Excerpts from Sample Certificate Insurance is subject to the eligibility and effective date requirements of the group policy and all of its terms and conditions. This document is neither a policy nor a certificate. It contains only parts of the certificate language for demonstration purposes. POLICYHOLDER: GROUP POLICY NO.: AMERICAN ADVANTAGE ASSOCIATION SAMPLE Plans AM A1a, A2b and A3c Eligibility: Each person who is enrolled for the Policyholder's Membership Program and his or her Eligible Dependents (if family program is elected). Period of Coverage: Coverage begins on the later of: 1) the Policy Effective Date; or 2) the date that the Insured becomes eligible. Coverage will end on the earlier of the date: 1) the policy terminates; 2) the Insured is no longer eligible; or 3) the period ends for which the premium is paid. For insurance to take effect, each person must be in Active Service. If an Eligible Person or Dependent is not in Active Service on the date insurance would otherwise be effective, it will be effective on the date he or she returns to Active Service. A Dependent's insurance will not be in effect prior to the date an Eligible Person is insured. Active Service means a Covered Person is either: 1) actively at work performing all regular duties on a full-time basis either at his or her primary employer's place of business or someplace the employer requires him or her to be; 2) employed, but on a scheduled holiday, vacation day or period of approved paid leave of absence; or 3) if not employed, able to engage in substantially all of the usual activities of a person in good health of like age and sex and not confined in a Hospital or rehabilitation or rest facility. Accidental Death & Dismemberment Benefits: We will pay the benefit shown below if Injury or Death occurs due to a Covered Accident, 24 hours a day, anywhere in the world, subject to the limitations listed below. If Your Injury results in any of the following losses within 365 days after the date of the Covered Accident, We will pay the amount shown below for that loss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident. Covered Loss Life; Both Hands or Both Feet; Sight of Both Eyes One Hand and One Foot; Either Hand or Foot and Sight of One Eye Either Hand or Foot, or Sight of One Eye Thumb and Index Finger of the Same Hand Indemnity Principal Sum Principal Sum 50% of the Principal Sum 25% of the Principal Sum "Loss of Hand or Foot" means complete Severance through or above the wrist or ankle joint. "Loss of Hand" includes "Loss of Four Fingers of the Same Hand." "Loss of Sight" means the total, permanent Loss of Sight of one eye that is irrecoverable by natural, surgical or artificial means. "Loss of a Thumb and Index Finger in the Same Hand" or "Loss of Four Fingers of the Same Hand" means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). "Severance" means the complete separation and dismemberment of the part from the body. Principal Sum: $ 15,000.00 Family Plan Coverage (if family program is elected): Your Spouse is automatically insured for 50% of your Principal Sum (the amount increases to 60% if there are no dependent children); each Dependent child is automatically insured for 20% of your Principal sum (increases to 25% if no Spouse). Accident Medical/Dental Expense Benefits: We will pay Accident Medical/Dental Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident. These benefits are subject to a $100 Deductible, and a $5,000 Benefit Maximum. The first Covered Expenses must be incurred within 90 days of the Accident. Accident Medical/Dental Benefits are only payable: (1) for Usual and Customary Charges incurred after the Deductible has been met; (2) for those Medically Necessary Covered Expenses incurred by or on behalf of the Covered Person; and (3) for charges incurred within 365 days after the date of the Covered Accident. No benefits will be paid for any expenses incurred that, in Our judgment, are in excess of Usual and Customary Charges. Covered Expenses: Hospital Room and Board Expenses: the daily room rate when a Covered Person is Hospital Confined and general nursing care is provided and charged for by the Hospital. Ancillary Hospital Expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines (excluding take home drugs) when Hospital Confined. Registered Nurse Services Expenses for private duty nursing while a Covered Person is Hospital Confined; these services must be ordered by a Doctor. X-ray Expenses (including reading charges) but not for dental X-rays. Dental Expenses including dental X-rays for the repair or treatment of each injured tooth that is whole, sound and a natural tooth at the time of the Accident. Ambulance Expense for transportation from the emergency site to the Hospital. Prescription Drug Expenses (for injuries only) prescribed by a Doctor and administered on an outpatient basis. Medical Emergency Care (room and supplies) Expenses; incurred within 72 hours of a Covered Accident and including the attending Doctor's charges, X-rays, laboratory procedures, use of the emergency room and supplies. Accident Disability Benefits – Applicable to Insured and insured Spouse who are under age 70: We will pay a Monthly Benefit of $600 if you or your insured Spouse (if family program is elected) is Totally Disabled directly and independently of all other causes, from a Covered Accident. Disability benefits will begin after such Covered Person's Total Disability has lasted for 90 days and we receive satisfactory proof of Total Disability. Benefits are payable for up to 12 months while the Total Disability continues. Benefit payments will end on the first of the following dates: 1) the date the Covered Person dies; 2) the date the Covered Person is no longer Totally Disabled; 3) the date the Maximum Benefit Period (12 months) for this benefit ends; 4) the date the Covered Person attains age 70; or 5) the date the Covered Person fails to submit satisfactory proof of continuing Total Disability. Hospital Stay Benefits – Applicable to Covered Persons who are under age 65: We will pay $XXX (depending on plan selected) a day, up to 180 days, if the Covered Person requires a Hospital Stay due to an Injury or Sickness, subject to the following conditions. The Hospital Stay must (a) be at the direction and under the care of a Doctor; and (b) begin while the Covered Person's insurance is in effect. