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Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12. In New York, group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GSLFL-10239-a SLPC 30782 06/21 (exp 06/23) The content on this page is not approved for use in New Mexico
Kevin Strain President and Chief Executive Officer
Troy Krushel Vice-President, Associate General Counsel and Corporate Secretary
To Table of Contents
PLEASE READ YOUR POLICY CAREFULLY Non-Participating This is a reimbursement policy. You, or Your Plan administrator, are responsible for making benefit determinations under your Plan. We have no duty or authority to administer, settle, adjust or provide advice regarding claims filed under Your Plan.
Policyholder: ABC Company Policy Number: 12345 Policy Effective Date: January 1, 20XX This Policy is delivered in [State] and is subject to the laws of that jurisdiction. Sun Life Assurance Company of Canada agrees to pay the benefits provided by this Policy in accordance with the provisions contained herein. This Policy is issued in consideration of the Application submitted by the Policyholder, a copy of which is attached, and continued payment of premium by the Policyholder. The Application, and any Riders, Endorsements, Addenda and Amendments to this Policy are made part of this Policy. The Policyholder will hereafter be referred to as “You,” “Your,” and “Yours.” Sun Life Assurance Company of Canada will hereafter be referred to as “We,” “Our,” and “Us.” When determining any date under this Policy, all days begin at 12:00:00 a.m. and end at 11:59:59 p.m. standard time for Your headquarters. Signed at Our U.S. headquarters, 96 Worcester Street, Wellesley Hills, Massachusetts, by:
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Schedule of benefits
I - Definitions
II - Benefit provisions
Table of contents
III - Claim provisions
IV - Your rights and responsibilities
V - Our rights and responsibilities
VI - General provisions
Riders & endorsements
Section Description Page Schedule of Benefits I Definitions II Benefit Provisions Specific Benefit Aggregate Benefit Expenses Eligible for Reimbursement Limitations & Exclusions III Claim Provisions IV Your Rights and Responsibilities V Our Rights and Responsibilities VI General Provisions Premium Provisons Termination Provisions
To Schedule of Benefits
Jump to any section by clicking on the section description
Original Specific Benefit Effective Date [January X, 20XX]
Benefit Specifications
Policy Year January X, 20XX through December XX, 20XX
Reimbursement Percentage 100% of Eligible Expenses
Covered Benefits Medical, Prescription Drug Plan (PDP)
Specific Benefit Lifetime Maximum Eligible Expenses Unlimited
Specific Benefit Claims Basis 24/12 (12 Month Run-In) Eligible Expenses include only those expenses Incurred during the Policy Year, or within 12 months prior to the Policy Year (the “Run-In Period”), and Paid during the Policy Year.
Specific Benefit Deductible $XXX,XXX
Covered Unit(s) Single Employee, Employee and Spouse, Employee and Child, Employee and Family
Retirees [Not] covered
Specific Benefit Premium Rate $XXX.XX per Single Employee per Month $XXX.XX per Employee and Spouse per Month $XXX.XX per Employee and Child per Month $XXX.XX per Employee and Family per Month
Schedule of Benefits Aggregate Benefit
Original Aggregate Benefit Effective Date [January X, 20XX]
Aggregate Benefit Maximum $X,XXX,XXX
Aggregate Benefit Maximum Eligible Expenses per Covered Person $XX,XXX
Aggregate Deductible Factor ("ADF") The ADF per Benefit Month for each Covered Unit by Covered Benefit is as follows: Covered Benefit Covered Units ADF Medical Single Employee $XXX.XX Employee and Family $XXX.XX PDP Single Employee $XXX.XX Employee and Family $XXX.XX
Minimum Aggregate Deductible The Minimum Aggregate Deductible for the current Policy Year is the greater of: a) $X,XXX,XXX; or b) XXX% of the Monthly Aggregate Deductible for the first month of the Policy Year, then multipled by 12.
Aggregate Benefit Attachment Point The Aggregate Benefit Attachement Point is the greater of: a) the sum of the Monthly Aggregate Deductibles for the Policy Year; or b) the Minimum Aggregate Deductible.
Aggregate Benefit Claims Basis 24/12 (12 Month Run-In) Eligible Expenses include only those expenses Incurred during the Policy Year, or within 12 months prior to the Policy Year (the “Run-In Period”), and Paid during the Policy Year.
Aggregate Benefit Premium Rate $XXX.XX per Covered Units per month.
To Schedule of Benefits - Aggregate
The maximum amount of covered expenses that Sun Life will apply towards the Specific Benefit for a person under the plan in their lifetime. All covered expenses for a person during the first policy year and any renewal policy year count toward the maximum.
The Schedule of Benefits sets forth the type and amount of coverage provided under the Policy.
The monthly premium amount due per covered unit for Specific Benefit coverage.
To Section I Definitions
The Reimbursement Percentage is the percent of eligible expenses that will be reimbursed under the policy. The Stop Loss premium may be reduced if the Reimbursement Percentage is less than 100%.
Covered Benefits defines what is covered under the stop-loss plan. For specific and aggregate coverage, you can choose to cover medical expenses only or medical expenses and prescription drug expenses. For Aggregate coverage, you can also choose to extend coverage to health benefits including Short-Term Disability (STD), Dental and Vision. There is an added cost to include other health benefits and Sun Life must approve it.
The Specific Benefit Deductible is the amount of eligible expenses you must pay for a person covered under your plan before the expenses paid for that person become eligible for repayment under the policy.
The Aggregating Specific Deductible is an amount of claims over and above the Specific Benefit Deductible that must be paid under the plan before a Specific Benefit becomes payable under the Stop Loss policy. The additional amount can be met by paying expenses on one claim or across multiple claims. The Deductible only needs to be satisfied once during the policy year. It allows an employer to take on more risk in exchange for a lower premium.
The Claims Basis is the time period within which expenses must be incurred and paid under your plan in order to be eligible for reimbursement under the Stop Loss policy. You can choose from a number of different Claims Basis to best meet your needs. • 12/12 (Incurred in 12/Paid in 12): Claims must be incurred and paid under your plan during the twelve month Policy Year. • 15/12 (Incurred in 15/Paid in 12): Claims must be incurred under your plan during the Policy Year or the three months prior to it and paid by the end of the Policy Year. This is referred to as a “run-in” policy as claims from a period prior to the policy term are allowed to “run” into it. • 12/15 (Incurred in 12/Paid in 15): Claims must be incurred under your plan during the Policy Year and paid by the end of the Policy Year or the three months following it. This is called a “run-out” policy as claims paid after the policy term during the “run out” period can be covered under it. Note: Other Claims Basis are available, such as 12/24 and 24/12, and are subject to Sun Life’s approval.
Covered units are categories of covered persons able to receive benefits under your plan. They include: employee only, employee + 1, employee + spouse, employee + child(ren), family.
Covered Benefits defines what is covered under the stop-loss policy. For Specific and Aggregate coverage, you can choose to cover medical expenses or medical expenses and prescription drug expenses. For Aggregate coverage, you can also choose to extend coverage to Short-Term Disability, Dental and Vision. There is an added cost to include other health benefits and Sun Life must approve it.
The Aggregate Benefit Maximum is the maximum Aggregate Benefit paid under the Stop Loss policy and is determined by Sun Life.
The Aggregate Benefit Maximum Eligible Expenses Per Covered Person is the maximum amount of expenses paid for a Covered Person that will be applied to the calculation of the Aggregate Benefit.
The Aggregate Deductible Factor (ADF) is an amount that reflects per-employee projected claims inclusive of the stop-loss corridor, calculated using your claims experience. The stop-loss corridor is a percentage multiplied onto the projected claims and is often 20% or 25%. There is a separate ADF for each line of coverage (e.g., medical, prescription drug, and dental).
The minimum amount of expenses you must pay under your plan before becoming eligible for an Aggregate Benefit reimbursement.
The Aggregate Benefit Attachment Point is the amount of medical expenses you must pay under your plan during the claims period before a reimbursement is payable under the Stop Loss policy.
The Aggregate Benefit Premium Rate is the monthly premium owed for Aggregate Benefit Coverage for each covered unit.
The Schedule of Benefits defines the type and amount of coverage p rovided under the Policy.
Premium Due Date The Policy Effective Date and the first day of each succeeding month.
Incurred: The date on which Treatment is provided.
To Section II Provisions
Alternative care is a treatment plan for a Covered Person identified through case management services. If the care results in a cost savings to your plan and is medically necessary and appropriate, it may qualify for reimbursement under the Stop Loss policy.
Covered units are categories of covered persons able to receive benefits under your plan. They include: employee only, employee + 1, employee + spouse, employee + child(ren), family. The covered unit(s) covered by the Stop Loss policy are shown in the Schedule of Benefits.
A Treatment is considered to be experimental and investigational if it: 1) has not been approved by the FDA (United States Food and Drug Administration) at the time it is provided; or 2) is part of an ongoing clinical trial; or, 3) there is medical literature that states the further research is needed to determine the safety, toxicity or efficacy of the Treatment.
Benefit Month: Any calendar month during which this Policy is in force. Catastrophic Diagnosis: Any medical condition that results in a Covered Person being a Special Risk.
Original Specific Benefit Effective Date: When We provide You with Specific Benefit coverage under this Policy for consecutive Policy Years, the Original Specific Benefit Effective Date is the date Specific Benefit coverage first became effective in the consecutive year period. Paid: Your payment of expenses Incurred by a Covered Person. A payment will be considered to be made on the date the payment is delivered to the payee provided that the account upon which the payment is drawn contains sufficient funds to permit the payment to be honored. Plan: Your self-funded benefit plan established to provide benefits to Covered Persons as described in Your plan document. For the purpose of determining benefits payable under this Policy, the Plan shall not include any amendments made to the plan document after the Original Aggregate Benefit Effective Date, the Original Specific Benefit Effective Date, the beginning of the Policy Year, or the beginning of the Renewal Policy Year, whichever is earlier, unless We notify You in writing from Our U.S. Headquarters that We accept the amendment. Policyholder: You, the legal entity to whom this Policy is issued. Prescription Drugs: For the purpose of determining Eligible Expenses under this Policy, Prescription Drugs includes all prescription drugs covered under Your Plan, other than prescription drugs administered to a Covered Person while he or she is confined in a hospital or other medical facility.
Transplant Facility:A hospital or facility which is accredited by the Joint Commission on Accreditation of Healthcare Organizations to perform a Transplant. Treatment: Any treatment, procedure, service, device, supply or drug provided to a Covered Person.
