State information for group benefits and individual disability insurance

This content was developed for the purpose of disseminating information required by specific states. We believe this information is complete and accurate at the time of publication. Regulations and interpretations may change.

Arizona residents

Accident insurance limitations and exclusions

Covered conditions and related limitations, exclusions, and reductions¹

Burn² – must be diagnosed and treated by a physician within 72 hours; 150% of the benefit is payable if the burn requires a skin graft performed within 90 days; excludes 1st degree burns; there are 4 benefit levels based on the degree and extent of the burns.
Coma² – must be diagnosed and treated by a physician within 30 days, last 15 or more consecutive days and require intubation for respiratory assistance; excludes medically-induced comas.
Concussion² – must be diagnosed and treated by a physician using a medical imaging procedure within 72 hours.
Dental Injury² – a broken tooth requiring extraction or repair with a crown, implant or denture must be treated by a dentist within 60 days; excludes injuries to teeth that are not sound, natural teeth and injuries caused by biting or chewing.
Dislocation³ – must be diagnosed, treated, and require correction with anesthesia by a physician within 90 days; the benefit varies based on the affected joint and whether it requires open (surgical) or closed (non-surgical) reduction; 25% benefit if physician corrects without anesthesia; 25% benefit for partial dislocation; for multiple dislocations due to the same accident, the policy pays a maximum of 200% of the dislocation with the highest benefit; subsequent dislocations of the same joint are excluded.
Eye Injury With Surgical Repair² – must be diagnosed and treated by a physician within 90 days; excludes exams and injuries which involve only the eyelid.
Fracture⁴ – must be diagnosed and treated by a physician within 90 days; the benefit varies based on the location and whether it requires open or closed reduction; 25% benefit If chip fracture; the policy pays one benefit per bone, per accident; for multiple fractures due to the same accident, the policy pays a maximum of 200% of the fracture with the highest benefit; if benefits were paid for a fracture, any new claim for a fracture is payable only if it is the result of a separate and distinct accident that occurs after the previous fracture is completely healed.
Injuries Not Specifically Listed² – must be diagnosed and treated by a physician within 30 days; pays 200% if it requires surgical repair.
Internal Injury² – must be diagnosed and treated by a physician within 72 hours; excludes exploratory surgery without repair and injuries related to a hernia; pays 200% if requires surgical repair.
Knee Cartilage Injury With Surgical Repair² – must be diagnosed and treated by a physician within 60 days and surgically repaired by a physician within 365 days of the accident; excludes exploratory surgery without repair.
Ruptured Disc With Surgical Repair² – must be diagnosed and treated by a physician within 60 days and surgically repaired by a physician within 365 days; excludes exploratory surgery without repair.
Tendon / Ligament / Rotator Cuff Injury With Surgical Repair – must be diagnosed and treated by a physician within 60 days and surgically repaired by a physician within 365 days; excludes exploratory surgery without repair; pays up to two benefits per accident.

Bodily injuries must result directly from an accident and be wholly independent of sickness, disease, bodily infirmity and other causes. The injury must be incurred while insured under this policy. All time limits for diagnosis, treatment, and surgical repair are from the time or date of the accident. If a benefit is paid for an injury and the covered person later qualifies for a higher benefit for the same accident, we’ll pay the appropriate benefit less any amount previously paid.

General limitations and exclusions

Benefits not paid for injuries caused indirectly or directly by, contributed to, or resulting from willful self-injury or self-destruction, while sane or insane; voluntary participation in an auto-erotic activity; war or act of war; voluntary participation in an assault, felony, criminal activity, insurrection, or riot; duty as a member of a military organization; injuries diagnosed outside of the United States unless the diagnosis can be confirmed by a physician in the United States; the use of any drug, narcotic, hallucinogen, or other controlled substance not prescribed for the covered person by a physician, or if prescribed, not used in a manner consistent with that prescription, directly or indirectly; deliberate use of poison, gas, fumes, or household items (such as aerosols), whether by ingestion, injection, inhalation or absorption; intoxication (a covered person will be considered intoxicated when their blood alcohol level exceeds the legal limit used for operating a motor vehicle in the jurisdiction in which the covered accident occurs regardless of whether they were actually operating a motor vehicle or not); sickness, disease, medical or surgical treatment of disease, or complications following the surgical treatment of disease; operating, learning to operate, or serving as a crew member or flight for life personnel of any aircraft or hot air balloon except as a crew member in a policyholder owned or leased aircraft on company business; jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven; parasailing, bungee jumping or other aeronautic activities; riding in or driving any motor driven vehicle in a race, stunt show or speed test; any dental injury that occurs from biting or chewing; practicing for or participating in any semi-professional or professional competitive athletic activity, including officiating or coaching, for which any type of compensation or remuneration is received; and any injury to a dependent child received during child birth.

