Cancer Screening TestPayable for one annual cancer screening test, including but not limited to mammography screening, pap smear (test only); CA125 (blood test for ovarian Cancer); PSA (blood test for prostate Cancer); hemocult stool specimen; flexible sigmoidoscopy; CEA (blood test for colon Cancer); colonoscopy; chest X-ray; thermography; or serum protein electrophoresis. Payment based on benefit amount selected. Not payable if received through any free-testing program or for any other cancer screening test for which a charge is not made.
First Occurrence Benefit (Rider)
Payable when a covered person is diagnosed with cancer for the first time. Payable only once for each covered person and not payable for skin cancer. Not available for ages 65 and above.
Daily Hospital Confinement Benefit
Payable when a covered person is confined to the hospital for the treatment of cancer or a dread disease. Payment is based on the daily benefit amount selected. Payable for the first 70 days of each period of confinement.
Payable for surgeries performed in or out of the hospital to treat cancer or a specified dread disease. Benefits for surgical procedures are calculated as a percentage of the per-surgery maximum benefit amount selected.
Radiation, Chemotherapy and Other Benefits
We will pay the actual charges for Teleradiotherapy, Radio-Active Isotopes Therapy, Chemotherapy, Chemotherapy Enhancer Drugs, and Anti-Nausea and Immunotherapy drugs, as indicated in the policy, for the treatment of cancer or a specified dread disease. Benefits are based on the maximum monthly benefit amount selected. Actual Charges means the amount(s) actually paid by or on behalf of the Covered Person and accepted by the provider as full payment for the covered services provided. This benefit is not payable if treatment is received in a government or charity hospital.
The following defines the list of Dread Diseases covered under the Policy:
• Addison’s Disease • Muscular Dystrophy • Tay-Sachs Disease • Amyotrophic Lateral Sclerosis • Myasthenia Gravis • Tetanus • Diphtheria • Niemann-Pick Disease • Toxic Epidermal Necrolysis • Encephalitis • Osteomyelitis • Toxic Shock Syndrome • Epilepsy • Poliomyelitis • Tuberculosis • Legionnaire’s Disease • Reye’s Syndrome • Tularemia • Lupus Erythematosus • Rheumatic Fever • Typhoid Fever • Meningitis • Rocky Mountain Spotted Fever • Whipple’s Disease • Multiple Sclerosis• Sickle-Cell Anemia • Whooping Cough
Prescribed Drugs and Medicines
Actual charges for drugs and medicines prescribed while confined in a hospital. Limited to the first 70 days for each period of confinement.
Actual charges to a maximum of 20% of the Daily Hospital Confinement Benefit.
If the regular physician visits during a confinement in the hospital.
$50 per day
For transfer of a covered person to or from a hospital for confinement as an inpatient.
$250 per trip
3 trips per year
Private Duty Nursing Service
When confined in a hospital and a private duty nursing service is retained.
$150 per day
Beginning on the 71st day of one continuous period of hospital confinement for cancer or a dread disease. Payable in lieu of all other benefits payable for the same time period.
$1,000 per day
Government or Charity Hospital
Pays a total benefit of $200 per day of treatment for outpatient Teleradiotherapy, Radio-Active Isotopes Therapy, Chemotherapy, Chemotherapy Enhancer Drug, Anti-Nausea, and Immunotherapy, as indicated in the policy, received in a government or charity hospital. Paid in lieu of all other benefits except for transportation and lodging benefits.
$200 per day
Extended Care Facility
Confinement must be recommended by the attending physician and begin within 14 days of a covered hospital confinement. All days for which a Hospital Confinement benefit is paid will be included in determining the maximum of 70 days for the Extended Care Facility benefit.
$100 for each day
of confinement to a
maximum of 70 days
For confinement in a hospice care center for care provided if a covered person has diagnosed as terminally ill due to cancer or dread disease. Limited to a lifetime maximum of 180 days for confinement in a hospice care center, or 30 days if hospice services are provided in the covered person’s home.
$100 per day
Transportation and Lodging for Bone Marrow Donors
Paid for a donor who is either a covered person, or someone donating to a covered person. When a covered person is the donor, this benefit is payable in lieu of any other benefits payable under the policy.
• Actual charges to $2,500 for medical expenses directly relating to the services provided to the donor during the transplant.
• Actual charges for round trip coach fare on a common carrier, or a personal automobile allowance of 50 cents per mile if distance is more than 50 miles one-way. Maximum 700 miles round trip.
• Actual charges to $75 per day for lodging and meal expenses incurred by the donor.
*Transportation for Non-Local Treatment Which Requires Hospital Confinement
Actual charges for round trip coach fare, or a personal automobile allowance of 50 cents per mile if the distance is more than 50 miles one-way. Maximum 700 miles round trip.
Prescribed treatment must not be available locally and must require hospital confinement.
*Transportation and Lodging for Non-Local Treatment Which Does Not Require Hospital Confinement
• Actual charges for round trip coach fare, or a personal automobile allowance of 50 cents per mile if the distance is more than 50 miles one way, maximum 700 miles round trip. Maximum of $1,500 per calendar year.
• Actual charges to $50 per day for lodging and meal expenses. Payable only for the days you receive treatment for cancer or dread disease for which a benefit is payable.
Prescribed treatment must not be available locally and must not require hospital confinement.