The date on which any treatment, procedure, service, device, supply or drug is provided to a Covered Person.
Medically Necessary and Appropriate Treatment must meet the following criteria: 1) it is provided by a licensed doctor other medical practitioner; 2) it is accepted as standard medical practice or care for the medical condition; and 3) it is approved by the FDA (United States Food and Drug Administration), if applicable.
Off-Label Drug Use refers to a drug used for a purpose other than what the FDA approved it for.
The date on which you paid for an eligible expense.
A plan or plan provision that pays prescription drug expenses separate from other medical expenses. If the Prescription Drug Plan is a covered benefit in the Schedule of Benefits, then Sun Life will cover Prescription Drug Plan expenses.
Provider Networks are any care networks available under your plan.
Covered Unit: A category of participants under Your Plan. The Covered Unit(s) for this Policy are shown on the Schedule(s) of Benefits. Dependent: A person enrolled in Your Plan and entitled to receive benefits under Your Plan as a dependent of a Covered Person. Employee: A person employed by You who is enrolled in Your Plan and entitled to receive benefits under Your Plan. If You are a school or college, Employee will include students enrolled in Your Plan and entitled to receive benefits under Your Plan. If You are a union or an association, Employee will include union or association members enrolled in Your Plan and entitled to receive benefits under Your Plan.
Medical Management Vendor: A third party hired to reduce or control the cost of services or supplies provided to Covered Persons under Your Plan.
Original Aggregate Benefit Effective Date: When We provide You with Aggregate Benefit coverage under this Policy for consecutive Policy Years, the Original Aggregate Benefit Effective Date is the date Aggregate Benefit coverage first became effective in the consecutive year period.
Prescription Drug Plan: A benefit provision of Your Plan, or a separate benefit plan maintained by You, under which prescription drug expenses are paid independently of other medical expenses. Expenses incurred under a Prescription Drug Plan will be included as Eligible Expenses only if the Prescription Drug Plan is included as a Covered Benefit in the Schedule of Benefits. Provider Network: A Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), Point of Service Plan (POS), self-funded Health Maintenance Organization (HMO), or any managed care network offered under Your Plan
Reimbursement Percentage: The percent of Eligible Expenses that will be considered for reimbursement under this Policy.
Schedule of Benefits: This Policy’s schedule of Specific Benefit coverage or Aggregate Benefit coverage provided under this Policy. Special Risk: A Special Risk is any Covered Person who (a) is expected to incur expenses under Your Plan during the Policy Year and any Run-In Period in an amount that is expected to exceed the lesser of [50%] of the Specific Benefit Deductible or $100,000, or (b) incurred expenses under Your Plan during the twelve months prior to the Policy Effective Date in an amount that exceeded the lesser of 50% of the Specific Benefit Deductible or $100,000.
A report we require in order to underwrite a policy. It provides information about individuals who may present a special risk.
The policy defines a transplant as the transplant of organs from human to human, including bone marrow, stem cell and cord blood. For Sun Life to cover a transplant, Medicare must have approved the Transplant on or before the date of surgery, the transplant must not be excluded under the policy, and the transplant must be performed at a Transplant Facility.
Transplant: The transplant of organs from human to human, including bone marrow, stem cell and cord blood transplants. Transplants include only those transplants that: (a) are approved for Medicare coverage on the date the Transplant is performed; and (b) are not otherwise excluded by this Policy. A Transplant must be performed at a Transplant Facility in order to be considered for reimbursement under this Policy.
The amount paid for a medical service based on what providers in the geographic area usually charge for the same or similar service.
Third Party Administrator (“TPA”): A third party that You have entered into an agreement with to provide administrative services to Your Plan. Your TPA is not Our agent.
Usual and Reasonable Charge: The usual and reasonable charge for the Treatment provided to a Covered Person for the locality where Treatment was provided, not to exceed the usual charge made by the majority of like providers for the same or like Treatment in the same locality where the Treatment is provided. The Usual and Reasonable Charge must be reasonable for the Treatment provided and comply with generally accepted billing practices. U.S. Headquarters: Our United States headquarters located at 96 Worcester Street, Wellesley Hills, Massachusetts.
A Covered Person is an individual enrolled in your plan and able to receive benefits under it while the Stop Loss policy is in force. The categories of Covered Persons covered by the policy is shown in the Schedule of Benefits.
Covered Person: A person enrolled in Your Plan and entitled to receive benefits under Your Plan while this Policy is in force or during any Run-In Period. Retirees, as defined by Your Plan, may be Covered Persons if they are included on the Schedule(s) of Benefits.
Claims Basis: The period of time, shown on the Schedule(s) of Benefits, during which Eligible Expenses must be Incurred by a Covered Person and Paid by You to be eligible for reimbursement under this Policy. Covered Benefits: The benefit provisions of Your Plan that are insured for stop loss coverage under this Policy. The Covered Benefits for this Policy are shown on the Schedule(s) of Benefits.
Catastrophic Diagnosis are medical conditions that Sun Life considers a special risk. Please see the list of conditions below. There may be more conditions that are considered Catastrophic Diagnosis that are not listed.
Eligible expenses are amounts by paid by your plan for medically necessary and appropriate expenses incurred by a Covered Person. In order to be eligible for reimbursement under the Stop Loss policy, the expenses must be paid in accordance with the terms of your plan, be incurred and paid within the Claims Basis and be covered by the policy.
Definitions:
To Section II Benefit Provisions Aggregate Benefit
Aggregate Benefit Attachment Point: The amount of Eligible Expenses You must pay during the Aggregate Benefit Claims Basis before We will consider an Aggregate Benefit claim. The Aggregate Benefit Attachment Point is shown on the Schedule of Benefits.
Eligible Expenses If We determine that: 1. You have paid expenses incurred by a Covered Person in accordance with the terms of Your Plan; 2. the expenses were Incurred and Paid during the applicable Claims Basis; 3. the expenses are paid under a Covered Benefit as shown on the Schedule of Benefits; and 4. the expenses are not otherwise excluded under this Policy; then the expenses paid by You shall be considered Eligible Expenses.
To Section III Claims Provisions
The Aggregating Specific Deductible is an amount of claims over and above the Specific Benefit Deductible that must be paid under the plan before a Specific Benefit becomes payable under the Stop Loss policy. The additional amount can be met by paying expenses on one claim or across multiple claims. The Deductible only needs to be satisfied once during the policy year. It allows an employer to take on more risk in exchange for a lower premium. Please see the Schedule of Benefits for your Aggregating Specific Deductible.
Specific Benefit Deductible: The amount of Eligible Expenses relating to a Covered Person that You must pay before You become eligible for a Specific Benefit.
Specific Benefit The Specific Benefit for any Covered Person for any Policy Year equals: 1. The total amount of Eligible Expenses for the Covered Person; minus 2. The Specific Benefit Deductible. multiplied by the Reimbursement Percentage shown on the “Schedule of Benefits – Specific Benefit,” if the Reimbursement Percentage is less than 100%. The amount of Eligible Expenses with respect to any Covered Person is subject to the Specific Benefit Lifetime Maximum Eligible Expenses.
Specific Benefit Lifetime Maximum Eligible Expenses: The Specific Benefit Lifetime Maximum Eligible Expenses is the maximum amount of Eligible Expenses We will ever apply towards the Specific Benefit for a Covered Person during his or her lifetime. All Eligible Expenses incurred by a Covered Person during the first Policy Year or any subsequent Renewal Policy Year will apply toward the Specific Benefit Lifetime Maximum Eligible Expenses. The Specific Benefit Lifetime Maximum Eligible Expenses amount is shown in the Schedule of Benefits.
The Specific Benefit Deductible is the amount of eligible expenses you must pay for a person covered under your plan before the expenses paid for that person become eligible for reimbursement under the policy.
The maximum amount of covered expenses that Sun Life will apply towards the Specific Benefit for a person under the plan in their lifetime. All covered expenses for a person during the first policy year and any renewal policy year count toward the maximum. You can find this amount on the Schedule of Benefits.
Specific Benefit coverage provides protection against a large claim incurred by a plan member.
Aggregate Deductible Factor: The deductible factor per Benefit Month per Covered Unit by Covered Benefit. The Aggregate Deductible Factor for each Covered Benefit is shown on the Schedule of Benefits.
Aggregate Benefit Maximum Eligible Expenses per Covered Person: The maximum amount of Eligible Expenses for any one Covered Person that will be used to calculate the Aggregate Benefit. The Aggregate Benefit Maximum Eligible Expenses per Covered Person is shown on the Schedule of Benefits. This maximum applies only to Eligible Expenses Incurred and Paid for the following Covered Benefits: Medical, Prescription Drug Plan.
Monthly Aggregate Deductible: The sum of the deductibles for all Covered Benefits for each Benefit Month. The deductible for each Covered Benefit is calculated by multiplying the number of Covered Units on the first day of the Benefit Month by the Aggregate Deductible Factor for each Covered Benefit.
Minimum Aggregate Deductible: The minimum amount of Eligible Expenses You must pay before You become eligible for an Aggregate Benefit. The Minimum Aggregate Deductible is shown on the Schedule of Benefits.
Aggregate Benefit The Aggregate Benefit equals: 1.The total amount of Eligible Expenses for all Covered Persons, subject to the Aggregate Benefit Maximum Eligible Expenses Per Covered Person, multiplied by the Related Provider Reimbursement Percentage, if applicable; minus 2.The Aggregate Benefit Attachment Point; and multiplied by the Reimbursement Percentage shown on the “Schedule of Benefits – Aggregate Benefit,” if that Reimbursement Percentage is less than 100%. The Aggregate Benefit will be calculated after the end of the Aggregate Benefit Claims Basis. Aggregate Benefit Maximum The Aggregate Benefit We will pay will not exceed the Aggregate Benefit Maximum shown on the Schedule of Benefits.
The Aggregate Benefit Maximum Eligible Expenses Per Covered Person is the maximum amount of expenses paid for a Covered Person that will be applied to the calculation of the Aggregate Benefit. Please see the Schedule of Benefits for the amount.
Sun Life calculates the Monthly Aggregate Deductible (also known as the Attachment Point) each policy month. We multiple the Aggregate Deductible Factor (ADF) by the number of covered units in the month. Sun Life uses the Monthly Aggregate Deductibles to find the Aggregate Deductible for the year.
The 5% Adjustment Rule states that from one month to the next, Sun Life will not lower the amount of the Monthly Aggregate Deductible by more than 5% even if the actual decrease in the Deductible is greater than 5%.