Employee coverage may exclude injury arising from or during employment for wage or profit (on-the-job). Check with your employer regarding these provisions.

No benefits will be paid for any injury incurred while residing outside the United States for more than six months; or incurred while incarcerated in any type of penal or detention facility.

¹Refer to the policy for definitions applicable to all terms used in this document, and for other applicable terms and conditions, and relevant clinical and diagnostic criteria. Proof of diagnosis and submission of medical records are required. Claim procedures must be satisfied. Limitations and exclusions must not apply.

²Limit of one benefit per injury type per accident.

³Includes dislocation of the ankle, collarbone, elbow, foot (excludes toes), hand (excludes fingers), hip, knee, lower jaw, shoulder, and wrist.

⁴Includes fracture of the ankle, arm, collarbone, elbow, facial bones, foot (excludes toes), hand (excludes fingers), hip, jaw, knee cap, lower leg (fibula, tibia), pelvis, rib, shoulder blade, skull (depressed), skull (non-depressed), sternum, tailbone (coccyx), thigh (femur), vertebrae, vertebral processes, and wrist.

ACCIDENT INSURANCE PROVIDES LIMITED BENEFITS. This summary is not an insurance contract or a complete statement of its provisions. It does not modify or change the provisions of any policy or rider. If there is a discrepancy, the policy is the final arbiter of the coverage. For cost and coverage details, contact your 51�ԹϺ�� financial representative. 2742176-022023

Critical illness insurance limitations and exclusions

Covered conditions and related limitations, exclusions, and reductions¹

Alzheimer’s Disease – must require substantial physical assistance to perform at least 2 Activities of Daily Living (ADLs) for at least 90 days; excludes other forms of dementing organic brain disorders and psychiatric illnesses.
Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) – must require substantial physical assistance to perform at least 2 ADLs for at least 90 days; excludes other motor-neuron diseases.
Benign Brain Tumor – excludes tumors of the skull, pituitary adenomas, angiomas and germinomas.
Carcinoma in Situ (25% benefit) – excludes carcinoma and melanoma in situ of the skin and all skin cancers, and evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only with no lesion amenable to tissue diagnosis.
Coma – must be due to disease and last at least 7 days; excludes medically-induced comas and comas directly resulting from alcohol or drug use.
Coronary Artery Disease Requiring Coronary Artery Bypass Graft²(25% benefit)
Heart Attack² – excludes sudden cardiac arrest and any heart attack occurring during or within 24 hours of a cardiac or coronary artery procedure.
Invasive Cancer² – excludes certain chronic lymphocytic leukemias; tumors that are nonmalignant, benign, premalignant, noninvasive, dysplasia, or carcinoma in situ; certain skin cancers; certain prostate cancers; microcarcinoma of the thyroid; certain noninvasive papillary cancer of the bladder; and evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only with no lesion amenable to tissue diagnosis.
Loss of Hearing (both ears)³
Loss of Sight (both eyes)^{3, 4}
Loss of Speech^{3, 4} – excludes congenital birth defects and developmental delays.
Major Organ Failure² – must be listed with United Network of Organ Sharing (UNOS) or have a suitable donor, or for kidney failure, dialysis is initiated; excludes bone marrow failure resulting from cancer treatment and failure of organs other than bone marrow, heart, kidney, liver, lung and pancreas.
Multiple Sclerosis – must have qualifying neurological deficits for at least 6 months.
Occupational Infectious Disease resulting in HIV or Hepatitis B, C or D – accidental exposure must occur while performing normal job duties for which you are paid; excludes infections from IV drug use or sexual transmission; reporting requirements apply.
Paralysis – requires permanent, complete and irreversible loss of use of two or more arms or legs due to disease, which has continued for 90 days.
Parkinson’s Disease – must progress to Stage 4 on the Hoehn and Yahr scale; excludes other Parkinsonian syndromes or substance-induced diseases; initial diagnosis of any stage must occur while insured under this policy.
Skin Cancer ($250 benefit)
Stroke² – must have qualifying neurologic deficit measured 30 days or more after the event; excludes symptoms due to TIA’s, migraines, hypoxia, traumatic injury to brain tissue or blood vessels, and vascular disease affecting the eye, optic nerve or vestibular functions.

