Health Insurance Policy Bulletin

HEALTH INSURANCE POLICY BULLETIN

Issuer and Bulletin Identification

Issuer Name:    Bulletin No.:

Effective Date of Bulletin:    Policy Affected (Policy No.):

Applicant / Insured Information

Policy Details

Policy Type: Individual Family Group

Coinsurance:    Out-of-Pocket Maximum:

From:    To:

Covered Benefits (select applicable)

Hospitalization (inpatient)
Outpatient services and physician visits
Prescription drugs
Preventive services and screenings
Mental health and substance use disorder services
Maternity and newborn care
Rehabilitative and habilitative services
Other   

Exclusions and Limitations

The following exclusions and limitations apply to the coverage described above. Select all that apply:

Pre-existing conditions not disclosed and excluded by prior agreement
Experimental, investigational, or unproven treatments
Cosmetic and elective procedures not medically necessary
Losses arising from acts of war or civil unrest
Self-inflicted injury, attempted suicide, or illegal acts
Services rendered outside approved network without prior authorization
Other exclusions

Claims and Documentation

Documentation checklist (submit as applicable):

Original itemized bills and receipts
Attending physician's report and medical records
Police or incident report (if applicable)
Other supporting documentation

Beneficiary Designation

Designate primary beneficiaries for any benefit payable to a beneficiary pursuant to this policy bulletin.

Administrative Provisions

This bulletin constitutes an administrative amendment to the named policy and shall be interpreted in accordance with the terms of the policy. In the event of any conflict between this bulletin and the policy declarations, the terms set forth in this bulletin shall govern to the extent explicitly stated herein. Any other terms of the policy not expressly modified by this bulletin remain in full force and effect.

The issuer retains the right to correct clerical errors, to apply underwriting rules consistently, and to deny coverage where application or claim information materially misrepresents facts that affect coverage eligibility or benefits.

Certification and Applicant Declaration

By signing below, the applicant certifies under penalty of perjury that the information provided in this bulletin and any attachments is complete and accurate to the best of the applicant’s knowledge. The applicant acknowledges receipt of this bulletin and that the bulletin’s terms will apply to the policy identified above as of the Effective Date stated herein. The applicant further acknowledges that submission of materially false information may result in rescission, denial of benefits, or other remedies permitted by law and policy terms.

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