Aggregate Benefit coverage protects you against higher than expected medical expenses paid across your entire plan. The Aggregate Benefit equals the total amount of expenses paid under your plan for all Covered Persons minus the deductible amount you are required to pay multiplied by the Reimbursement Percentage.
The Aggregate Benefit Maximum is the maximum Aggregate Benefit paid under the Stop Loss policy and is determined by Sun Life. Please see the Schedule of Benefits for your Aggregate Benefit Maximum.
Reimbursement of Certain Fees Eligible Expenses may also include fees incurred and paid by You in connection with the following services provided to Your Plan by a Medical Management Vendor or other third-party service provider relating to a Covered Person: 1. Hospital bill audits; and 2. Access to non-directed provider networks; and 3. Negotiating out of network bills; and 4. Cost containment; and 5. Reasonable hourly fees for case management services provided by a registered nurse case manager retained by You or Your TPA; and In order for such fees to be considered Eligible Expenses, You must: 1. Obtain Our approval of the fee in writing from Our U.S. Headquarters prior to incurring the fee; and 2. Demonstrate to Us that the service that generated the fee resulted in a cost saving to the Plan. If You satisfy the criteria, Eligible Expenses will include the fee amount up to 25% of the cost saving to the Plan.
State Health Care Surcharges If You pay a state health care surcharge in connection with the payment of Eligible Expenses, the health care surcharge shall be considered an Eligible Expense. Penalties or fines associated with the health care surcharge or the underlying expenses will not be considered Eligible Expenses.
The Reimbursement of Certain Fees provision sets forth certain fees that may qualify for reimbursement under the Stop Loss policy.
Experimental or Investigational Treatment
Transplant
cosmetic Treatment
Cosmetic treatments are those primarily used to improve, change or enhance your physical appearance.
Usual and Customary Charge
The amount paid for a medical service based on what providers in the geographic area usually charge for the same or similar service.v
We will NOT reimburse You for: 1. Expenses relating to non-human organ or tissue transplants, xenographs or cloning. 2. Expenses in excess of the Usual and Reasonable Charge. 3. Any amount paid by You in excess of a negotiated provider discount, or any penalty or late charge incurred, or any discount lost, unless previously approved in writing by Us at Our U.S. Headquarters. 4. Expenses associated with the administration of Your Plan including, but not limited to, claim payment fees, cost containment administrative fees, capitation fees, pharmacy benefit manager administration fees, PPO access fees, premium functions, medical review and consultant fees, unless otherwise covered under this Policy. 5. Expenses paid by You relating to any litigation concerning Your Plan, including, but not limited to, attorneys’ fees, extra-contractual damages, compensatory damages and punitive damages. 6. Any portion of an expense which You are not obligated to pay under Your Plan, or which is reimbursable to You under: a) Another group health benefit program; or b) A government or privately supported medical research program; or c) Medicare; or d) Any coordination of benefits or non-duplication of benefits provision of Your Plan; or e) Worker’s compensation; or f) Any other source. 7. With respect to a Specific Benefit claim or an Aggregate Benefit claim, any portion of an expense for which You (a) receive a rebate; or (b) are entitled to receive a rebate whether or not You receive the rebate or assign it to another party. 8. Expenses covered under a Prescription Drug Plan, unless Prescription Drug Plan coverage is a Covered Benefit on the Schedule of Benefits. 9. Expenses for benefits in excess of Your Plan’s limits, or expenses that are excluded under Your Plan.
Covered Person
Alternative Care
Transplants
Covered Persons
Covered Benefit
Definitions
10. Expenses incurred by a person who is employed by You at any unit, subsidiary or division of Yours that has not been underwritten by Us. 11. Expenses incurred for any illness or injury due to, or aggravated by, war or an act of war, whether declared or undeclared. 12. Expenses relating to cell and gene therapy Treatment unless the Treatment complies with the terms of any prior authorization policy, guideline, requirements, and criteria used by You, Your TPA, Your network, or other party to determine whether the Treatment was proper and You provide Us with documentation that demonstrates such compliance. 13. Expenses for any Transplant if You have a separate insurance policy that covers Transplants for Covered Persons regardless of whether the Covered Person is covered by that policy. 14. Expenses for any transplant not included in the definition of Transplant.
To Section II Expenses Eligible for Reimbursement
To Section II Benefit Provisions Limitations & Exclusions
Proof of Claim Proof of claim must be provided to Us at Our U.S. Headquarters. Expenses for claims submitted to Us that are not submitted in accordance with the Proof of Claim provisions of this Policy are not reimbursable and shall not be considered Eligible Expenses under the Policy.
To Section IV Your Rights & Responsibilities
Specific Benefit Written proof of claim, in a form and content satisfactory to Us, must be provided to Us as soon as reasonably possible after the Specific Benefit Deductible for a Covered Person has been satisfied. Proof of claim must be provided to Us no later than 12 months after the end of the Specific Benefit Claims Basis during which the claim arose. Proof of claim for a Specific Benefit claim shall include the following: 1. A copy of the Covered Person’s original enrollment record in Your Plan and records relating to any change in the Covered Person’s eligibility for coverage under Your Plan; 2. Copies of all bills over $25,000 and invoices for expenses submitted for reimbursement under this Policy; 3. Proof of payment of any expenses submitted to Us for reimbursement under this Policy or a claims paid report, which includes: Dates of Service, Provider Name or Provider TIN, Amount Billed, Discount Amount, Eligible Amount, Amount Paid, Date Paid, Previously Paid Amount, ICD 10 codes and CPT Codes; and 4. Any additional information We may require to fulfill Our obligations under this Policy.
Aggregate Benefit Written proof of claim, in a form and content satisfactory to Us, must be provided to Us as soon as reasonably possible after the end of the Aggregate Benefit Claims Basis for the Policy Year. Proof of claim must be provided to Us no later than twelve (12) months after the end of the Aggregate Benefit Claims Basis. Proof of claim for an Aggregate Benefit claim shall include the following: 1. A complete aggregate calculation report; 2. A detailed claims history report for all Eligible Expenses Incurred and Paid during the Aggregate Benefit Claims Basis; 3. A report listing all Covered Units eligible for benefits under Your Plan at any time during the Aggregate Benefit Claims Basis; 4. A copy of Your Plan in effect during the Policy Year and any amendments thereto; 5. If Prescription Drug Plan coverage is included as a Covered Benefit on the Schedule of Benefits, a copy of all prescription drug invoices and an itemization thereof, including the amounts of any rebates received by You; and 6. Any additional information We may require to fulfill Our obligations under this Policy.
Appeal of a Claim Determination You may appeal the initial claim determination made by Us under this Policy by submitting a written appeal to Us at Our U.S. Headquarters within 90 days from the date of Our determination. Your appeal should state the basis of Your disagreement with Our initial claim determination and should include all documentation and information supporting Your appeal that has not been previously provided to Us. Once you receive a determination from Us regarding Your appeal, You will have exhausted Your administrative remedies under this Policy. Deferred Payments by You You must obtain prior written approval from Us during the Policy Year from Our U.S. Headquarters in order for any Eligible Expenses Incurred in the Policy Year that will be Paid after the end of the applicable Claims Basis to be considered eligible for reimbursement. Payment of Claims All benefits due under this Policy will be paid to You or Your designee. During the Policy Year, reimbursements will be disbursed when the amount payable exceeds $1,000.00. Any reimbursable amount remaining unpaid at the end of a Policy Year will be paid after the end of the Policy Year.
Authorizations to Release Information You are responsible for authorizing Your TPA, Plan Administrator, case manager or other third party service provider to release to Us information We request to underwrite, review potential claims, make claim determinations, calculate potential reimbursements, or perform other obligations under this Policy. If We do not receive requested information, it may result in the delay, reduction or denial of a claim. Disclosure Requirements This Policy, and any renewal of it, has been underwritten based upon the information You provided to Us concerning all persons eligible for benefits under Your Plan. Your signature on the Application for this Policy or Your acceptance of a renewal policy warrants and represents to Us that: 1. You or Your authorized representative have consulted with Your Human Resources Department, precertification, utilization review and Medical Management Vendors, pharmacy benefit manager and Your TPA, or former TPA, to determine who is a Special Risk, and 2. You have disclosed to Us any person who is a Special Risk. If You fail to disclose an individual as a Special Risk who should have been disclosed as a Special Risk, We will have the right to revise the premium rates, deductibles, deductible factors and terms and conditions of this Policy or any renewal policy in accordance with Our underwriting practices in effect at the time the Policy or renewal policy was underwritten, retroactive to the earlier of the Original Specific Benefit Effective Date, the Original Aggregate Benefit Effective Date, the beginning of the Policy Year or the beginning of the Renewal Policy Year.
To Section V Our Rights and Responsibilities
Reporting Requirements You are required to provide periodic reports to Us as described below. If You, or Your TPA, do not provide the reports, or do not provide them on a timely basis, We reserve the right, once we receive them, to take whatever action We could have taken if the reports had been provided when required. Such action may include, but is not limited to, the right to revise premium rates, deductibles, and deductible factors, and to do so retroactive to the earlier of the Original Specific Benefit Effective Date, the Original Aggregate Benefit Effective Date, the beginning of the Policy Year or the beginning of the Renewal Policy Year.
Specific Benefit Reporting You, or Your TPA, are required to provide Us with notice of any potential Specific Benefit claim within 31 days of the date: 1. A Covered Person’s Eligible Expenses exceed 50% of the Specific Benefit Deductible; or 2. You, Your TPA, or Your medical management, utilization review or precertification vendors, or any other party acting on Your behalf, are notified that a Covered Person has been diagnosed with, or treated for, a Catastrophic Diagnosis.
