Totally Disabled or Total Disability means disability which wholly and continuously prevents a covered person from performing the substantial and material duties or his or her usual occupation.
Hospital does not mean any institution or part thereof which is used primarily as 1) a nursing home, convalescent home, or skilled nursing facility; 2) a place for drug addicts or alcoholics; or 3) a place for rest, custodial care, or for the aged.
Successive Periods of Disability: Periods of Disability: a) due to the same or related medical causes; and b) separated by less than 6 months during which the covered person is Actively-at-Work; will be considered one Period of Disability. "Actively at Work" means the Covered Person is performing all of the regualar duties of an occupation for wage or profit on a full time basis (at least 20 hours a week). Periods of Disability separated by at least 6 months during which the covered person is Actively-at-Work will be considered separate Periods of Disability. Concurrent Disabilities: Benefits during any Period of Disability as the result of more than one accident will be considered the same as if the Disability resulted from only one cause.
Exclusions:
As part of our ongoing effort to hold costs as low as possible, this CSEA endorsed Plan is intended to provide coverage for accidents, and is not intended to cover any loss resulting from: intentionally self-inflicted injury, suicide or attempted suicide, whether sane or insane; war or act of war, whether declared or undeclared; injury sustained while full-time in the armed forces of any country or international authority (we will refund the prorated premium paid to cover a person during a period of such services); injury sustained while in or on, boarding or alighting from, any aircraft: as a pilot, crew member, student pilot, flight instructor, or examiner; or being used for tests, experimental purposes, stunt flying, racing, or endurance tests; injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription, including sedatives, barbiturates, amphetamines, or hallucinogens, unless the drug taken is prescribed or administered by a licensed physician; or injury sustained while intoxicated. The policy will only pay one benefit (whichever is greater) for all losses due to the same accident.
Coverage Effective Date and Injury
Your coverage becomes effective on the first day of the month following payroll/pay warrant deduction and the date the administrator receives your application.
Injury means bodily injury resulting directly from accident and independently of all other causes which occurs while the Covered Person is covered under the policy. Loss resulting from:
a) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or
b) medical or surgical treatment of a sickness or disease;
is not considered as resulting from Injury.
Covered Person means You or your Eligible Dependent Spouse while You, he or she is covered under the policy.
Confined and Confinement means:
a) being admitted to a Hospital for receiving inpatient hospital services due to an Injury sustained in an accident while covered under the Policy; and
b) the patient is charged for at least one day's room and board by the hospital for each time the Covered Person is admitted.
Confinement does not mean being admitted to a Veterans Administration or other Government owned or operated Hospital if the Covered Person is not charged room and board.
Period of Confinement means the interval of time during which a Covered Person is Confined as an inpatient in a Hospital. A Period of Confinement begins on the date of admission to the Hospital and ends on the date of release from the Hospital.
If a benefit is payable, and the Covered Person is subsequently Confined to a Hospital for the same Injury within 90 days, it will be considered the same Period of Confinement.
Who Is Eligible to Enroll
You are eligible for coverage under this plan as long as you are age 18-59, are Actively-at-Work and are a resident of the United States. Eligible Members must enroll for coverage themselves in order to enroll for coverage of their eligible spouses. Coverage is issued on a guaranteed-issue basis, regardless of health history. All you have to do is decide which option you want.
Eligible Spouse
An Eligible Member's spouse who is a) at least age 18, but under age 60; and b) actively at work on a full-time basis (at least 20 hours per week); and c) a full-time resident of the United States; and d) not legally separated or divorced from the Eligible Member.
Eligibility Restrictions
When a husband and wife are both Eligible Members, coverage may not be duplicated by enrolling as dependents of each other. Eligible Members must enroll for coverage of themselves in order to enroll for coverage of their Eligible Spouse.
This is limited accident only coverage.
Limitation: The Policy will only pay one benefit (whichever is greater) for all losses due to the same accident.
Deferred Effective Date: If an Eligible Person is to become: covered under the Policy; or covered for increased benefits under the Policy: and is not Actively at Work on that date, he or she will not be so covered until the first day of the month on or the next following date he or she is Actively at Work for 31 consecutive days.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement Insurance.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance.
This insurance duplicates Medicare benefits when:
- any expenses or services covered by the policy are also covered by medicare.
Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reasons you need them. These include:
- hospitalization
- physician services
- hospice
- other approved items and services
Before You Buy This Insurance
- Check the coverage in all health insurance policies you already have.
- For more information about Medicare and Medicare Supplement Insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
- For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries including issuing company Hartford Life Insurance Company. This information explains the general purpose of the insurance described, but in no way changes or affects Master Policy ADD-11209 as actually issued. In the event of a discrepancy between this information and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states.
The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life Insurance Company.
Endorsed by:
CSEA incurs certain administrative expenses in connection with this sponsored program. To provide and maintain this valuable membership benefit it is reimbursed for such expenses.
California State Employees Association
Administered by A.G.I.A., Inc.
P.O. Box 21408, Santa Barbara, CA 93121
Questions? Call toll-free 1-800-952-5283
A.G.I.A., Inc. is licensed/authorized to transact business in all 50 United States, and the District of Columbia. Their state of domicile is California. John B. Wigle, California License No. 0482924
Underwritten by:
Hartford Life & Accident Insurance Company
Simsbury, CT 06089