AICPA Insurance Programs

Catastrophe Major Medical is not accepting new applicants at this time.

Group Catastrophe Major Medical Insurance
Benefit Summary

Benefit Summary for NY Residents

Provides benefits for a hospital stay
If you are not a Medicare beneficiary, you will receive a $2,000 credit toward your plan deductible for each day you are confined in a hospital, regardless of the actual charge but not in excess of the elected cash deductible amount. After your deductible is met, your hospital benefits for inpatient or intensive care charges per benefit period are:

• $75 per day for the first 30 days
• $100 per day for the next 100 days
• $150 per day there after

If you are a Medicare beneficiary, your benefits will equal the reasonable and customary inpatient or intensive care charges up to $400 per day for hospital room and board charges, and up to $800 per day for confinement in an intensive care unit after your deductible is satisfied.

Pays for convalescent care
Anyone at any age may require convalescent care or custodial care in a convalescent home due to a non-job related injury or sickness. That's why this is an important benefit for you - a benefit that is either not included or is limited in most basic health insurance plans. This plan pays up to $300 per week for convalescent care, to a lifetime maximum of $46,800, while insured.

The confinement must begin within 14 days after hospitalization ends and must be due to the injury or sickness which required the hospitalization.

NOTE: Convalescent Home means a licensed institution that has on its premises: organized facilities to care for and treat its patients, a staff of physicians to supervise such care and treatment, and a registered nurse on duty at all times.

Convalescent home does not mean a place, or part of one, which is used mainly for: the aged, alcoholics; drug addicts, persons with mental, nervous or emotional disorders.

Includes home health care benefits
The plan pays for up to 100 home health care visits per benefit period. And should the insured require medically necessary private duty nursing care, by a registered or licensed practical nurse the plan pays up to $300 per day, to a maximum of $30,000 per benefit period.

Special provisions
If 2 or more insured family members are injured in the same accident, the covered charges incurred by each person due to the accident will be combined. If the total exceeds one deductible amount, no further deductible will be required for such persons for any injury caused by the accident. In the event of a recurring illness or injury, all eligible expenses up to the lifetime maximum are covered once the benefit period begins. If the benefit period for the illness or injury ends, and you have no eligible expenses for that illness or injury in the next 12 consecutive month period, any recurrence will be treated as a new illness or injury with a new deductible and benefit period.

Other Features
Other eligible Group Catastrophe Major Medical Insurance expenses include:

• Doctors' fees for diagnosis, treatment, surgery, and prescriptions
• Charges for x-rays, lab tests, radiation treatment
• Treatment by a licensed physiotherapist
• Up to $2,000 per benefit period for ambulance service to and from a hospital.


PRE-EXISTING CONDITION
A pre-existing condition is: an injury or sickness which manifested itself within 6 months before a person became insured under the group policy in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment; an injury or sickness for which a person was recommended or received medical advice, diagnosis, care or treatment within 6 months before a person became insured under the group policy; or a pregnancy that exists on the date a person became insured under the group policy. No charges incurred for a pre-existing condition will be considered covered charges until the person stays insured for 12 continuous months.

LIMITATIONS
Benefits will be paid for covered charges incurred for the following medical services only to the extent described: charges for dental care, treatment or surgery will be covered only if such charges result from a non-job related injury to natural teeth, the injury is caused by an accident which occurs while insured, and such services are rendered within 12 months of the accident or they are made by a hospital while hospitalized; charges for treatment for temporomandibular joint dysfunction (TMJ) services will be covered, except for those charges for crowns or bridgework; charges for eye exams to prescribe or fit corrective lenses for eye glasses will be covered only if such charges result from a non-job related injury and the injury is caused by an accident which occurs while insured; charges for cosmetic treatment or surgery services will be covered only if such charges result from a non-job related injury or sickness or a congenital disease or anomaly of a dependent child resulting in a functional defect.

Charges incurred for diagnosis and treatment of alcoholism, alcohol abuse, substance abuse or substance dependency will be covered. Non Medicare Beneficiaries receive coverage for charges incurred for outpatient diagnosis and treatment in a certified or accredited alcoholic or substance abuse treatment center, up to 60 visits per calendar year. Up to 20 of such visits may be for family members of the alcoholic or substance abuser. Medicare Beneficiaries receive the aforementioned coverage plus that for charges incurred while the person is hospitalized; and for charges incurred for inpatient rehabilitation in a certified or accredited alcoholic or substance abuse treatment center, up to 30 days per calendar year.

Charges incurred for diagnosis and treatment of psychiatric, mental, nervous or emotional disorders, ailments or illness will be covered. Non Medicare Beneficiaries receive coverage for charges incurred for outpatient visits, up to 30 visits per calendar year, subject to a maximum benefit of $50 per visit (the facility for such visits must have been issued an operating certificate by the commissioner of mental health pursuant to the mental hygiene law; or be operated by the office of mental health, a psychiatrist or psychologist licensed to practice in New York or a professional corporation of such psychiatrists or psychologists); and charges incurred for up to three psychiatric emergency visits per calendar year, subject to a benefit of $60 per visit. (Benefits provided for emergency visits will reduce benefits otherwise payable for outpatient care as described.) Medicare Beneficiaries receive the aforementioned coverage plus coverage for charges incurred while hospitalized, up to 30 days per calendar year. Benefits provided for emergency visits will reduce benefits otherwise payable for inpatient or outpatient care as described.

The insurance described in this brochure meets the minimum standards for limited benefit health insurance as defined by the New York State Insurance Department. It does NOT provide basic hospital, basic medical, major medical, nursing home and/or home care, or long term care insurance as defined by the New York State Insurance Department.

CHARGES NOT COVERED
Charges to buy or rent air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, eye glass frames or lenses, hearing aids, swimming pools or supplies for them or general exercise equipment will not be covered. Charges for a routine physical exam, except charges for preventive mammography and cytologic screening will not be covered.

EXCLUSIONS
No medical care benefits will be paid by the group policy for charges incurred for treatment which is given after a person's insurance ends, regardless of when the injury or sickness occurred; is not essential for the necessary care or treatment of the injury or sickness involved; would be given free of charge if the person was not insured; results from a war or an act of war; results from intentionally self-inflicted injury; is given by a person's spouse or his or his spouse's father, mother, son, daughter, brother or sister; or is given by a person's employer or an employee of such employer.

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