Aggregate Benefit Reporting You, or Your TPA, are required to provide Us with a monthly report that lists: 1. The total amount of Eligible Expenses Incurred by any Covered Person and Paid by You, or Paid on Your behalf, during the Benefit Month; and 2. The number of each type of Covered Unit on the first day of the Benefit Month. You must provide the Aggregate Benefit report to Us within 31 days after the end of each Benefit Month. Renewal Reporting If You intend to renew this Policy, then three months prior to the end of the Policy Year, You, or Your TPA, are required to provide Us with a report that includes the following information: 1. Monthly Paid claims and enrollment data, organized by Covered Benefit; 2. Large claim information, including amount, diagnosis and prognosis, and any Covered Person who has been diagnosed with a Catastrophic Diagnosis; 3. A census of all Covered Persons; 4. A summary of the number of Covered Persons by workplace zip code, if this Policy covers Employees at multiple locations; 5. A summary report of precertification, utilization review and case management services; 6. A summary report of Your Provider Network(s) or per diem arrangements, setting forth the average hospital discount or per diem charge per day; 7. A copy of changes adopted by or proposed for Your Plan during the Policy Year or Renewal Policy Year. Plan Changes You must notify Us in writing at Our U. S. Headquarters at least (31) days before the effective date of any change in, or to: 1. Your Plan; 2. Your TPA; 3. Your Provider Networks; or 4. Your Medical Management Vendors; or 5. Your pharmacy benefit manager. With respect to any change in Your Plan, Our prior written agreement is required before the coverage under this Policy will apply to the change. Otherwise, benefits under this Policy will be paid based upon the terms of Your Plan, as it existed prior to the change. If You change Your Plan, TPA, Provider Networks, Medical Management Vendors, or pharmacy benefit manager, We reserve the right to terminate this Policy as of the change. Notice of Legal Action You agree to give Us prompt notice of: (a) any event that might result in a lawsuit relating to this Policy; or (b) any lawsuit involving this Policy; and to promptly provide Us with copies of any correspondence and pleadings relating to any such event or lawsuit.
Refund of Overpayment If We, You, or Your TPA determine that We have overpaid You under this Policy, You will promptly refund such overpayment to Us within 60 days of such a determination. If We are required to take legal action to collect such overpayment, You agree to indemnify Us for any costs of collection, including, but not limited to, attorneys’ fees and court costs. Responsibility for Your TPA You are solely responsible for the actions of Your Plan Administrator, Your TPA and any other agent of Yours. Your TPA acts on Your behalf, not on Our behalf. Your TPA is not Our agent. We are not responsible for any compensation owed to, or claimed by, Your TPA or other agents for services provided to, or on behalf of, Your Plan. This Policy does not make Us a party to any agreement between You and Your TPA, nor does it make Your TPA a party to this Policy. Right of Recovery You must pursue all valid claims including, but not necessarily limited to, claims for restitution, constructive trust, equitable lien, breach of contract, injunction, and any other state or federal law claims You or Your Plan may have against any third party responsible, in whole or in part, for any Eligible Expenses Paid by You. You must immediately advise Us of any amount You recover from them. If You fail to pursue such a claim, We will be subrogated to all of Your rights to make the claim. You are required to cooperate fully and do all things necessary and required to permit Us to pursue the claim and to file any action against the third party, including executing an assignment of the claim to Us and granting Us the right to commence litigation or other legal proceedings in Your name against the third party. If You receive payment from a third party for an expense paid by You under Your Plan and we have reimbursed You in whole or in part for the expense, You must reimburse Us the amount We paid You or the amount You received from the third party if it is less than the amount We paid You. Your reimbursement obligation continues and remains in effect whether or not the Policy is in effect on the date You receive payment from the third party.
Audit We have the right to inspect and audit any and all of Your records and procedures, and those of Your TPA and any other party, that relate to any claim made by You under this Policy. We have the right to require documentation from You that demonstrates You paid an Eligible Expense and that the payment was made in accordance with the terms of Your Plan. We reserve the right to employ a third party, at Our expense, to assist Us with any audit function.
To Section VI General Provisions
Determination of Eligible Expenses For the purpose of determining Eligible Expenses under this Policy, We have the right to determine whether an expense was Paid by You in accordance with the terms of Your Plan. Cost Containment We have the right to retain the services of a Medical Management Vendor, or other service provider at Our expense, to (a) assist Us with cost containment with respect to claims under Your Plan; or (b) provide services to You, Your Plan, or Your Plan Participants to reduce cost, risk or expenses under Your Plan. We may also cause a Medical Management Vendor or other service provider, with which we may have negotiated a set or discounted rate, to contact You if, in Our determination, the Medical Management Vendor or other service provider provides a service that may allow You or Your Plan to reduce Your risk, costs and expenses. Confidentiality We will protect the privacy and confidentiality of all personally identifiable and/or medical information provided to Us in the course of underwriting or administering this Policy in accordance with Our policies and applicable state and federal laws. Recoupment We have the right to recoup from any benefit payable to You under this Policy any premium You owe to Us that has not been paid. Our right of recoupment does not impair Our right to terminate this Policy for non-payment of premium under the Termination Provisions of this Policy.
Right to Recalculate We have the right to recalculate any Specific Benefit Premium Rate, Specific Benefit Deductible, Aggregating Specific Deductible, Aggregate Benefit Premium Rate, Aggregate Deductible Factor or Minimum Aggregate Deductible with respect to this Policy Year whenever any one or more of the following events occur: 1. Your Plan changes; 2. You change Your TPA, Your Provider Network(s), Medical Management Vendor(s), or pharmacy benefit manager; 3. This Policy is amended; 4. The number of Covered Units on the first day of a Benefit Month increases or decreases by more than 15% from the number of Covered Units on the first day of the Policy Year; 5. The number of Covered Units on the first day of a Benefit Month increases or decreases by more than 10% from the first day of the prior Benefit Month;
6. A unit, division, subsidiary, or affiliated company of Yours is added to, or deleted from, this Policy; 7. The amount of Eligible Expenses paid in any one of the 3 months immediately preceding the Policy Effective Date (the “three month period”) exceeds 125% of the monthly average of Eligible Expenses Incurred during the 9 months immediately preceding the three month period; or 8. There are changes in Your, or Your TPA’s, claim paying system or payment practices that causes a variation of 15 days or more in the most recent 12 month average of claim processing time. Any right to recalculate exercised under this section may be made retroactive to the Policy Effective Date at Our election. Any recalculation will be made in accordance with Our underwriting practices in effect at the time the Policy was underwritten. The right to recalculate shall survive the termination of this Policy. Right of Reimbursement Any portion of an Eligible Expense which You recover from a third party: 1. Is not eligible for reimbursement under this Policy; and 2. Cannot be used to satisfy any deductible or attachment point under this Policy; and 3. Must be repaid to Us if We previously reimbursed You for it. Any repayment amount You owe Us may be reduced, with Our consent, by any reasonable and necessary expenses You incurred in obtaining the recovery from the third party. Any repayment amount You owe to Us shall survive the termination of this Policy
A third party hired to reduce or control the cost of services or supplies provided to Covered Persons under Your Plan.
Assignment Your interest in this Policy cannot be assigned. Bankruptcy or Insolvency The bankruptcy, insolvency, dissolution, receivership or liquidation of You, Your Plan or Your TPA will not impose upon Us any obligations other than those set forth in this Policy.
No New Special Conditions Rider at Renewal We guarantee that if You renew Your Policy with Us, Your renewal stop loss policy will not contain a new or revised Special Conditions Rider, provided that: 1. Your Plan contains no changes that materially affect or alter the risk covered by Your current Policy; 2. Your renewal stop loss policy contains no material changes from Your present Policy; and 3. A new unit, division, subsidiary, affiliated company or class of covered people is not added to this Policy. We reserve the right to carry over to the renewal stop loss policy any Special Conditions Rider that is part of Your current Policy. We, in Our sole discretion, shall determine whether any of the changes referenced in sections 1 through 3 above are material. If We determine that any change is material, this provision shall be of no force and effect.
To Policy Endorsements & Riders
Special Conditions Rider at Renewal If You renew Your Policy with Us, Your renewal stop loss policy may contain a new or revised Special Conditions Rider. Premium Provisions Premium Payments Premium is due on or before the Premium Due Date.
Click the buttons below to see the policy text for No New Laser and Laser at Renewal. Please reference your specific policy to determine the applicable language.
No New Laser
Laser at Renewal
Non-Participating Policy This Policy is non-participating and does not share in Our surplus earnings. Policy Amendment No change in this Policy, or waiver of any of its provisions, will be valid unless such change or waiver is in writing and agreed to by Us at Our U.S. Headquarters and made a part of this Policy. No agent, broker, TPA, or managing general underwriter has authority to change this Policy or waive any of its provisions. Policy Renewal This Policy may be renewed unless it has been terminated or is subject to termination in accordance with the Termination Provisions of this Policy. Policy changes for any renewal policy will appear on a revised Schedule of Benefits and/or a Policy amendment. Your payment of premium in connection with the renewal policy once We have approved and issued it shall constitute Your acceptance of the renewal policy.
Clerical Error In the event of a clerical error in this Policy, the Policy will be revised to correct the error. Your failure to: 1. Report the existence of a Covered Person; or 2. File proof of claim in a timely manner; or 3. Comply with the reporting requirements of this Policy; shall not constitute clerical error. Entire Contract This Policy, along with any Attachments, Riders, Endorsements, Addenda or Amendments, and the Application completed by You constitutes the entire contract of insurance between us. Legal Action You may not bring a legal action against Us to recover on this Policy earlier than 60 days after You have furnished Us with proof of claim in accordance with the Proof of Claim provisions of this Policy. You may not bring any legal action against Us to recover on this Policy after 3 years from the time proof of claim is required under this Policy. Misrepresentation If: 1. You make any misstatement, omission or misrepresentation, whether intentional or unintentional, in the information or documentation You, Your TPA or any other party acting on Your behalf, provide to Us, and which We rely upon during the underwriting of this Policy; or 2. After this Policy is issued, We learn of expenses or claims that were incurred or paid, but not reported to Us, during the underwriting of this Policy; We have the right, at Our election, to rescind this Policy or to revise the premium rates, deductibles, and terms and conditions of this Policy in accordance with Our underwriting practices in effect at the time the Policy was underwritten. Any such revisions may be made retroactive to the Policy Effective Date. No ERISA Liability Under no circumstance will We accept responsibility as a “Plan Administrator” or be deemed a “plan fiduciary” with respect to your Plan under the Employee Retirement Income Security Act of 1974, as amended.
If your policy has the No New Special Conditions Rider at Renewal, when your policy renews, Sun Life will not apply a new or revised laser to any Covered Person, subject to certain conditions. An existing laser may be carried over to the renewal policy. A “laser” is either a higher deductible applied to expenses incurred by a Covered Person who has incurred or may incur significant health care expenses.
