death during amount if death during amount if death during survival
period. survival period. survival period. Settlement Options Standard
- TCA, Standard - TCA, Standard - TCA, Check Check optional Check
optional optional
[0119] An exemplary certificate of insurance is included as Appendix
A.
Actuarial Memorandum
Group Specified Disease Coverage
[0120] 1. Scope and Purpose
[0121] This is an initial filing of Group Policy Form xxxxx and
Group Certificate Form xxxxx. These forms are new and do not replace
any forms previously filed with your Department.
[0122] 2. Description of Benefits
[0123] The Company will pay a lump-sum benefit amount, subject
to the terms and conditions of the Group Policy, if a Covered Condition
First Occurs while a Covered Person is insured under the Group Policy.
[0124] The Covered Conditions available under the Group Policy
are:
14 COVERED CONDITION STANDARD OFFERING BENEFIT Full Benefit Cancer
100% of Total Benefit Amount Partial Benefit Cancer Lesser of {$15,000,
25% of Total Benefit Amount} Skin Cancer $250 Other Cancer $1,000
Heart Attack 100% of Total Benefit Amount Coronary Artery Bypass
Graft Lesser of {$15,000, 25% of Total Benefit Amount} Kidney Failure
100% of Total Benefit Amount Major Organ Transplant 100% of Total
Benefit Amount Stroke 100% of Total Benefit Amount
[0125] The Covered Conditions included in a particular group policy,
the percentage of the Total Benefit Amount payable for each Covered
Condition, and the inside maximum amount payable for Partial Benefit
Cancer and Coronary Artery Bypass Graft may vary to reflect the
requirements of a particular employer's plan. If any form of cancer
is included in the policy as a Covered Condition however, all forms
included in the table will be provided.
[0126] Total Benefit Amounts will be offered for sale in even increments
of $1,000. In no event shall coverage on any single individual exceed
$500,000. For certain clearly identifiable forms of diseases with
significantly lower expected treatment costs (e.g. basal cell and
squamous cell skin cancers), lesser amounts may be offered, but
in no event shall any such amount be lower than $250. The benefit
for any Covered Condition will be paid in a single lump-sum.
[0127] Coverage is subject to a thirty (30) day Waiting Period
(probationary period) for all Covered Conditions. In addition, the
Group Certificate contains a six (6) month pre-existing condition
exclusion.
[0128] Coverage may be offered on a non-contributory basis with
premiums paid by the group policyholder or on a contributory basis
with premiums paid by group certificate holders. Coverage may also
be provided for dependent spouses and dependent children of employees.
[0129] 3. Proposed Effective Date
[0130] This form is intended to be used as soon as approval has
been obtained.
[0131] 4. Morbidity
[0132] Expected claim costs for the benefits provided under the
group policy were derived primarily from population data. Adjustments
to the available population data were made as necessary to reflect
the policy terms. The data sources used as the basis for developing
expected claim costs for each of the Covered Conditions are as follows:
[0133] Cancer (all benefit types).sub.--
[0134] SEER Cancer Statistics Review
[0135] Incidence of Non-Melanoma Skin Cancer in the United States.
[0136] Heart Attack
[0137] Heart Disease & Stroke Statistics--2004 Update
[0138] ARIC Surveillance Study.
[0139] The Framingham Heart Study.
[0140] Stroke
[0141] Incidence and Occurrence of Total (First-Ever and Recurrent)
Stroke.
[0142] Incidence and Characteristics of Total Stroke in the United
States
[0143] Coronary Artery Bypass Graft
[0144] National Hospital Discharge Survey: 2000
[0145] Major Organ Transplant
[0146] 2002 Annual Report, U.S. Organ Procurement and Transplantation
Network.
[0147] Kidney Failure
[0148] U.S. Renal Data System Report, 2003.
[0149] Smoking Status
[0150] Health, United States
[0151] 5. Expense Assumptions
[0152] As this is a new form filing, expense assumptions are based
on expected company experience. The expense assumptions include
provisions for administration, underwriting, claims, marketing,
general overhead, taxes, and commissions. Based on the expected
distribution of business, the average expenses included in this
set of manual rates are:
15 Administration, claims, marketing, underwriting, xx.x% of premium
and general overhead: Taxes, Licenses, & Fees: xx.x% of premium
Standard Commissions: xx.x% of premium Total Expenses: xx.x% of
premium
[0153] 6. Margin
[0154] The premium rates in this filing were developed with xx
% of annual claims margin.
[0155] 7. Expected Loss Ratio
[0156] Based on the assumptions contained herein, the incurred
loss ratio under this set of manual rates is expected to be:
[0157] X %
[0158] 8. Valuation
[0159] Claim Liabilities
[0160] A. Pending claims: The underwriter will hold a percentage
of the benefit amount of all claims pending on the valuation date.
[0161] B. Claims Incurred but Not Reported: For claims that have
been incurred but not reported to the Company (IBNR), the underwriter
will hold an incurred but not reported claim liability as a function
of claims, using factors developed from claim lag studies. From
time to time, the underwriter will update its IBNR factors according
to the results of ongoing claim lag studies.
[0162] C. Active Life Reserves: Group Specified Disease coverage
is annual term insurance. No active life reserves are necessary
for the group policy.
[0163] 9. Actuarial Certification
[0164] To the best of my knowledge and judgement:
[0165] the expected loss ratio under this set of rates meets the
minimum requirements of the State of New York; and
[0166] the rates are structured on an actuarially sound basis;
and
[0167] the benefits are reasonable in relation to the premiums
charged.
[0168] As will be recognized by those skilled in the art, various
aspects illustrated above can be implemented on a various computer
systems. For example, in one embodiment, a computer system can be
implemented providing a database for storing information about the
insurance provider, the group policyholder, or the insured member.
Further, the computer system may be further operable to calculate
the described premiums. Further, the computer system may provide
an interface for various parties to the policy to track, edit, or
view policy related data.
[0169] While the present invention has been illustrated and described
above regarding various embodiments, it is not intended to be limited
to the details shown, since various modifications and structural
changes may be made without departing from the spirit of the present
invention. Without further analysis, the foregoing will so fully
reveal the gist of the present invention that others can, by applying
current knowledge, readily adapt it for various applications without
omitting features that, from the standpoint of prior art, fairly
constitute essential characteristics of the generic or specific
aspects of this invention.
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