Childhood conditions

The following conditions apply only to Dependent Children diagnosed prior to the age of 18 and while insured under the policy.⁵

Cerebral Palsy – excludes similar conditions
Cleft Lip/Palate
Cystic Fibrosis
Down Syndrome
Muscular Dystrophy
Spina Bifida – excludes spina bifida occulta

Benefits are payable for a first occurrence of a different covered condition if more than 12 months has elapsed since the prior critical illness. Total payment for all critical illnesses resulting from the same illness or disease will not exceed the Scheduled Benefit amount.

A spouse may be covered for up to 50% of the employee benefit amount. Dependent Children are automatically covered at 25% of the employee benefit amount for both Childhood Conditions and other covered Critical Illnesses.

General limitations and exclusions

Benefits will not be paid for a critical illness caused by, contributed to, or resulting from willful self-injury or self-destruction, while sane or insane; war or act of war; voluntary participation in an assault, felony, criminal activity, insurrection, or riot; duty as a member of a military organization; conditions diagnosed outside of the United States unless the diagnosis can be confirmed by a licensed physician in the United States; the use of any drug, narcotic, or hallucinogen not prescribed for the covered person by a licensed physician, or if prescribed, not used in a manner consistent with that prescription; the use of alcohol, including the operation of a motor vehicle if, at the time of operation, the operator’s alcohol concentration exceeds the legal limit allowed by the jurisdiction where the injury occurs; a cosmetic surgery or other elective procedures that are not medically necessary; or a preexisting condition.

No benefits will be paid for any critical illness incurred while residing outside the United States for more than 6 months; or incurred while incarcerated in any type of penal or detention facility.

The covered person must incur the critical illness and the initial diagnosis of any stage of the illness must be made while insured for that critical illness under this policy.

Preexisting condition limitation

A Preexisting Condition is any sickness or injury, including all related conditions and complications, or a pregnancy, for which a covered person received medical treatment, consultation, care, or services, or was prescribed or took prescription medications in the 6 month period before they became insured under the policy.

No benefits will be paid for a critical illness that results from a Preexisting Condition until the covered person has been insured for 12 months. After 12 months, the Member must be actively at work for one full day or the Dependent must be insured for one full day for their illness to be covered.

²These conditions (Carcinoma in Situ, Coronary Artery Disease, Heart Attack, Invasive Cancer, Major Organ Failure, and Stroke) pay a benefit for multiple occurrences of the same critical illness if more than 12 months has elapsed between occurrences, and no treatment is received for at least 12 months. All other conditions listed above do not pay for multiple occurrences of the same illness.

³Must be due to disease, total and irrevocable, which cannot be partially or totally corrected by any procedure, aid or device.

⁴A Dependent Child must be at least 3 years old on the date of diagnosis. If the child is diagnosed before age 3, a benefit will be paid if the child is insured at the time of the initial diagnosis, the diagnosis is confirmed on or after the child reaches age 3, and the child remains insured.

⁵Childhood Conditions diagnosed prior to birth are covered if the member was insured under the policy at the time of diagnosis and the Dependent Child became insured at live birth.

CRITICAL ILLNESS INSURANCE PROVIDES LIMITED BENEFITS. This summary is not an insurance contract or a complete statement of its provisions. It does not modify or change the provisions of any policy or rider. If there is a discrepancy, the policy is the final arbiter of the coverage. For cost and coverage details, contact your 51�ԹϺ��^® financial representative.
2742176-022023

Dental insurance limitations and exclusions

Eligibility, covered charges and related limitations, exclusions, and reductions

Eligibility

Active, full-time employees living in the United States (except part-time, seasonal, temporary or contract employees) who work a minimum number of hours per week as defined by the employer. If you are not actively at work on the day your benefits would otherwise become effective, your insurance will not be in force until the day you return to active work. If dependent coverage is offered, the employee must be enrolled before their dependents are eligible.