Renewal Rate Increase Cap If You renew Your Policy with Us, We guarantee that the Specific Benefit Premium Rate and the Aggregating Specific Deductible on Your renewal stop loss policy will not be increased more than 50% over the Specific Benefit Premium Rate shown on the Schedule of Benefits, provided that: 1. Your Plan contains no changes that materially affect or alter the risk presented by Your current Policy; 2. Your renewal stop loss policy contains no material changes from Your present Policy; including, but not limited to, changes to: (a) the length of the Policy Year; (b) Covered Benefits; (c) coverage for Retirees; (d) the Specific Benefit Deductible; (e) the Claims Basis; (f) the commission payable; (g) Your TPA; (h) Your Provider Networks; or (i) Your pharmacy benefit manager; 8[(j) the Specific Benefit Lifetime Maximum Eligible Expenses or Specific Benefit Annual Maximum Eligible Expenses;] 9[(k) the Specific Benefit Reimbursement Percentage;] 3. There are no material changes in the demographic distribution of the group covered by Your current Policy versus the group covered by the renewal stop loss policy; and 4. A new unit, division, subsidiary, affiliated company or class of covered people is not added to this Policy. 5. There is no charge in any assessment levied against Us by the state in which this Policy was issued. We, in Our sole discretion, shall determine whether any of the changes referenced in sections 1 through 3 above are material. If We determine that any change is material, we shall adjust the Renewal Rate Increase Cap accordingly Premium Provisions Premium Payments Premium is due on or before the Premium Due Date.
Grace Period A grace period of 45 days will be allowed for the payment of each premium due after the first premium has been paid. This Policy will continue in force during the grace period. If a premium is not paid by the end of the Grace Period, this Policy will terminate, without notice to You, as of the last date for which premium was paid. Premium Data You must provide a report to Us with each premium payment, in a form satisfactory to Us, that lists: 1. The number of each type of Covered Unit, for each Covered Benefit, under Your Plan on the first day of the Benefit Month; and 2. The amount of premium paid. We use such premium data reports solely to process premium. They do not replace any report required, or which may be required, under Section IV of this Policy. Severability In the event that a court of competent jurisdiction invalidates any provision of this Policy, all remaining provisions of the Policy shall continue in full force and effect. Termination Provisions 1. If You fail to pay the premium, this Policy will terminate in accordance with the Premium Provision of this Policy; 2. If Your Plan is terminated, this Policy will terminate on the date the Plan terminated; 3. If You fail to maintain a minimum of 25 participants in Your Plan at any time during the Policy Year, We may elect to terminate this Policy at the end of the first month during which there are less than 25 participants; 4. This Policy will terminate at the end of the Policy Year unless You and We agree to renew it; 5. If You, or Your TPA, fail to satisfy any of Your obligations under this Policy, We may terminate this Policy by giving You 60 days advance written notice; 6. We may terminate this Policy at the end of the Policy Year by providing you 31 days advanced written notice; 7. You may terminate this Policy at any time by providing Us with 31 days advance written notice at Our U.S. Headquarters. The parties to this Policy may agree in writing to terminate it at any time.
If a policy includes the No New Special Conditions Rider at Renewal provision, we include the Renewal Rate Increase Cap for no additional cost. The Cap guarantees that when the policy is renewed, the Specific Benefit premium rate for the new policy year cannot be increased by more than a defined percentage, usually 40%, over the prior year, subject to meeting certain requirements.
The grace period is the length of time that the Stop Loss policy will stay in force after the premium due date if the premium has not been paid. Sun Life has a standard grace period of 45 days. This means that the employer has 45 days after a premium due date to make the premium payment. If the premium payment is not made by the end of the grace period, the policy will terminate as of the last date for which premium was paid.
If a court finds a Policy provision invalid, all remaining provisions will remain valid and in force.
If a policy is terminated for non-payment of premium, Sun Life may allow the policy to be reinstated if certain conditions are met.
Reinstatement If this Policy is terminated for non-payment of premium, We may, at Our sole discretion, agree to reinstate it as of the date it terminated upon payment of all outstanding premiums. We may require You to provide certain information to Us before We will consider reinstating the Policy. Time Limitations If any time limitation in this Policy is less than that permitted by the law of the state in which the Application was taken, the limitation is hereby extended to the minimum period permitted by the law.
Grace Period A grace period of forty five (45) days will be allowed for the payment of each premium due after the first premium has been paid. This Policy will continue in force during the grace period. If a premium is not paid by the end of the Grace Period, this Policy will terminate, without notice to You, as of the last date for which premium was paid. Premium Data You must provide a report to Us with each premium payment, in a form satisfactory to Us, that lists: 1. The number of each type of Covered Unit, for each Covered Benefit, under Your Plan on the first day of the Benefit Month; and 2. The amount of premium paid. We use such premium data reports solely to process premium. They do not replace any report required, or which may be required, under Section IV of this Policy.
Severability In the event that a court of competent jurisdiction invalidates any provision of this Policy, all remaining provisions of the Policy shall continue in full force and effect. Termination Provisions 1. If You fail to pay the premium, this Policy will terminate in accordance with the Premium Provision of this Policy. 2. If Your Plan is terminated, this Policy will terminate on the date the Plan terminated. 3. If You fail to maintain a minimum of 25 participants in Your Plan at any time during the Policy Year, We may elect to terminate this Policy at the end of the first month during which there are less than 25 participants. 4. This Policy will terminate at the end of the Policy Year unless agreed by You and Us to renew. 5. If You, or Your TPA, fail to satisfy any of Your obligations under this Policy We may terminate this Policy at the end of the Policy Year by providing You 60 days advanced written notice. 6. We may terminate this Policy at the end of the Policy Year by providing You 31 days advanced written notice. 7. You may terminate this Policy at any time by providing Us with 31 days advance written notice at Our U.S. Headquarters. The parties to this Policy may agree in writing to terminate it at any time. Reinstatement If this Policy is terminated for non-payment of premium, We may, at Our sole discretion, agree to reinstate it as of the date it terminated upon payment of all outstanding premiums. We may require You to provide certain information to Us before We will consider reinstating the Policy. Time Limitations If any time limitation in this Policy is less than that permitted by the law of the state in which the Application was taken, the limitation is hereby extended to the minimum period permitted by the law.
The Special Conditions Rider at Renewal provision allows Sun Life to add a new laser or maintain or increase a current laser when the policy renews. A “laser” is a higher deductible applied to a Covered Person who has incurred or may incur significant health care expenses.
Section Description Schedule of Benefits I Definitions II Benefit Provisions Specific Benefit Expenses Eligible for Reimbursement Limitations & Exclusions III Claim Provisions IV Your Rights and Responsibilities V Our Rights and Responsibilities VI General Provisions Premium Provisons Termination Provisions
[Renewal] Policy Year January X, 20XX through December XX, 20XX
Reimbursement Percentage [100%] of Eligible Expenses
Covered Benefits Medical, [Prescription Drug Plan (PDP)]
Specific Benefit Deductible [$XXX,XXX]
Specific Benefit Lifetime Maximum Eligible Expenses [Unlimited]
Specific Benefit Claims Basis [12/12] Eligible Expenses include only those expenses incurred and paid within the Policy Year.
Covered Unit(s) [Single Employee, Employee and Spouse, Employee and Child, Employee and Family]
Specific Benefit Premium Rate [$XXX.XX] per Single Employee per Month [$XXX.XX] per Employee and Spouse per Month [$XXX.XX] per Employee and Child per Month [$XXX.XX] per Employee and Family per Month
The Claims Basis is the time period within which expenses must be incurred and paid under your plan in order to be eligible for reimbursement under the Stop Loss policy. You can choose from a number of different Claims Basis to best meet your needs. • 12/12 (Incurred in 12/Paid in 12): Claims must be incurred and paid under your plan during the twelve month Policy Year. • 15/12 (Incurred in 15/Paid in 12): Claims must be incurred under your plan during the Policy Year or the three months prior to it and paid by the end of the Policy Year. This is referred to as a “run-in” policy as claims from a period prior to the policy term are allowed to “run” into it. • 12/15 (Incurred in 12/Paid in 15): Claims must be incurred under your plan during the Policy Year and paid by the end of the Policy Year or the three months following it. This is called a “run-out” policy as claims paid after the policy term during the “run out” period can be covered under it. • First year Gapless (15/12 [3] month modified run in): Eligible Expenses include only those expenses Incurred during the Policy Year, or within [3] months prior to the Policy Year (the “Run-In Period”), and Paid during the Policy Year. However, expenses Incurred prior to [1/1/2022] and Paid [1/1/2022 through 3/31/2022] are excluded under the Policy Note: Other Claims Basis are available, such as 12/24 and 24/12, and are subject to Sun Life’s approval.
Incurred: The date on which Treatment is provided. Medical Management Vendor: A third party hired to reduce or control the cost of services or supplies provided to Covered Persons under Your Plan. Original Specific Benefit Effective Date: When We provide You with Specific Benefit coverage under this Policy for consecutive Policy Years, the Original Specific Benefit Effective Date is the date Specific Benefit coverage first became effective in the consecutive year period.
Paid: Your payment of expenses Incurred by a Covered Person. A payment will be considered to be made on the date the payment is delivered to the payee provided that the account upon which the payment is drawn contains sufficient funds to permit the payment to be honored. Plan: Your self-funded benefit plan established to provide benefits to Covered Persons as described in Your plan document. For the purpose of determining benefits payable under this Policy, the Plan shall not include any amendments made to the plan document after the Original Aggregate Benefit Effective Date, the Original Specific Benefit Effective Date, the beginning of the Policy Year, or the beginning of the Renewal Policy Year, whichever is earlier, unless We notify You in writing from Our U.S. Headquarters that We accept the amendment. Policyholder: You, the legal entity to whom this Policy is issued. Prescription Drugs: For the purpose of determining Eligible Expenses under this Policy, Prescription Drugs includes all prescription drugs covered under Your Plan, other than prescription drugs administered to a Covered Person while he or she is confined in a hospital or other medical facility.
Schedule of Benefits: This Policy’s schedule of Specific Benefit coverage or Aggregate Benefit coverage provided under this Policy. Special Risk: A Special Risk is any Covered Person who (a) is expected to incur expenses under Your Plan during the Policy Year and any Run-In Period in an amount that is expected to exceed the lesser of [50%] of the Specific Benefit Deductible or [$100,000], or (b) incurred expenses under Your Plan during the twelve months prior to the Policy Effective Date in an amount that exceeded the lesser of [50%] of the Specific Benefit Deductible or [$100,000].
Transplant: The transplant of organs from human to human, including bone marrow, stem cell and cord blood transplants. Transplants include only those transplants that: (a) are approved for Medicare coverage on the date the Transplant is performed; and (b) are not otherwise excluded by this Policy. A Transplant must be performed at a Transplant Facility in order to be considered for reimbursement under this Policy. Transplant Facility: A hospital or facility which is accredited by the Joint Commission on Accreditation of Healthcare Organizations to perform a Transplant. Treatment: Any treatment, procedure, service, device, supply or drug provided to a Covered Person. Usual and Reasonable Charge: The usual and reasonable charge for the Treatment provided to a Covered Person for the locality where Treatment was provided, not to exceed the usual charge made by the majority of like providers for the same or like Treatment in the same locality where the Treatment is provided. The Usual and Reasonable Charge must be reasonable for the Treatment provided and comply with generally accepted billing practices. U.S. Headquarters: Our United States headquarters located at 96 Worcester Street, Wellesley Hills, Massachusetts.
