1980 002 Ordinance - Laserfiche WebLink

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For the 91st through the 120th day of confinement (exclusive of any benefits payable for such day under Medicare Part A) -Covered hospital charges for room and board, including regular daily services and supplies the hospital _ furnishes, up to the hospital semi-private room daily rate. -Covered cha"rges for other hospital non-professional services and supplies for inpatient medical care. After satisfaction of a 550 annual deductible, this benefit will pay for each qualified person 80% of eligible charges for drugs and medicines the hospital doesn't furnish, and for private duty nursing other than by a close relative. There is a 52,000 yearly maximum and a 510,000 maximum while the policy is in force. No expense will be eligible if eligible under Medicare. Conversion Of Medical Care Coverage To An Individual Expense Insurance Policy Conversion is available in accordance with Prudential's rules for: • You, should your employment terminate, or should you transfer to a class of employees not eligible for insurance. • Your covered dependents should you die. • Your covered child whose insurance is terminated because of marriage or attainment of the age limit. • A spouse whose coverage terminates because of legal separation, divorce or annulment of an insured employee's marriage. This conversion option must be exercised within 31 days after termination of insurance. Evidence of insurability is not required. F. ®ental Expense Insurance Benefits are payable for more than 100 eligible Basic and Major dental services and supplies. Eligible charges are based on reasonable and customary charges for the area. Basic Services-Among the dental procedures eligible are extractions • polishing of teeth filling of cavities root canal work • X-rays • drainage of abscess • oral surgery periodontal treatment other services. In the first year a person is covered, Prudential will pay 70% for eligible Basic services after satisfaction of a 575 lifetime Basic services deductible. The percentage will be increased in each of the following benefit years to 80%, 90% and 100% respectively, provided he or she, while covered under this plan, has satisfied the following requirements in each benefit year: • visit a dentist for examination and diagnosis at least once each benefit year, and then • have all eligible Basic services recommended by the dentist in the first visit of the benefit year completed during that benefit year. If, in any benefit year, a person fails to satisfy these two requirements, his or her benefit percentage will revert to 70% in the following year, and increases thereafter will be as provided above. Major Services-Among the dental procedures eligible are the installation of • crowns • inlays prosthe- tics (bridges, dentures and partial dentures). Prudential will pay 50% for eligible Major services., after an individual has satisfied a 575 per benefit year deductible. When any two members of a person's covered family have satisfied their deductibles in a benefit year, each other covered family member will be considered to have then satisfied his or her deductible for the remainder of that benefit year. A deductible may be carried over from one benefit year to the next for the same Treatment Plan. Basic and Major Services-There is a combined Basic-Major benefit year maximum of S 1,200 per covered person. When the charge for a course of non-emergency treatment will exceed 5300, a Treatment Plan must be submitted to Prudential for review and predetermination of benefits before the work is started. No review is ever necessary for emergency care. Certain benefits will not be available during the first year of coverage for persons not enrolling within 31 days after becoming eligible.