You must request insurance for you or your dependent within 31 days of becoming eligible or within 31 days of terminating your insurance. Otherwise, you must request insurance during the annual enrollment period, special enrollment period, or in compliance with a legal mandate.

Maximum benefit

The employer elects calendar year and lifetime maximum benefits for the group.

Maximum accumulation

If offered, allows a portion of unused maximum benefit to roll over to the next year. The entire accumulation amount is forfeited if no dental service is submitted within a calendar year. Individuals with fourth quarter effective dates will not qualify for rollover until the next calendar year. Qualifications, annual rollover limits, and total accumulation limits are elected by the employer for the group.

Payment limits

Benefits payable for all covered treatments and services cannot exceed the maximum payment limits per unit, per calendar year, per member and dependent. The employer elects the maximum payment limit.

Coordination of benefits

As allowed by state law, we coordinate benefits with coverage provided by any other employer, trust, union, association, or educational institution – other than student accident policies, governmental program, or state law. Total benefits from all sources cannot exceed 100% of covered charges.

Covered charges

Covered charges are limited to the listed procedures shown in the Schedule of Dental Procedures section of your policy. All covered charges are subject to frequency limits, age restrictions and clinical criteria. A treatment or service is considered a covered charge if prescribed by a dentist and determined by 51�ԹϺ�� Life to be necessary, appropriate, and generally accepted. If there is more than one way to correct a dental condition, covered charges will be limited to the prevailing charge for the least expensive procedure that would provide professionally acceptable results. Covered charges will only include charges for treatment or service that begin and are completed while you and your dependents are insured under the policy.

Limitations and exclusions

Covered charges will not include and no benefits will be paid for any treatment or service: that is not a covered charge; performed by any person who is not a dentist or dental hygienist; that exceeds prevailing charges; for implants; that does not meet professionally recognized standards of quality; for veneers, anterior 3/4 cast crowns, personalization of dentures or crowns, or any other treatment or service that is primarily cosmetic; for drugs, medicines, or therapeutic drug injections; for instructions for plaque control, oral hygiene, or diet; for bite registration or occlusal analysis; to alter or maintain vertical dimension or restore or maintain occlusion; for the purpose of duplicating or replacing a lost or stolen prosthetic device or appliance; orthodontic treatment or service if the appliance or bands were placed prior to being insured under the group policy, unless you or your dependent are currently in a treatment plan which was covered under prior group orthodontic coverage, and there has been no lapse in coverage; for orthodontia, unless specifically covered; for provisional or permanent splinting; for which you or your dependent have no financial liability or that would be provided at no charge or at a different charge in the absence of insurance; that is temporary; that is paid for or furnished by the United States Government or one of its agencies (except as required under Medicaid provisions or Federal law); resulting from a sickness that is covered by a Workers' Compensation Act or other similar law; resulting from an injury arising from or in the course of any employment for wage or profit, except for partners, proprietors, or corporate officers of the employer who are not covered by a Workers' Compensation Act or other similar law; resulting from war or act of war; resulting from participation in criminal activities; provided outside the United States, unless you or your dependent are outside of the United States for: a) travel (for a reason other than securing dental care), or b) temporary business assignments, or c) full-time students in certain academic arrangements, or d); Mormon missionary work of a dependent child; to replace tooth structure lost from abrasion, attrition, erosion, or abfraction; which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years; that is an experimental or investigational measure; paid for by a Medicare Supplement Insurance Plan; for temporomandibular joint disorders; charged by an anesthesiologist for services that were performed in facilities other than a dental office; for emergency room charges or outpatient facility charges (including but not limited to hospital outpatient facility charges); for patient management (including but not limited to nitrous oxide and analgesia), local anesthetic and general anesthesia and IV sedation, except as otherwise provided in the group policy; for occlusal guards; for charges that are billed incorrectly or separately for treatment or services that are an integral part of another billed treatment or service, as determined by 51�ԹϺ�� Life.

This summary is not an insurance contract or a complete statement of its provisions. It does not modify or change the provisions of any policy or rider. If there is a discrepancy, the policy is the final arbiter of the coverage. Refer to the policy for definitions applicable to all terms used in this document, and for other applicable terms and conditions. All claim procedures must be satisfied. Policy limitations and exclusions must not apply. 2742176-022023

Hospital indemnity insurance limitations and exclusions

Covered conditions and related limitations, exclusions, and reductions^*

Mandatory benefit
•&�Բ��;Daily Hospitalization - hospital confinement of at least 18 hours is required. Excludes care received in an emergency room, observation unit, urgent care facility, outpatient surgery, or routine newborn post-natal care.