To Section II Benefit Provisions
Specific Benefit The Specific Benefit for any Covered Person for any Policy Year equals: 1. The total amount of Eligible Expenses for the Covered Person; minus 2. The Specific Benefit Deductible multiplied by the Reimbursement Percentage shown on the “Schedule of Benefits – Specific Benefit,” if the Reimbursement Percentage is less than 100%. The amount of Eligible Expenses with respect to any Covered Person is subject to the Specific Benefit Lifetime Maximum Eligible Expenses.
Appeal of a Claim Determination You may appeal the initial claim determination made by Us under this Policy by submitting a written appeal to Us at Our U.S. Headquarters within 90 days from the date of Our determination. Your appeal should state the basis of Your disagreement with Our initial claim determination and should include all documentation and information supporting Your appeal that has not been previously provided to Us. Once you receive a determination from Us regarding Your appeal, You will have exhausted Your administrative remedies under this Policy. Deferred Payments by You You must obtain prior written approval from Us at Our U.S. Headquarters during the Policy Year in order for any Eligible Expenses Incurred in the Policy Year, but that will be Paid after the end of the applicable claims basis to be considered eligible for reimbursement under this Policy. Payment of Claims All benefits due under this Policy will be paid to You. During the Policy Year, reimbursements will be disbursed when the amount payable exceeds $1000.00. Any reimbursable amount remaining unpaid at the end of a Policy Year will be paid after the end of the Policy Year.
Authorizations to Release Information You are responsible for authorizing Your TPA, Plan Administrator, case manager or other third party service provider to release to Us information We request to underwrite, review potential claims, make claim determinations, calculate potential reimbursements, or perform other obligations under this Policy. If We do not receive requested information, it may result in the delay, reduction or denial of a claim. Disclosure Requirements This Policy, and any renewal of it, has been underwritten based upon the information You provided to Us concerning all persons eligible for benefits under Your Plan. Your signature on the Application for this Policy or Your acceptance of a renewal policy warrants and represents to Us that: 1. You or Your authorized representative have consulted with Your Human Resources Department, precertification, utilization review and Medical Management Vendors, pharmacy benefit manager and Your TPA, or former TPA, to determine who is a Special Risk, and 2. You have disclosed to Us any person who is a Special Risk. If You fail to disclose an individual as a Special Risk who should have been disclosed as a Special Risk, We will have the right to revise the premium rates, deductibles, deductible factors and terms and conditions of this Policy or any renewal policy in accordance with Our underwriting practices in effect at the time the Policy or renewal policy was underwritten, retroactive to the earlier of the Original Specific Benefit Effective Date, the beginning of the Policy Year or the beginning of the Renewal Policy Year.
Specific Benefit Reporting You, or Your TPA, are required to provide Us with notice of any potential Specific Benefit claim within thirty-one (31) days of the date: 1. A Covered Person’s Eligible Expenses exceed 50% of the Specific Benefit Deductible; or 2. You, Your TPA, or Your medical management, utilization review or precertification vendors, or any other party acting on Your behalf, are notified that a Covered Person has been diagnosed with, or treated for, a Catastrophic Diagnosis.
Renewal Reporting If You intend to renew this Policy, then three months prior to the end of the Policy Year, You, or Your TPA, are required to provide Us with a report that includes the following information: 1. Monthly Paid claims and enrollment data, organized by Covered Benefit; 2. Large claim information, including amount, diagnosis and prognosis, and any Covered Person who has been diagnosed with a Catastrophic Diagnosis; 3. A census of all Covered Persons; 4. A summary of the number of Covered Persons by workplace zip code, if this Policy covers Employees at multiple locations; 5. A summary report of pre-certification, utilization review and case management services; 6. A summary report of Your Provider Network(s) or per diem arrangements, setting forth the average hospital discount or per diem charge per day; 7. A copy of changes adopted by or proposed for Your Plan during the Policy Year or Renewal Policy Year. Plan Changes You must notify Us in writing at Our U. S. Headquarters at least (31) days before the effective date of any change in, or to: 1. Your Plan; 2. Your TPA; 3. Your Provider Networks; or 4. Your Medical Management Vendors; or 5. Your pharmacy benefit manager. With respect to any change in Your Plan, Our prior written agreement is required before the coverage under this Policy will apply to the change. Otherwise, benefits under this Policy will be paid based upon the terms of Your Plan, as it existed prior to the change. If You change Your Plan, TPA, Provider Networks, Medical Management Vendors, or pharmacy benefit manager, We reserve the right to terminate this Policy as of the change. Notice of Legal Action You agree to give Us prompt notice of: (a) any event that might result in a lawsuit relating to this Policy; or (b) any lawsuit involving this Policy; and to promptly provide Us with copies of any correspondence and pleadings relating to any such event or lawsuit.
Refund of Overpayment If We, You, or Your TPA determine that We have overpaid You under this Policy, You will promptly refund such overpayment to Us within [60] days of such a determination. If We are required to take legal action to collect such overpayment, You agree to indemnify Us for any costs of collection, including, but not limited to, attorneys’ fees and court costs. Responsibility for Your TPA You are solely responsible for the actions of Your Plan Administrator, Your TPA and any other agent of Yours. Your TPA acts on Your behalf, not on Our behalf. Your TPA is not Our agent. We are not responsible for any compensation owed to, or claimed by, Your TPA or other agents for services provided to, or on behalf of, Your Plan. This Policy does not make Us a party to any agreement between You and Your TPA, nor does it make Your TPA a party to this Policy. Right of Recovery You must pursue all valid claims including, but not necessarily limited to, claims for restitution, constructive trust, equitable lien, breach of contract, injunction, and any other state or federal law claims You or Your Plan may have against any third party responsible, in whole or in part, for any Eligible Expenses Paid by You. You must immediately advise Us of any amount You recover from them. If You fail to pursue such a claim, We will be subrogated to all of Your rights to make the claim. You are required to cooperate fully and do all things necessary and required to permit Us to pursue the claim and to file any action against the third party, including executing an assignment of the claim to Us and granting Us the right to commence litigation or other legal proceedings in Your name against the third party. If You receive payment from a third party for an expense paid by You under Your Plan and we have reimbursed You in whole or in part for the expense, You must reimburse Us the amount We paid You or the amount You received from the third party if it is less than the amount We paid You. Your reimbursement obligation continues and remains in effect whether or not the Policy is in effect on the date You receive payment from the third party.
Right to Recalculate We have the right to recalculate any Specific Benefit Premium Rate, Specific Benefit Deductible, Aggregating Specific Deductible, or Minimum Aggregate Deductible with respect to this Policy Year whenever any one or more of the following events occur: 1. Your Plan changes; 2. You change Your TPA, Your Provider Network(s), Medical Management Vendor(s), or pharmacy benefit manager; 3. This Policy is amended; 4. The number of Covered Units on the first day of a Benefit Month increases or decreases by more than 15% from the number of Covered Units on the first day of the Policy Year; 5. The number of Covered Units on the first day of a Benefit Month increases or decreases by more than 10% from the first day of the prior Benefit Month;
6. A unit, division, subsidiary, or affiliated company of Yours is added to, or deleted from, this Policy; 7. The amount of Eligible Expenses Incurred and Paid in any one of the 3 months immediately preceding the Policy Effective Date (the “3 month period”) exceeds 125% of the monthly average of Eligible Expenses Incurred and Paid during the 9 months immediately preceding the 3 month period; or 8. There are changes in Your, Your TPA’s, or Your pharmacy benefit manager’s claim paying system or payment practices that causes a variation of 15 days or more in the most recent 12 month average of claim processing time. Any right to recalculate exercised under this section may be made retroactive to the Policy Effective Date at Our election. Any recalculation will be made in accordance with Our underwriting practices in effect at the time the Policy was underwritten. The right to recalculate shall survive the termination of this Policy. Right of Reimbursement Any portion of an Eligible Expense which You recover from a third party: 1. Is not eligible for reimbursement under this Policy; and 2. Cannot be used to satisfy any deductible or attachment point under this Policy; and 3. Must be repaid to Us if We previously reimbursed You for it. Any repayment amount You owe Us may be reduced, with Our consent, by any reasonable and necessary expenses You incurred in obtaining the recovery from the third party. Any repayment amount You owe to Us shall survive the termination of this Policy
Clerical Error In the event of a clerical error in this Policy, the Policy will be revised to correct the error. Your failure to: 1. Report the existence of a Covered Person; or 2. File proof of claim in a timely manner; or 3. Comply with the reporting requirements of this Policy; shall not constitute clerical error. Entire Contract This Policy, along with any Attachments, Riders, Endorsements, Addenda or Amendments, and the Application completed by You constitutes the entire contract of insurance between us. Legal Action You may not bring a legal action against Us to recover on this Policy earlier than 60 days after You have furnished Us with proof of claim in accordance with the Proof of Claim provisions of this Policy. You may not bring any legal action against Us to recover on this Policy after 3 years from the time proof of claim is required under this Policy. Misrepresentation If: 1. You make any misstatement, omission or misrepresentation, whether intentional or unintentional, in the information or documentation You, Your TPA or any other party acting on Your behalf, provide to Us, and which We rely upon during the underwriting of this Policy; or 2. After this Policy is issued, We learn of expenses or claims that were incurred or paid, but not reported to Us, during the underwriting of this Policy, We have the right, at Our election, to rescind this Policy or to revise the premium rates, deductibles, and terms and conditions of this Policy in accordance with Our underwriting practices in effect at the time the Policy was underwritten. Any such revisions may be made retroactive to the Policy Effective Date. No ERISA Liability Under no circumstance will We accept responsibility as a “Plan Administrator” or be deemed a “plan fiduciary” with respect to your Plan under the Employee Retirement Income Security Act of 1974, as amended.
