Healthcare Insurance Policy

HEALTHCARE INSURANCE POLICY

This Healthcare Insurance Policy is issued by: . Policy Number: . The coverage set forth herein becomes effective on and expires on unless earlier terminated as provided in this Policy.

1. Insured Information

2. Policy and Premium

Plan Type: . Coverage Tier: .

Payments not received within days of the due date are delinquent and may result in suspension or termination of coverage in accordance with the Termination provisions below. A late fee of may apply to late payments.

3. Covered Benefits

Subject to the terms, conditions, exclusions and limitations of this Policy, the Insurer will provide benefits for Medically Necessary services including but not limited to: inpatient hospital care, outpatient services, emergency services, physician services, diagnostic testing, and prescription drugs as described in the Benefit Schedule attached hereto.

4. Dependents Covered

5. Exclusions and Limitations

Coverage does not apply to services that are Experimental, Investigational or Cosmetic; care for conditions arising from acts of war; intentionally self-inflicted injuries; charges for which the Insured is not liable; or services excluded by specific endorsement. Pre-existing condition limitations, if any, are described in the Benefit Schedule.

6. Claims and Notice Requirements

Claims must be submitted in writing to the Insurer within days of the date of service, except where state law requires otherwise. Proof of loss and supporting documentation must accompany each claim. The Insurer will pay or deny a properly presented claim within the time period required by applicable law.

7. Coordination of Benefits and Subrogation

If the Insured is entitled to benefits under any other plan or is entitled to recover damages from a third party for expenses covered by this Policy, the Insurer may coordinate benefits, seek reimbursement, and exercise subrogation rights to the extent of benefits paid. By accepting coverage under this Policy the Insured assigns to the Insurer the Insured's rights to such recovery up to the amount paid by the Insurer.

8. Termination and Cancellation

This Policy may be cancelled by the Insurer for non-payment of premiums following written notice as required by law. The Insured may cancel this Policy by providing written notice to the Insurer. Termination will not affect claims for covered services incurred prior to the effective date of termination, subject to policy provisions for notice and proof of loss.

9. Privacy and Acknowledgments

The Insurer will use and disclose Protected Health Information in accordance with applicable privacy laws. By signing below, the Insured acknowledges receipt of the Insurer's Notice of Privacy Practices and authorizes the Insurer to obtain medical records as reasonably necessary to process claims and administer benefits.

I acknowledge I have received and understand the Notice of Privacy Practices.

10. Representations, Warranties and Conditions

The Insured represents and warrants that all information provided in connection with this Policy is true and complete. Material misrepresentation, fraud, or intentional omission of facts by or on behalf of the Insured may render the Policy voidable and may result in denial of claims or rescission of coverage to the extent permitted by law. The Insured must cooperate with the Insurer in the investigation and processing of claims.

This Policy, together with any endorsements or riders, constitutes the entire agreement between the Insurer and the Insured. No agent or representative has authority to alter the terms of this Policy except by express written endorsement signed by an authorized officer of the Insurer.

11. Dispute Resolution

Any dispute arising under this Policy shall be resolved by the procedures set forth in the Dispute Resolution provision of the Benefit Schedule. Unless otherwise provided by law, the prevailing party in any dispute is entitled to recover reasonable costs and attorneys' fees as allowed by the applicable provision.

12. Notices

All notices required or permitted under this Policy must be in writing and delivered to the address on file for the party to whom notice is given. The Insured must promptly notify the Insurer in writing of any change of address or other contact information.

Certification and Signature

By signing below, the undersigned certifies, under penalty of perjury to the best of the undersigned's knowledge, that the information provided in this Policy application and any attachments is true, complete, and correct. The undersigned understands and agrees to the terms, conditions, exclusions, and limitations of this Policy and authorizes the Insurer to obtain medical and other records as necessary to administer this Policy and process claims.

Certification: The undersigned acknowledges that providing false information may constitute insurance fraud and may result in denial of coverage, rescission of the Policy, civil liability, and criminal prosecution to the fullest extent permitted by law.

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