Optional benefits
•&�Բ��;First day Hospital Confinement - payable only once per day. If discharged and confined again for the same or related condition within 30 days of discharge, the later confinement will be considered a continuation and no benefits will be payable.
•&�Բ��;First day Hospital Intensive Care Unit - payable only once per day. If discharged and confined again for the same or related condition within 30 days of discharge, the later confinement will be considered a continuation and no benefits will be payable.
•&�Բ��;Daily Hospital Intensive Care Unit - hospital confinement of at least 18 hours is required. Excludes care received in an emergency room, observation unit, urgent care facility, outpatient surgery, or routine newborn post-natal care.
•&�Բ��;Newborn Nursery Confinement - must be for newborn child confined to a hospital receiving routine nursing or well-baby care.
•&�Բ��;Rehabilitation Facility - must be prescribed by a physician, and immediately follow a hospital confinement.
•&�Բ��;Skilled Nursing Facility - must be prescribed by a physician.
•&�Բ��;Hospice Care - must be diagnosed with a terminal illness by a physician.
•&�Բ��;Mental Disorder Inpatient Treatment Facility - lifetime maximum of 180 days.
•&�Բ��;Substance Abuse Inpatient Treatment Facility - lifetime maximum of 180 days.
•&�Բ��;Mental Disorder Outpatient Treatment - treatment is based on diagnosis, evaluation, and treatment of a mental disorder.
• Substance Abuse Outpatient Treatment - treatment is based on diagnosis, evaluation, and treatment of a substance abuse disorder.
•&�Բ��;Physician Visit and Telemedicine - excluded for routine health examinations, immunizations, normal pregnancy examinations, well baby examinations, any mental disorder, or substance abuse or for any day that a hospital confinement benefit is payable.
•&�Բ��;Lab test or X-Ray - excluded during a routine physical, annual wellness examination, or for preoperative testing.
•&�Բ��;Major Diagnostic Procedure - excluded during a routine physical, annual wellness examination, preoperative testing, or during a hospital confinement.
•&�Բ��;Invasive Diagnostic Procedure - excluded during a routine physical, annual wellness examination, preoperative testing, or during a hospital confinement.
•&�Բ��;Prescription Drug - Must be prescribed on an outpatient basis by a physician and dispensed by a licensed pharmacist, payable only once per day.
•&�Բ��;Durable Medical Equipment - must be prescribed by a physician, and equipment must be rented or purchased.
•&�Բ��;Home Health Services - must be prescribed by a physician, excluded for days that a hospital confinement is payable.
•&�Բ��;Therapy Services - payable only once per day. If emergency room, urgent care facility, physician office visit, therapy services, or observation unit are payable for the same day, only the highest benefit will be payable.
•&�Բ��;Chiropractic Care - must be prescribed from a physician. Massage therapy, treatment of chronic conditions, or injuries not related to a structural imbalance will not be covered.
•&�Բ��;Air ambulance - must be a licensed professional ambulance company.
•&�Բ��;Ground or water ambulance - must be a licensed professional ambulance company.
•&�Բ��;Emergency Room - the exam or treatment must be within 96 hours of the sickness or injury. If emergency room, urgent care facility, physician office visit, therapy services, or observation unit are payable for the same day, only the highest benefit will be payable.
•&�Բ��;Observation Unit - the exam or treatment must be within 96 hours of the sickness or injury. If emergency room, urgent care facility, physician office visit, therapy services, or observation unit are payable for the same day, only the highest benefit will be payable.
•&�Բ��;Inpatient surgery - payable only once per day.
•&�Բ��;Outpatient surgery - if more than one surgical procedure occurs on the same day, only the highest surgical benefit will be payable up to once per day.
•&�Բ��;General Anesthesia - excluded if a surgical procedure is not payable.
•&�Բ��;Medical travel - treatment must be prescribed by a physician and is measured as the most direct route from primary residence to the facility of hospitalization or treatment.
•&�Բ��;Companion lodging - excluded if a hospital confinement is not payable. An adult companion must incur a lodging expense due to hospital confinement of the covered person.
•&�Բ��;Doula Care - services must begin during pregnancy or within 90 days from delivery.
• Family Care - excluded if a hospital confinement is not payable, the family care facility must not be owned or operated by a covered person or their immediate family.
•&�Բ��;Pet Care - excluded if a hospital confinement is not payable, the pet care facility must not be owned or operated by a covered person or their immediate family.