No New Special Conditions Rider at Renewal We guarantee that if You renew Your Policy with Us, Your renewal stop loss policy will not contain a new or revised Special Conditions Rider, provided that: 1. Your Plan contains no changes that materially affect or alter the risk presented by Your current Policy; 2. Your renewal stop loss policy contains no material changes from Your present Policy; and 3. A new unit, division, subsidiary, affiliated company or class of covered people is not added to this Policy. We reserve the right to carry over to the renewal stop loss policy any Special Conditions Rider that is part of Your current Policy. We, in Our sole discretion, shall determine whether any of the changes referenced in sections 1 through 3 above are material. If We determine that any change is material, this provision shall be of no force and effect.
Renewal Rate Increase Cap If You renew Your Policy with Us, We guarantee that the Specific Benefit Premium Rate on Your renewal stop loss policy will not be increased more than 40% over the Specific Benefit Premium Rate shown on the Schedule of Benefits, provided that: 1. Your Plan contains no changes that materially affect or alter the risk presented by Your current Policy; 2. Your renewal stop loss policy contains no material changes from Your present Policy; including, but not limited to, changes to: (a) the length of the Policy Year; (b) Covered Benefits; (c) coverage for Retirees; (d) the Specific Benefit Deductible; (e) the Claims Basis; (f) the commission payable; (g) Your TPA; (h) Your Provider Networks; or (i) Your pharmacy benefit manager; (j) the Specific Benefit Lifetime Maximum Eligible Expenses or Specific Benefit Annual Maximum Eligible Expenses; (k) the Specific Benefit Reimbursement Percentage; 3. There are no material changes in the demographic distribution of the group covered by Your current Policy versus the group covered by the renewal stop loss policy; and 4. A new unit, division, subsidiary, affiliated company or class of covered people is not added to this Policy. 5. There is no change in any assessment levied against Us by the state in which this Policy was issued. We, in Our sole discretion, shall determine whether any of the changes referenced in sections 1 through 3 above are material. If We determine that any change is material, We shall adjust the Renewal Rate Increase Cap accordingly. Premium Provisions Premium Payments Premium is due on or before the Premium Due Date.
Grace Period A grace period of forty five (45) days will be allowed for the payment of each premium due after the first premium has been paid. This Policy will continue in force during the grace period. If a premium is not paid by the end of the Grace Period, this Policy will terminate, without notice to You, as of the last date for which premium was paid. Premium Data You must provide a report to Us with each premium payment, in a form satisfactory to Us, that lists: 1. The number of each type of Covered Unit, for each Covered Benefit, under Your Plan on the first day of the Benefit Month; and 2. The amount of premium paid. We use such premium data reports solely to process premium. They do not replace any report required, or which may be required, under Section IV of this Policy. Severability In the event that a court of competent jurisdiction invalidates any provision of this Policy, all remaining provisions of the Policy shall continue in full force and effect. Termination Provisions 1. If You fail to pay the premium, this Policy will terminate in accordance with the Premium Provision of this Policy. 2. If Your Plan is terminated, this Policy will terminate on the date the Plan terminated. 3. If You fail to maintain a minimum of 25 participants in Your Plan at any time during the Policy Year, We may elect to terminate this Policy at the end of the first month during which there are less than 25 participants. 4. This Policy will terminate at the end of the Policy Year unless agreed by You and Us to renew. 5. If You, or Your TPA, fail to satisfy any of Your obligations under this Policy We may terminate this Policy at the end of the Policy Year by providing You 60 days advanced written notice. 6. We may terminate this Policy at the end of the Policy Year by providing You 31 days advanced written notice. 7. You may terminate this Policy at any time by providing Us with 31 days advance written notice at Our U.S. Headquarters. The parties to this Policy may agree in writing to terminate it at any time.
Endorsements and riders both work to provide additional protection and coverage. However, they can also result in additional questions about how they work and what they mean as you are reading through your contract. There are a variety of endorsements and riders available to you- and this tool is designed to provide you more information about them so you can make coverage decisions right for your group.
Advance Funding
Transplant Vendor Endorsement
Experience Rating Refund
Cancer Benefit
COVID-19 Products (Specific & Aggregate)
Special Conditions (Lasers)
Fee Reimbursement
Please click on what Riders and Endorsements you may have on your policy to see a sample:
Specific & Aggregate Policy
Specific only Policy
Transplant Vendor Endorse.
Special Conditions Rider
Cancer benefit
COVID-19 Products
This Endorsement is part of the Policy to which it attaches and is effective on [January 1, 20XX]. It is part of, and subject to, the other terms and conditions of the Policy. If the terms of the Endorsement and the Policy conflict, then the terms of the Endorsement will control.
DEFINITIONS
BENEFIT
GENERAL
Business Day: Any day the New York Stock Exchange (NYSE) is open for regular trading.
Upon receiving a written request from You or Your TPA, We will advance funds to You or Your TPA to pay expenses incurred by a Covered Person if all of the following conditions are met:
1. You have satisfied the Specific Benefit Deductible for the Covered Person and the Aggregating Specific Deductible, if any. 2. The expenses incurred by the Covered Person: (a) were for Medically Necessary and Appropriate Treatment; (b) are covered under the terms of Your Plan; (c) were incurred within the Specific Benefit Claims Basis; (d) are covered under a Covered Benefit shown on the Schedule of Benefits; and (e) are not otherwise excluded under the Policy; 3. You have approved the expenses incurred by the Covered Person for payment under Your Plan; 4. You have completed and submitted the Stop Loss Advance Funding Request Form; 5. The advance funding request is for an amount equal to or greater than $5,000; 6. The Policy is in force at the time the request for advance funding is made; and 7. We receive the advance funding request at least 30 days before the end of the Specific Benefit Claims Basis. Any advance funding request received after that date is not eligible for advance funding.
Upon receipt of the advance funding payment from Us, You or Your TPA must:
(a) Pay the expenses giving rise to the advance funding request within [10] Business Days after receiving the advance funding payment. If the expenses are paid within this time period, We will consider them to be Paid within the Specific Benefit Claims Basis even if the payment occurs after it. If the expenses are not paid within this time period, You or Your TPA must immediately refund the advance funding payment to Us. (b) Provide Us with Proof of Claim which demonstrates payment of the expenses incurred by the Covered Person within [10] Business Days of the date You or Your TPA make the payment; and (c) Refund to Us immediately any funds that are not used to pay the expenses incurred by the Covered Person.
If You do not comply with these requirements, in addition to any other remedy available to Us, we may choose to not advance any other funds under this endorsement. If We subsequently determine that the expenses incurred by the Covered Person are not eligible for reimbursement under the Policy, You agree to return to Us immediately the amount of the advance funding payment.
Termination This endorsement will terminate on the date the Policy terminates. If this endorsement terminates and You owe Us any money under it, the total amount owed by You will become immediately due and payable and shall survive the termination of the endorsement. Kevin Strain President and Chief Executive Officer
To learn more about Advance Funding, click here
The Advance Funding Endorsement allows you to be reimbursed before you have paid a medical expense under your plan and can assist with cash flow. Advance Funding is available to any client using a Third-Party Administrator.
To Transplant Vendor Endorsement
Transplant Vendor Contract: A contract between You and a Transplant Vendor that results in a discount to the billed charges for a Transplant. Transplant Vendor: A third party retained by You, and approved in writing by Us, that obtains a discount to the billed charges for a Transplant. Transplant Contract: A contract between a Transplant Vendor and a Transplant Facility that results in a discount to the billed charges for a Transplant.
If a Covered Person receives a Transplant at a Transplant Facility and You, Your TPA or the Transplant Vendor notify Us in writing of the Transplant and provide documentation that demonstrates that a Transplant Vendor Contract and Transplant Contract were in place prior to the Transplant, We will: • Reduce the Specific Benefit Deductible for the Covered Person by $10,000 for the Policy Year in which the Transplant occurs; and • Reimburse up to a combined maximum of $5,000 for travel and lodging expenses incurred by the Covered Person and the parent(s)/legal guardian(s) of a Covered Person who is a minor for the purpose of traveling to and from the Transplant if such expenses are covered under Your Plan.
Termination This Endorsement will end on the earliest of the following to occur: • the date You terminate the Endorsement; or • the date the Policy terminates.
The Endorsement states that if its requirements are satisfied, Sun Life will reduce the Specific Benefit Deductible for a Covered Person by a certain amount for the policy year when the transplant occurs and may reimburse certain travel and lodging expenses related to the transplant.
A Transplant Vendor Contract is a contract between you, the PolicyHolder, and a transplant vendor that results in a discount to the billed charges for a transplant.
The Transplant Contract is a contract between the transplant vendor and transplant facility that results in a discount to the billed charges for a transplant.
To Policy Endorsement (Mirroring)
Policyholder: [ABC Company] Policy Number: [12345] Section VI, “General Provisions,” shall include: Experience Rating Refund On each Policy Anniversary a retrospective experience rating refund process is applied to the Specific Benefit [and Aggregate Benefit]. Sun Life allots to this Policy such amount, if any, as Sun Life determines to be available as a refund as a result of that process. Sun Life reserves the right to change the basis of this process. It is agreed this Policy Endorsement is effective on [January X, 20XX] and is part of the Policy to which it attaches. Signed for the Company at Wellesley Hills, Massachusetts. Kevin Strain President and Chief Executive Officer
To learn more about Experience Rating Refund, click here
The Experience Rating Refund Endorsement provides you, the Policyholder, with the opportunity to receive a portion of your stop-loss premium dollars back if you have a positive claims experience.
To Reimbursement of Certain Fees
To Special Conditions Rider (Lasers)
Signed for Sun Life Assurance Company of Canada at Wellesley Hills, Massachusetts. Kevin Strain President and Chief Executive Officer
This endorsement is part of Policy [12345], issued to [ABC Company] and is effective on [insert date]. It is subject to the terms and conditions of the Policy. If the terms of this endorsement and the Policy conflict, then the terms of this endorsement will control. The above-referenced policy is hereby endorsed as follows: The Reimbursement of Certain Fees provision set forth in Section II, Benefit Provisions, Expenses Eligible for Reimbursement, is hereby deleted and replaced with the following:
Reimbursement of Certain Fees Eligible Expenses may also include fees incurred and paid by You in connection with the following services provided to your Plan by a Medical Management Vendor or other third party service provider relating to a Covered Person: [1. Hospital bill audits; [and]] [2. Access to non-directed provider networks; [and]] [3. Negotiating out of network bills; [and]] [4. Cost containment; [and]] [5. Reasonable hourly fees for case management services provided by a registered nurse case manager retained by You or Your TPA]. In order for such fees to be considered Eligible Expenses, You must: 1.Obtain Our approval of the fee in writing from Our U.S. Headquarters prior to incurring the fee; and 2.Demonstrate to Us that the service that generated the fee resulted in a cost saving to the Plan. If You satisfy the criteria, Eligible Expenses will include the fee amount up to 25% of the cost saving to the Plan.