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge. Intensive Care Unit Benefits – Applicable to Covered Persons who are under age 65: We will pay an additional $1,000 a day, up to 14 days, if the Covered Person requires confinement in an Intensive Care Unit for Medically Necessary treatment of an Injury or Sickness during a Hospital Stay for which benefits are payable under the Policy. Emergency Room Benefits – Applicable to Covered Persons who are under age 65: We will pay $100 if the Covered Person requires Emergency Room services for the Medically Necessary treatment of an Injury or Sickness, to a maximum of 3 visits per calendar year. Doctor's Visits Benefits – Applicable to Covered Persons who are under age 65: We will pay $40 if the Covered Person visits a Doctor for other than surgery, due to an Injury or Sickness. These benefits are subject to a maximum of 5 visits per Family per calendar year. Ambulance Benefits – Applicable to Covered Persons who are under age 65: We will pay $500 if the Covered Person requires Medically Necessary ambulance transportation by air or ground, to or from a Hospital. The ambulance services provided must be for transportation: 1) To the nearest Hospital that is able to provide appropriate care; or 2) From the Hospital to a Covered Person's residence or another medical facility that is required for treatment of the Covered person's condition. These benefits are subject to a maximum of 3 transports per calendar year. Surgical Benefits – Applicable to Covered Persons who are under age 65: We will pay benefits according to the Surgical Schedule below when a Covered Person receives Surgery for the Medically Necessary treatment of an Injury or Sickness. The benefit for each surgical procedure shall be determined by multiplying the Point Value shown in the Surgical Schedule below by the Unit Value of $25, $40 or $60 (depending on plan selected). The most We will pay for all surgical procedures performed in a calendar year for a Covered Person is $20,000. If more than one surgical procedure is performed through the same operational field, We will only pay benefits for the procedure for which the higher benefit is payable. If a Covered Person receives a surgical procedure that is not listed in the Surgical Schedule, We will pay according to the Surgical Schedule for the most comparable surgical procedure. The surgical procedure may be performed in a Hospital, an ambulatory surgical center, or a Doctor's office, whichever is consistent with practices prevailing in the area for the surgical procedure.  Definitions: Insured means a person in a Class of Eligible Persons for whom the required premium is paid making insurance in effect for that person. An Insured is not an Eligible Dependent covered under the Policy. The Insured is referred to as "You" or "Your(s)." Covered Person means any Eligible Person and Eligible Dependent (if family program is elected) for whom the required premium is paid. Eligible Dependent means an Insured's lawful spouse; or an Insured's unmarried child, from the moment of birth to age 18 (23 if a full-time student), who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured's natural child; adopted child, beginning with any waiting period pending finalization of the child's adoption; or a stepchild who resides with the Insured or depends on the Insured for financial support. Insurance will continue for any dependent child who reaches the age limit and continues to meet the following conditions: 1) the child is handicapped; 2) is not capable of self-support; and 3) depends mainly on the insured for support and maintenance. The insured must send us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year. Accident means a sudden, unexpected and unintended event occurring external to the Covered Person. Covered Accident means an Accident that occurs while coverage is in force for a Covered Person and results in a loss or Injury covered by the Group Policy for which benefits are payable. Injury means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident. The Injury must be caused through accidental means. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury. Deductible means $100 of Covered Expenses that must be incurred as an out-of-pocket expense by each Covered Person per Accident before Accident Medical/Dental Expense Benefits are payable under the Group Policy. Doctor means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person's Immediate Family or household. Hospital means an institution that: 1) operates as a Hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons; 2) provides 24-hour nursing service by Registered Nurses on duty or call; 3) has a staff of one or more licensed Doctors available at all times; 4) provide organized facilities for diagnosis, treatment and surgery, either: (i) on its premises; or (ii) in facilities available to it, on a pre-arranged basis; 5) is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6) is not a place for drug addicts, alcoholics, or the aged. Medically Necessary means a treatment, service or supply that is: 1) required to treat an Injury; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the Covered Person's condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. Purchasing or renting: 1) air conditioners; 2) air purifiers; 3) motorized transportation equipment; 4) escalators or elevators in private homes; 5) swimming pools or supplies for them; and 6) general exercise equipment are not Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may, at Our discretion, consider the cost of the alternative to be the Covered Expense. Medical