Benefits may be payable if the sickness or injury occur while insured for the Hospital Indemnity policy. A policy of sickness only, or injury only may also be selected.

If eligible for multiple confinement benefits on the same day, the highest confinement benefit will be payable.

A spouse and Dependent Children may be covered for up to 100% of the employee benefit amount.

General limitations and exclusions
The proposed policy contains restrictions and limitations. Before making a purchase decision, review the following limitations and resolve any questions. The following limitations and restrictions are applied as required by state law or as otherwise described in the group policy.

Benefits will not be paid for a sickness or injury caused indirectly or directly by, contributed to, or resulting from willful self-injury or self-destruction, while sane or insane; voluntary participation in an auto-erotic activity; or war or act of war; or voluntary participation in an assault, felony, criminal activity, insurrection, or riot; or duty as a member of a military organization; or sickness or injury diagnosed outside of the United States unless the diagnosis can be confirmed by a licensed physician in the United States; or the use of any drug, narcotic, or hallucinogen not prescribed for the employee or covered dependent by a licensed physician, any mental disorder; voluntary intoxication (as defined by the law of the jurisdiction in which sickness or injury occurred) or while under the influence of any narcotic, drug or controlled substance, unless administered by or taken according to the instruction of a physician or medical professional; voluntary intoxication through use of poison, gas, or fumes, whether by ingestion, injection, inhalation or absorption; or the operation by the member of a motor vehicle or motor boat if, at the time of the injury, the employee or covered dependent’s alcohol concentration exceeds the legal limit allowed by the jurisdiction where the injury occurs; substance abuse; operating, learning to operate, or serving as a crew member or flight for life personnel of any aircraft or hot air balloon [except as a crew member in a policyholder owned or leased aircraft on company business]; jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven, parasailing, bungee jumping or other aeronautic activities; or riding in or driving any motor driven vehicle in a race, stunt show or speed test; any injury to a covered person’s tooth that occurs from biting or chewing; or practicing for or participating in any semi-professional or professional competitive athletic activity, including officiating or coaching, for which any type of compensation or remuneration is received; employee’s dependent spouse, sickness or injury arising from or during employment for wage or profit; or a cosmetic surgery or other elective procedures that are not medically necessary; services rendered to a newborn child following their birth, unless the newborn is sick or injured.

Unless specifically mentioned above, no benefits will be paid for mental disorder, substance abuse, or work-related sickness or injury.

No benefits will be paid for any injury or sickness incurred while residing outside the United States for more than six months; or incurred while incarcerated in any type of penal or detention facility.

The covered person must incur the diagnosis and treatment while insured for the hospital indemnity policy.

Preexisting condition limitation
A Preexisting Condition is any sickness or injury, including all related conditions and complications, or a pregnancy, for which a covered person received medical treatment, consultation, care, or services, or was prescribed or took prescription medications in the 12-month period before they became insured under the policy.

No benefits will be paid for hospital indemnity that results from a Preexisting Condition until the covered person has been insured for 12 months. After 12 months, the Member must be actively at work for one full day, or the Dependent must be insured for one full day for their treatment to be covered.

* Refer to the policy for definitions applicable to all terms used in this document, and for other applicable terms and conditions, and relevant clinical and diagnostic criteria. Proof of treatment and submission of medical records are required. Claim procedures must be satisfied. Limitations and exclusions must not apply.

HOSPITAL INDEMNITY INSURANCE PROVIDES LIMITED BENEFITS. This summary is not an insurance contract or a complete statement of its provisions. It does not modify or change the provisions of any policy or rider. If there is a discrepancy, the policy is the final arbiter of the coverage.

2742176-022023

Individual Disability Income (DI) insurance limitations and exclusions

Eligibility, benefits and related limitations, exclusions, and reductions

Eligibility

To be eligible for coverage, employees must be actively at work on a full-time basis for at least 20 hours per week; residing in the United States; US citizens or legally working in the United States at the time of application. Part-time under 20 hours per week and seasonal are not eligible. Proof of good health and financials may be required. The type and form of proof is determined by 51�ԹϺ��.