*Adult Companion Transportation and Lodging
Payable only for an adult companion residing and traveling within the continental United States.
• Actual charges for one adult companion to be near a covered person who is hospital confined in a non-local hospital for covered treatments. Maximum $2,500 per confinement.
• Actual charges to $50 per day for lodging and meal expenses incurred. Limited to the number of days of the covered person’s hospitalization.
• Actual charges of one round trip coach fare, or a personal automobile allowance of 50 cents per mile, if the distance is more than 50 miles one way. Maximum 700 miles round trip.
*Not payable for periodic checkups, cancer screening tests, or for treatments, services, or procedures for which a benefit is not payable under this policy
Pays for the procedure in which anesthesia is used. We will pay $50 for the administration of anesthesia for each skin cancer operation.
Pays 25% of the surgical benefit amount paid
Additional Surgical Opinions
Pays for a second and third surgical opinion if the surgical opinions differ.
$200 each opinion
Artificial Limb and Prosthesis
Pays per prosthetic device or artificial limb and the reconstructive procedure to affix or implant it. Benefits limited to only two of the same type of prosthetic device or artificial limb. Not payable if a breast reconstruction and breast prosthesis benefit is payable.
Actual charges to $1,500
Outpatient Surgery Benefit
Payable for outpatient surgery in a hospital or ambulatory surgical center. Not payable for surgery in a physician’s office or clinic, or for skin cancer treatment.
Pays $375 per operations for drugs, medicines and lab tests.
Pays maximum of 150% of surgery shown in surgical benefits schedule.
• If the diagnosis is made by a physician other than a pathologist, $150 for removal of skin cancer to a maximum of $600 per calendar year.
• If the diagnosis is made by a pathologist, actual charges to the maximum amount for such surgery shown in the surgical benefits schedule.
Pays $150 per calendar year.
Maximum benefit $600.
Breast Reconstruction/Breast Prosthesis
Actual Charges incurred for reconstructive surgery, and an external or internal breast prosthesis and the surgeon’s fee for implantation following a mastectomy. Lifetime maximum of $5,000. This benefit is in lieu of the surgical benefit provided in this policy.
Pays actual charges, lifetime maximum of $5,000.
Bone Marrow Transplant for Cancer
Actual charges incurred for bone marrow transplants or other forms of stem cell rescue and all related services and supplies. Lifetime maximum of $10,000. This benefit is in lieu of any other benefit associated with the treatment, service, or procedure underlying Bone Marrow Transplant, with the exception of the Transportation and Lodging for Bone Marrow Donors benefit.
Pays actual charges, lifetime maximum of $10,000.
Treatment must be received in the United States or its territories. This benefit is in lieu of all other benefits payable for the treatment of cancer or dread disease.
Pays actual charges, to a lifetime maximum of $10,000.
Physical, Occupational or Speech Therapy
$50 for each 60-minute session for Physical, Occupational or Speech Therapy.
$50 each session.
Lifetime maximum of $1,500.
Outpatient Positive Diagnosis Test
For a diagnostic test that leads to a positive diagnosis within 90 days of such test. Payable once per diagnosis.
$250 for a diagnostic test
Blood and Blood Plasma
For blood, blood plasma and platelets inserted into a covered person. Not payable for blood which is donated or replaced.
Pays actual charges, to a maximum of $5,000 per calendar year.
Home Health Care Services
Payable when services are provided by a licensed home health care agency.
Benefit paid in lieu of all other policy benefits. Must be prescribed by a physician and cannot be provided by a relative.
Pays $60 per day at home services, 180 days max per calendar year.
Pays $150 per day at home private duty nursing, 15 days max per calendar year.
Pays $50 per day at home physician visits, 15 days max per calendar year.
One-time benefit for a hairpiece when hair loss is the result of cancer treatment.
Rental or Purchase of Durable Medical Equipment
For the rental or purchase of a respirator or similar mechanical device; brace; crutches; hospital bed; or a wheel chair.
Pays actual charges, maximum $1,000 per calendar year.
Professional Mental Health Consultation
For a consultation with a licensed mental health professional when receiving treatment for cancer or a dread disease. The licensed mental health professional may not be a relative.
$50 per session.
Lifetime maximum of $250.
Tutor session for an insured child under age 19, when the child is receiving treatment for cancer or a dread disease.
$25 per 60-minute.
Lifetime maximum of
In MT only, pays actual charges for a mammography screening administered to a Covered Person according to the schedule listed in the policy.
Pays actual charges to a maximum of $70.
Benefits Reduce to ½ at age 70.
If a Covered Person is confined in an Intensive Care Unit of a Hospital, we will pay the ICU Daily Benefit Amount for each day of such confinement, not to exceed 30 days during any one period of confinement.
Pays $600 per day
If a Covered Person is confined in a Step-Down Unit of a Hospital, we will pay for each day of such confinement, not to exceed 30 days during any one period of confinement.
Pays $300 per day
step down unit
A Heart Disease benefit will be paid for the actual charges incurred by a Covered Person for the following due to Heart Disease: 1. pacemaker insertion; 2. angioplasty; and 3. heart catheterization. This benefit is limited to a lifetime maximum.
Pays Actual charges to lifetime max $2,500
A Heart Attack/Stroke benefit will be paid for the actual charges incurred by a Covered Person.
Pays Actual charges to lifetime max $5,000