SUPER GAP PLUS PLAN
Fighting the battle against out-of-pocket costs.
Group Accident Insurance
Group Accident Medical Expense Insurance
$25,000 Group Accident Medical Expense Insurance Annual Maximum Benefit.
$100 Deductible per accident.
Group Accidental Death & Dismemberment Insurance
$5,000 Group Accidental Death & Dismemberment Insurance Maximum Principal Sum.
Group Accident Insurance is underwritten by United States Fire Insurance Company.
Group Hospital Fixed Indemnity Insurance
Daily Hospital Confinement Benefit
$500 Daily Hospital Confinement Benefit
Days 1-3 for hospital confinement in a policy period
Group Hospital Fixed Indemnity Insurance is underwritten by United States Fire Insurance Company.
Group Hospital Fixed Indemnity Insurance
Emergency Room Visit Benefit
$500 per day Daily Emergency Room Visit Benefit for Accident & Sickness
Max 10 days per policy period for Accident & Sickness
Includes covered medical emergency visits at In-Hospital Emergency Rooms, Free Standing Emergency Rooms, and Licensed Urgent Care Centers.
Group Hospital Fixed Indemnity Insurance is underwritten by United States Fire Insurance Company.
Group Hospital Fixed Indemnity Insurance
Daily Physician Office Visit Benefit
$125 per day Daily Physician Office Visit Benefit
Max 1 day per play year for medically necessary visit and and additional 1 day for other Wellness visit.
Covered Wellness Services include: A history and physical examination & immunizations as provided by department of health regulation.
Note: The Wellness Visit for Daily Physician Office Visit Benefit is not available in the state of Michigan.
Group Hospital Fixed Indemnity Insurance is underwritten by United States Fire Insurance Company.
Group Hospital Fixed Indemnity Insurance
Daily Outpatient Diagnostic Radiology & X-Ray Benefit
$75 per day Daily Outpatient Diagnostic Laboratory Tests Benefit
Max 1 day per play year for medically necessary visit and and additional 1 day for other Wellness visit.
Daily Outpatient Diagnostic Radiology & X-Ray benefit does not include Radiation Therapy.
Note: The Wellness Visit for Daily Outpatient Diagnostic Radiology & X-Ray Benefit is not available in the state of Michigan.
Group Hospital Fixed Indemnity Insurance is underwritten by United States Fire Insurance Company.
Group Hospital Fixed Indemnity Insurance
Daily Outpatient Diagnostic Laboratory Tests Benefit
$75 per day Daily Outpatient Diagnostic Laboratory Tests Benefit
Max 1 day per play year for medically necessary visit and and additional 1 day for other Wellness visit.
In addition to medically necessary treatment, we will also cover wellness care for outpatient diagnostic laboratory tests to the extent that they are provided by, or under the supervision of, a single technician during the course of one visit.
Note: The Wellness Visit for Daily Outpatient Diagnostic Laboratory Tests Benefit is not available in the state of Michigan.
Group Hospital Fixed Indemnity Insurance is underwritten by United States Fire Insurance Company.
Group Critical Illness Insurance
Critical Illness Insurance Benefit
$25,000 Critical Illness Benefit Lifetime Maximum Benefit Amount
Maximum Lifetime Benefit Amount is $2500 if first diagnosis of a Covered Critical Illness occurs within the first year from the effective date. Invasive Cancer benefit will not be paid if Proof of Loss occurs prior to 45 days from the effective date. Benefit ends at age 65 and Critical Illness Insurance Benefit is only available for Covered Member and their Eligible Spouse.
Group Critical Illness Insurance is underwritten by Sirius America Insurance Company.
Group Term Life Insurance
$10,000 Principal Sum Maximum Benefit
Benefit ends at age 65 and Group Term Life Insurance is only available for Covered Member and their Eligible Spouse.
Group Term Life Insurance for this plan is only available in the following states: AL, AR, AZ, CA, FL, GA, IL, IN, KY, MI, MO, MS, NE, NM, OH, OK, PA, SC, TN, TX & VA.
Group Term Life Insurance is underwritten by Investors Heritage Life Insurance Company.
ASSOCIATION BENEFITS
PROVIDED BY:
GROUP ACCIDENT INSURANCE &
GROUP HOSPITAL FIXED INDEMNITY INSURANCE
UNDERWRITTEN BY:
United States Fire Insurance Company
GROUP CRITICAL ILLNESS INSURANCE
UNDERWRITTEN BY:
Sirius America Insurance Company
GROUP TERM LIFE INSURANCE
UNDERWRITTEN BY:
Investors Heritage Life Insurance Company
BILLING, FULFILLMENT &
CUSTOMER SERVICE PROVIDED BY:
THE INSURANCE PORTIONS OF THIS PLAN PROVIDE LIMITED COVERAGE. THEY DO NOT PROVIDE COMPREHENSIVE MAJOR MEDICAL INSURANCE. THIS IS A GROUP ACCIDENT & HOSPITAL FIXED INDEMNITY INSURANCE, GROUP CRITICAL ILLNESS & GROUP TERM LIFE INSURANCE ONLY POLICY.
The following monthly insurance rates apply to coverage underwritten by United States Fire Insurance Company1, Sirius America Insurance Company2, and Investors Heritage Life Insurance Company3. Your overall total association membership dues for the Super Gap Plus Plan also include these monthly insurance rates:
1Group Accident Insurance:
$5.42 (Individual), $10.87 (Ind+1), $19.00 (Family)
1Group Hospital Fixed Indemnity Insurance:
$11.36 (Individual), $22.69 (Ind+1), $36.85 (Family)
2Group Critical Illness Insurance:
$15.45 (Individual), $30.90 (Ind+1), $30.90 (Family)
3Group Term Life Insurance:
$3.80 (Individual), $7.60 (Ind+1), $7.60 (Family) - in available states
Read the Certificate(s) of Insurance carefully. This is a brief description of various group association insurance products and is not an insurance contract, nor part of the Certificate of Insurance and is subject to the terms, conditions, limitations, and exclusions of the Certificate(s) of Insurance and/or Certificate Riders. Coverage may vary or may not be available in all states. You'll find complete coverage details in the Certificate(s) of Insurance and/or Certificate Riders. Group Accident Insurance and Group Hospital Fixed Indemnity Insurance are underwritten by United States Fire Insurance Company, Eatontown, NJ. The insurance described in this document provides limited benefits. Limited benefit plans are insurance products with reduced benefits intended to help supplement comprehensive health insurance plans. The insurance coverage is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, the insurance coverage is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act. Group Critical Illness Insurance is underwritten by Sirius America Insurance Company. Covered Critical Illnesses are subject to the definitions, limitations and exclusions of the Group Policy. Coverage for Critical Illness is for Member and eligible Spouse between the ages of 18-64. Benefit for Group Critical Illness Insurance ends at age 65. Benefits are paid at 10% of the Benefit Maximum if first diagnosis occurs in the first year from the effective date. Group Term Life Insurance is underwritten by Investors Heritage Life Insurance Company and is available to Covered Member and Eligible Spouse only and coverage ends at age 65. Plan cost for the Super Gap Plus Plan does not include the separate $10 UBA Membership dues. You must be a member of the United Business Association in order to purchase this plan.
United Business Association, Crum & Forster, United States Fire Insurance Company, Sirius America Insurance Company, Investors Heritage Life Insurance Company and Healthy America are separate legal entities and have sole financial responsibility for their own products.
AH-2562 | HA-1000