Benefit qualification

All conditions have requirements to qualify. The disability must begin while insured is covered under this policy. Written notice of claim, proof of loss and any additional information need to process are required. Claim procedures must be satisfied. Documentation must be provided within the timelines established in the policy, and all claims requirements must be met.

Elimination period

The policy includes an elimination period, which is a set number of days of disability from the start of a continuous disability for which no benefits will be paid.

Benefit period

The period starts after the satisfaction of the elimination period and is the longest time for which benefits will be paid for any one continuous disability.

Recurring disability

A continuation of a prior disability when the recurrence of disability occurs while the policy is in force and results from the same or directly related cause as the prior disability for which benefits were paid or provided the waiver of premium benefit unless after the prior disability ends they return to work for at least 40 hours per week in any occupation for at least 6 consecutive months. No new elimination period is required and benefits will be paid during the recurring disability for the remainder of the benefit period.

Preexisting condition limitation

A preexisting condition is a condition for which medical treatment, testing or medication was recommended by a doctor or received from a doctor within the 2 year period prior to the effective date of coverage or which has caused symptoms within the 2 year period prior to the effective date of coverage which would have caused an ordinarily prudent person to seek diagnosis, care or treatment.

Claims for a disability or loss which begins within 2 years after the effective date of coverage and results from a pre-existing condition which was not disclosed or was misrepresented on the application may be excluded.

General limitations and exclusions

No benefits will be paid for an injury or sickness due to an intentional self-inflicted injury; commission of or attempt to commit a criminal act, or involvement in an illegal occupation or activity; suspension, revocation or surrender of your professional or occupational licenses or certification; active military service during a military action or conflict; loss that was excluded by name or specific description in any rider or endorsement. No benefits are payable for any period during a continuous disability when incarcerated in a penal or correctional institution for a period of 30 consecutive days or longer.

Benefit payments may be limited to 12 months during a continuous disability while residing outside of the US or Canada if not residing in the US or Canada for at least 6 consecutive months each calendar year.

Limitation of benefits for mental, nervous, and substance abuse for a total of 24 months during the life of the policy. If the elimination period is less than 90 days, then normal pregnancy and normal childbirth are not covered sicknesses. If the elimination period is greater than 90 days, then normal pregnancy and normal childbirth are covered sicknesses subject to the definition of disability.

Refer to the policy for definitions applicable to all terms used in this document, and for other applicable terms and conditions. Proof of disability, documentation of loss, submission of medical records, and proof of income are required. Claim procedures must be satisfied. Documentation must be provided within the timelines established in the policy. Limitations and exclusions must not apply for benefits to be payable.

51�ԹϺ�� has discretion to construe or interpret the provisions of this policy, to determine eligibility for benefits, and to determine the type and extent of benefits, if any, to be provided. The decisions of 51�ԹϺ�� in such matters shall be controlling, binding, and final.

Short-term disability (STD) and long-term disability (LTD) insurance limitations and exclusions

Eligibility, benefits and related limitations, exclusions, and reductions

Eligibility

To be eligible for coverage, employees must be actively at work on a full-time basis for at least 30 hours per week; residing in the United States; US citizens or legally working in the United States. Part-time, seasonal, temporary and contract are not eligible. In certain cases, eligibility hours of less than 30 hours per week may be available. Proof of good health may be required. The type and form of proof of good health is determined by 51�ԹϺ��.

Benefit qualification

All conditions have requirements to qualify. The disability must begin while insured under this policy. Proof of disability, documentation of loss, submission of medical records, and proof of income are required. Claim procedures must be satisfied. Documentation must be provided within the timelines established in the policy, and all claims requirements must be met. The loss of a professional or occupational license or certification does not in itself constitute a disability. Benefits will be offset by other income sources.

Elimination period

The employer determines the length of the unpaid waiting period that must elapse after a disability is incurred before benefits begin. A member cannot satisfy any part of the elimination period with any period of disability that results from a cause for which 51�ԹϺ�� does not pay benefits.