This rider is part of the Policy to which it attaches and is effective on [January 1, 20XX]. It is part of, and subject to the other terms and conditions of the Policy. If the terms of this rider and the Policy conflict, then this rider’s provisions will control. [The Schedule of Benefits is modified as follows for the Covered Person(s) named below:]
Covered Person [John Doe] ID # [JD123XX] Specific Benefit Deductible $50,000
Eligible Expenses include only those expenses Incurred after Incurral Date and Paid during the Policy Year. Termination This rider will terminate on the date the Policy terminates. Kevin Strain President and Chief Executive Officer
The Special Conditions Rider notes if there is a laser on a Covered Person. A "laser" is either a higher deductible, a coverage limit, or an exclusion placed on a person who has incurred or may experience large health care expenses.
To Employer Cancer Benefit Rider
This rider is part of the Policy to which it attaches and is effective on [January 1, 20XX]. It is part of, and subject to, the other terms and conditions of the Policy. If the terms of this rider and the Policy conflict, then this rider’s provisions will control.
Cancer Diagnosis: A cancer diagnosis for a Covered Person that has been made by a licensed physician and has been assigned an ICD (International Classification of Diseases) 10 Code which indicates a diagnosis of Cancer. Qualifying Group Insurance Policy: A Group Insurance Critical Illness and Cancer Policy issued by Us to You that is in force at the time a claim is made under this rider.
If You submit a Specific Benefit claim for expenses incurred by a Covered Person who has received a Cancer Diagnosis and You have a Qualifying Group Insurance Policy, We will reduce the Specific Benefit Deductible for the claim by [$2,500] for the first claim submitted during the Policy Year that involves cancer related expenses incurred by the Covered Person.
To learn more about the Cancer Rider, click here
Available to Stop Loss policyholders that also have Sun Life Critical Illness and/or Cancer coverages. The Rider decreases the Specific Benefit Deductible by up to $10,000 which results in the deductible being met sooner.
To Fee Reimbursement Endorsement
This endorsement is part of Policy [12345], issued to [ABC Company] and is effective on [January 1, 20XX]. It is subject to the terms and conditions of the Policy. If the terms of this endorsement and the Policy conflict, then the terms of this endorsement will control. The above-referenced policy is hereby endorsed as follows: 1. Section II, Benefit Provisions, Limitations and Exclusions, is hereby amended to add the following limitation/exclusion: [xx] Expenses in excess of the actual charge billed for Treatment provided to a Covered Person. 2. Section II, Benefit Provisions, Expenses Eligible for Reimbursement, is hereby amended to replace the Reimbursement of Certain Fees provision with the following provision:
Reimbursement of Certain Fees Eligible Expenses will include the following fees Incurred and Paid by You, when approved by Us at Our U.S. Headquarters: a. Reasonable hourly fees for case management services provided by a registered nurse case manager retained by You or Your TPA and fees for: (i) hospital bill audits; (ii) access to non-directed provider networks; and (iii) negotiating out of network bills. Such fees shall be considered Eligible Expenses only if You can demonstrate to Us that the work that generated the fees resulted in a cost savings to the Plan. If the Plan can demonstrate such a cost savings, We will reimburse You up to [XX%] of the amount saved. b. The per claim fee charged by the [program name] for Treatment provided to a Covered Person by a non-directly contracted provider up to a maximum of XX% of the actual charge billed for the Treatment provided to the Covered Person; c. The per claim fee charged by the [program name] for Treatment provided to a Covered Person by a directly contracted provider up to a maximum of XX% of the actual charge billed for the Treatment provided by the Covered Person. Fees charged for any service will be considered Eligible Expenses only if prior approval of the fee has been obtained in writing from Us at Our U.S. Headquarters.
Eligible Expenses
To COVID-19 Benefit Riders
This Rider is part of the Policy to which it attaches and is effective on [January 1, 20XX]. It is part of, and subject to, the other terms and conditions of the Policy. If the terms of this Rider and the Policy conflict, then this Rider’s provisions will control.
COVID-19 Specific Benefit
COVID-19 Aggregate Benefit
COVID-19 Diagnosis: A primary COVID-19 diagnosis for a Covered Person that has been made by a licensed physician and has been assigned an ICD (International Classification of Diseases) 10 Code which indicates a diagnosis of COVID-19. COVID-19 Workplace Monitoring Program: A COVID-19 workplace monitoring program approved by Us that You have in place when a claim is made under this Rider.
If You submit a Specific Benefit claim for expenses incurred by a Covered Person who has received a COVID-19 Diagnosis that resulted in an inpatient hospitalization and You have a COVID-19 Workplace Monitoring Program, We will reduce the Specific Benefit Deductible for the claim by [$2,500] for the first claim submitted during the Policy Year that involves COVID-19 related expenses incurred by the Covered Person.
Termination This Rider will end on the earliest of the following to occur: • the date You terminate this Rider; or • the date the Policy terminates. Kevin Strain President and Chief Executive Officer
If You submit an Aggregate Benefit claim and You have a COVID-19 Workplace Monitoring Program, We will reduce the Aggregate Benefit Attachment Point by [5%]. The Aggregate Benefit We pay, including the benefit provided by this Rider, will not exceed the Aggregate Benefit Maximum.
To learn more about the COVID-19 products, click here
To learn more about COVID-19 workplace monitoring program requirements, click here
Specific Benefit
Specific Benefit Deductible
This endorsement is part of Policy [12345], issued to [ABC Company] and is effective on [insert date]. It is subject to the terms and conditions of the Policy. If the terms of this endorsement and the Policy conflict, then the terms of this endorsement will control. The above-referenced policy is hereby endorsed as follows: The definition of Eligible Expenses set forth in Section II, Benefit Provisions, Expenses Eligible for Reimbursement, is hereby deleted and replaced with the following:
Eligible Expenses Eligible Expenses include any amount paid by You for Medically Necessary and Appropriate expenses incurred by a Covered Person which:
The term “Reference Rate” means the amount Your Plan would pay for the Eligible Expenses incurred by the Covered Person if the Plan contains a benchmark rate for the Eligible Expenses and used it to determine the amount it would pay. For example, if a Plan referenced paying expenses incurred by a Covered Person based upon the amount Medicare would pay for such expenses, the Reference Rate would equal the amount Medicare would pay for the expenses. Signed for Sun Life Assurance Company of Canada at Wellesley Hills, Massachusetts. Dean A. Connor President and Chief Executive Officer
Home (Endorsements & Riders)
Transplant Vendor
Policy Endorsement (Mirroring)
Special Conditions (Drug)
Cancer Rider
Reference Based Pricing
Medically Necessary and Appropriate
Medically Necessary and Appropriate Treatment is determined by the following criteria: 1) it is provided by a licensed doctor, 2) it is accepted as a standard medical practice or Treatment for the diagnosis and 3) it is approved by the FDA (United States Food and Drug Administration)
claims basis
The Claims Basis (also called the Contract Basis) identifies the incurral (date of service) and paid dates for a stop-loss plan. The Claims Basis helps determine an expense's eligibility. Common choices are: • 12/12 (Incurred in 12/Paid in 12): This choice covers claims incurred and paid within the 12-month benefit period. When the policy renews, this contract often reverts to a “Paid” contract basis. • 15/12 (Incurred in 15/Paid in 12): This “run-in” choice covers claims that occur within a 15-month period and paid during the 12-month contract period. The 15-month period includes the 3 months prior to the start of the Stop-Loss contract period. If your company changes administrators, 15/12 is the best run-in contract offered. • 12/15 (Incurred in 12/Paid in 15): This “run-out” choice covers claims incurred during the 12-month contract period and paid within a 15-month period. The 15-month period includes the 3 months after the end of the Stop-Loss contract period. Note: Other run-in and run-out choices are available (e.g., 12/24, 24/12). Sun Life must approve the Contract Basis.
A Covered Person is someone enrolled in the plan and qualified to get benefits through the plan during the policy year. If covered under the plan as seen in the schedule of benefits, Retirees are Covered Persons as well.
Specific coverage reimburses for eligible excess claims. The employer's underlying plan document defines covered expenses, depending on the exclusions and limitations in the Stop-Loss policy. You, the Policyholder, can include Prescription Drug Plan (PDP) as a covered benefit. There is an added cost to include PDP and Sun Life must approve it.
Schedule of Benefits
A schedule that specifies the amount of coverage provided for each class or group insured under this Policy.
Eligible expenses are both medically necessary and appropriate expenses incurred by a covered person that Sun Life will pay through the Stop-Loss policy. Expenses are considered eligible if: 1) they are within the plan terms, 2) the date of service and paid date fall within the claims basis, 3) they were paid under a covered benefit which can be found on the Schedule of Benefits and 4) they are not excluded under the policy.
1. Have been paid in accordance with the terms of Your Plan; and 2. Were Incurred and Paid during the applicable claims basis; and 3. Are paid under a Covered Benefit shown on the Schedule of Benefits; and 4. Are not otherwise excluded under this Policy. If the Eligible Expenses result from: (a) a negotiated resolution or settlement of the amount billed by the provider of the Treatment to the Covered Person; or (b) a single patient contract with the provider of the Treatment to the Covered Person, then: 1. if the Eligible Expenses are paid during the Policy Year, the Eligible Expenses amount shall be capped at [three times] the amount of expenses that would have been paid using the Reference Rate. 2. if the Eligible Expenses are paid after the end of the Policy Year and You renew Your Policy at the end of the Policy Year and pay the Eligible Expenses within twelve months from the end of the Policy Year, the Eligible Expenses amount shall be capped at [three times] the amount of expenses that would have been paid using the Reference Rate. 3. if the Eligible Expenses are paid after the end of the Policy Year and You renew Your Policy at the end of the Policy Year and pay the Eligible Expenses more than twelve months from the end of the Policy Year, they will not be reimbursed unless they qualify for reimbursement under the terms of the renewal Policy in effect at the time. If they qualify for reimbursement, they will be capped at [three times] the amount of expenses that would have been paid using the Reference Rate. 4. If the Eligible Expenses are paid after the end of the Policy Year and You do not renew Your Policy at the end of the Policy Year and You pay the Eligible Expenses within three months from the end of the Policy Year, then the Eligible Expenses amount shall be capped at [two times] the amount of expenses that would have been paid using the Reference Rate. If the Eligible Expenses are paid more than three months after the end of the Policy Year, they will not be reimbursed under the Policy.