Emergency means a condition caused by an injury that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy. Usual and Customary Charge means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. Hospital Confined or Hospital Stay or Confined to a Hospital means a stay of 24 or more consecutive hours as a registered resident bed-patient in a Hospital. Immediate Family means a Covered Person's parent, grandparent, spouse, child, brother, sister, stepchild, grandchild, step-grandchild or in-laws. Mental or Nervous Disorder means a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease of any kind, that is without demonstrable organic cause. Sickness means an illness or disease that is first diagnosed or treated after the effective date of insurance for the Covered Person. Intensive Care Unit means a specific unit in a Hospital that is designed to provide intensive care services on an interdisciplinary basis to critically ill inpatients. Total Disability or Totally Disabled means, due to an Injury from a Covered Accident, the Insured or insured Spouse: 1) if employed, cannot do any work for which he or she is, or may become, qualified by reason of education, experience or training; and 2) if not employed, cannot perform the normal and customary activities of a healthy person of like age and sex. Pre-Existing Conditions Limitation: Coverage is not provided for loss due to a pre-existing condition for 12 months from the effective date of the Covered Person's insurance. Pre-existing condition means: (a) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a one year period preceding the effective date of the Covered Person's insurance; or (b) a condition for which medical advice or treatment was recommended by a Doctor or received from a Doctor within a one year period preceding the effective date of the Covered Person's insurance. General Exclusions: We will not pay benefits for any loss or Injury that is caused by, results from, or is contributed to by: Intentionally self-inflicted Injury, suicide or attempted suicide, while sane. War or any act of war, whether declared or not. Active participation in a riot or insurrection. Service in the military, naval or air service of any country, or international organization. Piloting or serving as a crewmember or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline. Work related injuries covered under Worker's Compensation, Employer's Liability Laws, or similar occupational benefits Medical mishap or negligence, including malpractice While traveling outside the United States, Canada, Mexico, or any United States possessions, except for a Medical Emergency or a covered Accidental Death or Accidental Dismemberment.. Treatment provided in a governmental hospital, benefits provided under a government program (except Medicaid or Medicare), and any other services for which no charge is normally made in the absence of insurance. Treatment by an Immediate Family member or a member of the Covered Person's household. Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Doctor. Cosmetic care, except for Medically Necessary reconstructive plastic surgery. Reconstructive plastic surgery is defined as: Surgery to restore normal bodily functions; or Surgery to improve functional impairment by anatomic alteration made necessary as a result of a congenital birth defect; or Breast reconstruction following a mastectomy. Dental treatment, except for Injury to sound, natural teeth. Hernia, adenoids, tonsils, varicose veins, appendix, disorder of the reproductive organs, voluntary abortion, or elective sterilization with 6 months after the Covered Person's effective date of insurance. Rest care, convalescent care, or rehabilitative care. Treatment of Mental or Nervous Disorders. In addition to the General Exclusions, we will not pay benefits for Injury or death to which a contributing cause is: The Covered Person's violation or attempt to violate any duly-enacted law, or the commission or attempt to commit an assault or a felony, or that occurs while the Insured is engaged in an illegal activity or occupation. Injury or death from an Accident where the Covered Person's intoxication would be considered a contributing cause to the Accident. Intoxication is determined according to the laws and/or regulations of the jurisdiction in which the Accident occurred. It will be considered a contributing cause if: An investigation into the cause of the Accident by a police department or other government body makes such determination; or It meets a "prudent and reasonable" test. "Prudent and reasonable" means that a review of the circumstances of the Accident by an ordinarily prudent person would find that the most reasonable interpretation of the facts indicate that intoxication was a causal factor. Loss for which the Covered Person would not be responsible in the absence of this Coverage. In addition to the General Exclusions, Accident Medical/Dental Expense Benefits will not be paid for: Treatment of hernia, Osgood-Schlatter's Disease, osteochronditis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, or detached retina unless caused by Injury, whether or not caused by a Covered Accident. Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions. Mental and Nervous Disorders (except as provided in the Group Policy). Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the Group Policy). Expense incurred for treatment of Temporomandibular or Craniomandibular joint dysfunction and associated myofacial pain (except as provided by the Group Policy). Covered medical expenses for which the Covered Person would not be responsible in the absence of this Coverage. Any expense paid or payable by any other valid and collectible group insurance plan. Conditions that are not caused by a Covered Accident. Any treatment, service or supply not specifically covered by the Group Policy. Claim Payment Provisions The balance of the Certificate of Insurance (provided in the membership materials) outlines provisions related to how claims get paid.