Benefit payment period

Benefits are payable for a maximum duration stated in the policy. However, in no event will benefits continue beyond the date the member: dies; recovers from the disability; ceases to be under the regular and appropriate care of a physician; fails to provide any required proof of disability; fails to submit to a required medical examination; fails to report income from other sources or any other required earnings information; fails to pursue Social Security, Workers’ Compensation benefits or similar benefits within 10 days of receipt of notice from 51�ԹϺ��; or ceases to be under the regular and appropriate care of a physician.

Recurring disability

Disabled employees who recover and return to work for 30 days or less during the benefit duration are not required to complete a new elimination period if they become disabled again due to the same or related cause. The policy pays benefits for the remainder, if any, of the original benefit payment period established for the initial disability.

Preexisting condition limitation

A preexisting condition is any sickness or injury, including all related conditions and complications, or a pregnancy, for which a covered person received medical treatment, consultation, care, or services, or was prescribed or took prescription medications for a defined number of months before they became insured under the policy. For policies with a preexisting condition limitation, no benefits will be paid for a disability caused or substantially contributed by a preexisting condition unless, on the date the member becomes disabled, they’ve been actively at work for one full day after being insured under the policy for a defined number of consecutive months.

General limitations and exclusions

No benefits will be paid for a disability resulting from: willful self-injury or self-destruction while sane or insane; war or an act of war; voluntary participation in an assault, felony, criminal activity, insurrection, or riot; a new or continuing disability that begins after an employee’s benefit payment period has ended, but the member has not returned to active work; a work-related sickness or injury; a cosmetic surgery or other elective procedures that are not medically necessary.

Optional limitations for LTD

Benefit payments may be limited to 12 months for each period of continuous disability while residing outside of the US. Benefits for disabilities resulting from drug, alcohol or chemical abuse, dependency, addiction, and mental health conditions may be limited to a maximum lifetime benefit period of 12-36 months. For disabilities due to special conditions that are self-reported and difficult to diagnose, such as chronic fatigue syndrome, carpal tunnel syndrome, headaches, or certain back conditions, benefits may be limited to a lifetime maximum of 12-36 months.

Vision insurance limitations and exclusions

Eligibility, covered charges and related limitations, exclusions, and reductions

Eligibility

Active, full-time employees living in the United States (except part-time, seasonal, temporary or contract employees) who work at least the number of hours per week as defined by your employer. If you are not actively at work on the day your benefits would otherwise become effective, your insurance will not be in force until the day you return to active work. If dependent coverage is offered, the employee must be enrolled before their dependents are eligible.

Covered charges

Covered charges are limited to the treatments, services, and vision aids listed in the policy. All covered charges are subject to frequency limits. To qualify for benefits, the member or dependent must be insured under the policy on the date of treatment or service and satisfy the claims requirements listed in the claims procedures section of the policy.

Preferred providers and participating retail chain providers

Members who want to receive benefits from a preferred provider, should contact the provider before receiving services and inform them that they are covered by a Preferred Provider Organization (PPO). The provider will contact the PPO to obtain authorization. If the member received services from the preferred provider without authorization, any services or materials received from the provider may be treated as if they were provided by a non-preferred provider.

Some participating retail chain providers may be unable to provide all covered services and frame allowances are lower.

Limitations and exclusions

No benefits will be paid for: services and/or materials not specifically listed in the benefit schedule; Plano lenses (lenses with refractive correction of less than + .50 diopter); two pair of glasses instead of bifocals; replacement of lenses, frames, and/or contact lenses furnished under this plan which are lost or damaged; orthoptics or vision training and any associated supplement testing; medical or surgical treatment of the eyes; contact lens insurance policies or service agreements; refitting of contact lenses after the initial (90 day) fitting period; contact lens modification, polishing, or cleaning; local, state and/or federal taxes; a visual examination or vision aids provided outside the United States, unless the member or dependent is outside the United States for one of the following reasons: a) travel, (provided the travel is for a reason other than securing vision care diagnosis or treatment), or b) a temporary business assignment, or c) full-time student status, provided the student is either enrolled and attending an accredited school in a foreign country or is participating in an academic program in a foreign country, for which the institution of higher learning at which the student is enrolled in the U.S. grants academic credit.

California residents

Dental and vision language assistance notice

Dental and vision nondiscrimination notice

Colorado residents

Dental access plan

West Virginia residents

Dental access plan

Vision access plan (PDF)

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